■t?C4.G Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/textbookofpracti1913ande A TEXT-BOOK OF THE Practice of Medicine BY JAMES M, ANDERS, MX>., Ph.D., LL.D. Professor of Medicine and Clinical Medicine at the Medico-Chirurgical College ; Physician to the Medico=Chirurgical Hospital : Consulting Physician to the Jewish Hospital and to the Widener Home for Crippled Children ; formerly Physician to the Philadelphia and to the Protestant Episcopal Hospitals, Philadelphia ; Officier de I'lnstruction Publique. ILLUSTRATED ELEVENTH EDITION, THOROUGHLY REVISED PHILADELPHIA AND LONDON W, B. SAUNDERS COMPANY J9J3 Copyright, 1897, by W. B. Saunders. Revised, reprinted, and recopyrightcd iMarch, 1898. Re printed September, 1898. Revised, reprinted, and recopyrightcd August, 1899. Reprinted December, 1899. Revised, reprinted, and recopyrighted oeptember, 1900, and July, 1901. Reprinted February, 1902, and January, 7903. Revised, reprinted, and recopyrighted August, 1903. Reprinted March, 1904. Revised, reprinted, and recopy- righted August, 1905. Reprinted February, 1906. Revised, reprinted, and recopyrighted August, 1907. Reprinted March, 1908. Revised, reprinted, and recopyrighted August, 1909. Reprinted October, igio. Revised, reprinted, and recopyrighted August, 1911. Revised, reprinted, and recopyrighted September, 1913. Copyright, 1913, by W. B. Saunders Company. PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA PREFACE TO THE ELEVENTH EDITION. The revision of this Edition, upon which constant serious considera- tion has been bestowed during the past two years so as to bring it abreast of our present knowledge of the diagnosis and treatment of disease, has it is hoped yielded substantial improvements. It is believed that by far the majority of modern methods of diagnosis of medical complaints have been presented with sufficient detail, while it has been found neces- sary to make mere mention of a few special tests, together with their references, owing to the exigencies of space. The subject of the treat- ment of individual diseases in text-books of medicine too often receives scantier attention than its intrinsic importance would seem to warrant. This branch of my theme has, therefore, received close scrutiny, and where demanded it has been enlarged. Great care has also been taken to harmonize the Pathologic Sections with the present-day opinion of specialists in this department of mechcal science. As in former editions, so in the present one, the new matter introduced has been systematically classified. While the work throughout has been carefully revised, among the more important additions may be mentioned: McPhedran's sign of peritonitis in typhoid fever, Burke's reflex sign in typhoid fever, Prender- gast's test in typhoid fever, phlebotomy and transfusion in hemorrhage of typhoid fever, hot-air inhalations in diphtheria, Lee's sign in acute articular rheumatism. Iron's method of diag-nosis of gonorrheal arthritis, Pastia's sign of scarlet fever, copper arsenite and copper sulphate in amebic dysentery, Erb's syphilitic spinal paralysis, Weil's test in syphilis, vegetable days in diabetes, sugar solution in diabetic acidosis, effect of atophan in gouty subjects, radium emanations in gout, salvarsan and sodium cacodylate in progressive pernicious anemia, benzol in leukemia, vaccine treatment of goiter, hexamethylenamine in acute bronchitis, artificial pneumothorax in hemoptysis, Schepelmann's sign in acute plastic pleurisy, oxygen in sero-fibrinous pleurisy. Stem's sign in tricuspid incompetency, Graham-Steell murmur in pulmonary incompetency, Karell milk-cure in valvular heart disease, electricity in arterial sclerosis, diastolic expiration in aneurysm. Boas' method of testing motor function of stomach, McCaskey's method of treating gastroptosis, Meiostagmin reaction in gastric cancer, Falk and Salomon's reaction in gastric cancer, larval superacidity, Boas' phenolphthalein 1 2 PREFACE TO THE ELEVENTH EHITIOS. test for diagnosis of intestinal disease, Bastedo's test in appendicitis, chloride retention theory of renal dropsy, circumscribed serous spinal meningitis, progressive lenticular degeneration, dysbasia lordotica progressiva, myotonia atropliica, and tiie Towns-Lambert method of treating morphinism. Of the new subjects which have been discussed, the following may be enumerated: Diseases of the parathyroid gland, auricular fibrillation, auricular flutter, extra systole, streptococcus tonsillitis, stenosis of the duodenum, Lane's kink of the ileum, status thymico-lymphaticus. In addition the following subjects have been rewritten: Antityphoid vac- cination, diseases of the thjanus gland, and pellagra. I can only hope that the present Edition will maintain the position and standing which its predecessors have hitherto held. My indebted- ness to Dr. H. Leon Jameson for kind aid cannot be sufficiently expressed. The Section on Nervous Diseases was kindly revised by Dr. Charles S. Potts, who by reason of his standing as a neurologist is eminently fitted for the task. JAMES M. ANDERS. 1605 Walnut Street, Philadelphia, September, 1913. PREFACE. This work is meant to introduce the student to the present state of our knowledge of the practice of medicine in general and of the diagno- sis, differential diagnosis, and treatment of disease in particular. The historic development of the subjects treated has been either briefly given or intendedly omitted, since this scarcely falls within the scope of a prac- tical treatise on medicine. Although the book as a whole is submitted to the critical judgment of a learned profession, it may be pardonable to emphasize, provisionally, a few features pertaining to the mode of treat- ing the separate subjects, or the arrangement of the material under the latter — to indicate some of the more salient lineaments, so to speak, in the general design. Since in medical schools it is taught from a separate chair, the pathology (special) of the individual affections has almost in- variably been taken up before the etiology ; from this point the student will find the story of each affection a continuous one. The practitioner, however, must ever aim to associate the clinical symptoms with the morbid lesions. Under special etiology the bacteriology has been prominently men- tioned, since we owe to it the rapid progress that is being made in the study of the causation of disease. The differential diagnosis has in many instances been tabulated — an ear-mark that I confidently believe will be found especially helpful. It may be stated that not less than fifty-six diagnostic tables are scattered throughout the work, and that by far the greater number of these are my own. Such formulae have been introduced into the text, and only such, as a more, or less extended experience has shown to be possessed of real thera- peutic importance. Whilst these, and all additional points relating to the treatment of the single affections, may serve as guides, particularly to the beginner, I fully appreciate how often the practising physician is 4 PREFACE. placed in a position in which he is compelled to form a therapeutic judgment for himself. Whenever the dosage is stated, the metric equiv- alent is placed in parentheses, the number of grams being stated in round numbers (sj — 4.0 ;. 5J — 32.0) in order to render it of greater practical value. In all instances, however, in which this would involve an im- portant dift'erence in quantity the exact decimal figures are given. A consiilerable variation from the usual classification of diseases may be observed, but this is accounted for in the text wherever it occurs. Preference has been given to the modern orthography and termi- nology, not only because it is more euphonious, but also because of its adoption by the standard lexicographers. I have gleaned without stint from medical literature Avith a view to bringing the book up to date, and if I have failed to give full credit in every instance, my grateful acknowledgments are here due and are cheerfully made. The chief results of my personal experience and obser- vation, extending over a period of two decades, and derived from both hospital and private practice, will also be found upon these pages. I wish to thank Prof W. C. HoUopeter, who has written some of the articles upon the diseases of children, as measles, chicken-pox, mumps, whooping-cough, and the acute diarrheas, and who has kindly aided in the preparation of those upon diphtheria and scarlatina. My cordial thanks are due also to Dr. C. L. Furbush for kind aid in preparing some of the illustrations, to Doctors Robert N. Willson, Howard S. Anders, and Geo. W. Pfromm for valuable assistance while the work was passing through the press, and to Dr. A. M. Davis for preparing the index. JAMES M. ANDERS. CONTENTS. PART I.— INFECTIOUS DISEASES. I'AfJK Typhoid Fever 17. Paratyphoid Covers ''IJ Tyj)hus Fever ^*_' Dysentery if Bacillary Dysentery (Acute Dysentery) ^^ Catarrhal Dysentery i'' Diphtheritic Dysentery '4 Secondary Diphtheritic Dysentery 76 Chronic Dysentery • '° Cholera (Epidemic) °P Yellow Fever J" Cerebro-spinal Meningitis ^2 Lobar Pneumonia ■* '"' Secopdary Pneumonia !•/" Influenza iqu Dengue • \f The Plague ! ' l2 Erysipelas jiT Diphtheria .:.... 1^1 Septicemia ' ^2 Pyemia ^_ Acute Articular Rheumatism 1'4 Subacute Articular Rheumatism 184 Gonorrheal Arthritis ' 185 Variola ; 186 Vaccination "^^^ Varicella 202 Scarlet Fever ^r^ Fourth Disease ^-.^ Measles 220 Rubella qo^ Whooping-cough '^ Parotitis ° ] ;^" Tuberculosis -^. Bovine Tuberculosis • "^-^^ Tuberculosis of the Lymph-glands '--i^ Acute Tuberculosis ° -j^b General Miliary Tuberculosis ' ° ° Z,t Typhoid Form '. 11 '1% Pulmonary Jborm -^° Cerebral or Meningeal Form ° 249 Acute Pneumonic Phthisis '.9-7 Chronic Tuberculosis ._ '*''.*. o'^l Pseudo-tuberculosis -1* Fibroid Phthisis '-Lj Tuberculosis of the Alimentary Tract ' 1-^ Tuberculosis of the Serous Membranes ^i_^ Tuberculosis of the Pericardium '^oa Tuberculosis of the Peritoneum • • • ' ' ];^X Tuberculosis of the Liver • • • • ■ '-^^ Tuberculosis of the Genito-urinary System_ ■••••• -^^e Tuberculosis of the Fallopian Tubes, Ovaries, and Uterus 28o Tuberculosis of the Mammary Glands -ho Tuberculosis of the Brain -Jo Tuberculosis of the Spinal Cord ' -»£ Tuberculosis of the Heart -»' Tuberculosis of the Arteries and ^^eins -^^ Treatment of Tuberculosis .299 Leprosy ^^02 Glanders ' 304 Actinomycosis ■ '..'.... 30G Anthrax • 5 6 CONTENTS. PAGE Ilvdiophobia 309 IVumus 812 Beri-bori 31G Malta Fever 319 Probable Infeclious Diseases 321 Muscular Kbeuiualisui 321 Chronic Articular.Kbeumatisra 324 Mountain Fever 32(5 Kockv Mountain Spotted Fever 326 Weil's Disease 328 Sciiiarnintieber 328 Fel.ricula 329 Milk-siekness 330 Miliary Fever . 331 Foot-;uul-ni()utii Disease ... 332 Glandular Fever 332 PART II.— ANIMAL PARASITIC DISEASES. Parasites of Man 334 Amebic Dvsenterv 334 Flagellata". . . ' .• ... 338 Mastigophora 338 Trypanosomiasis 338 Sleeping Sickness 338 Febrile Tropical Splenomegaly 340 Psorospermiasis 341 Malarial Fever 342 Dislomiasis 361 Cestodes .... 363 Eehinococcus Disease 363 Tieniie or Tape-worms 367 Tsenia Nana 371 Tsenia Flavopunctata 371 Nematodes 372 Ascaria.sis 372 Uncinariasis ... 375 Trichiniasis 377 Filariasis 381 Dracontiasis 383 Other Filaria; 384 Other and Uncommon Nematodes 384 Parasitic Amchnida 385 Other Parasitic Insects 385 Pediculosis 385 Cimex Leetularius 386 Pulex Irritans 386 Piilex Penetrans 387 Ixodes 387 Dermany.ssus ,\vinm et Gallinae 387 Culicidie 387 Hirudo 387 Estrid* 387 Muscidte 387 Syphilis 388 Visceral Syphilis 394 Syphilis of the Liver 396 Syphilis of the Alimentary Tract 397 Svphilis of the Lungs . . .S98 Syphilis of the Spleen 399 Syphilis of the Circulatory System 400 Syphilis of the .Vrteries 400 Syphilis of the Kidneys 400 Svphihs of tlie Joint-s' 400 Syphilis of the Testicles 401 CONTENTS. 7 Diagnosis of Syphilis 4(j] Treatment of Syphilis 4q;^ Spii'illosis 4(j7 PART HI— CONSTITUTIONAL DISEASES. Diabetes 413 Diabetes Insipidus •. _ 425 Arthritis Deformans 427 GoH. 432 Lithemia 440 Rachitis 442 Scorbutus 447 Infantile Scorbutus 450 Purpura 452 Hemophilia 455 Hemorrhagic Diseases of the New-born 458 PART IV.— DISEASES OF THE BLOOD AND THE DUCTLESS GLANDS. Anemia 459 The Primary or Essential Anen^ias 460 Chlorosis 460 Progressive Pernicious Anemia , 465 The Secondary Anemias 472 Leukemia ( Leukocythemia) . 475 Leukanemia 483 Chloroma 483 Pseudo-leukemia 483 Anaemia Infantum Pseudo-leuksemica 488 Splenic Anemia 488 Polycythemia with Splenic Tumor 489 Diseases of the Ductless Glands 490 Diseases of the Suprarenal Capsules 490 Addison's Disease 490 Diseases of the Thymus Gland 494 Enlargement of Thymus 494 Status Thymico-Lymphaticus 494 Diseases of the Thyroid Gland 495 Thyroiditis 495 Goiter 496 Exophthalmic Goiter 498 Myxedema . . 502 Diseases of the Parathyroid Glands 506 PART V — DISEASES OF THE RESPIRATORY SYSTEM. L DISEASES OF THE NOSE. Acute Rhinitis .507 Chronic Rhinitis 508 Autumnal Catarrh 511 Epistaxis 512 II. DISEASES OF THE LARYNX. Acute Catarrhal Laryngitis 513 Chronic Laryngitis 515 Spasmodic Laryngitis 517 Edematous Laryngitis 519 Tumors of the Larynx 520 III. DISEASES OF THE BRONCHI. Catarrhal Bronchitis 520 Acute Bronchitis 521 Chronic Bronchitis 525 Bronchiectasis 529 Bronchial Stenosis 532 Asthma 533 Fibrinous Bronchitis 538 8 coy'TKyTS. IV. DISEASES OF THE LUNGS. I'AGE Circulatory Disturbances in tlie Lungs v>40 Congestion of the Lungs -i-iO Active HyiRMeniiii o40 Passive Hvpcieuiiu 541 Pulmonary Edema 542 Hemoptysis . . . .• •_>3'1 Pneumorrliagia 4 lnterlol>nlar Emphysema 5G4 Vesicular Emphysema 564 Compensating Emphysema 564 Hypertrophic Emphysema 565 Senile Emphysema 570 (langrene of the Lungs 571 Abscess of the Linigs •>7.'i Pneumonokoniosis 57.) New (irowths of the L\nigs 577 Carcinoma of the Lung ^7/ Sarcoma of the Lung 579 Hydatid Cyst of the Lung 579 V. DISEASES OF THE PLEURA. Pleurisy • 5B0 Acute Plastic Pleurisy 581 Sero-fibrinous Pleurisy 58o Empyema 597 Chronic Pleurisy ■ f 601 Pneumothorax . . 603 Hvdrothorax 608 New Growths of the Pleura 609 Diseases of the Mediastinum ■ '.'J Inflammation of the Mediastinum . ',^ Tumors of the Mediastinum • ,' ,' Mediastinal Hemorrhage ''^'^ PART VL— DISEASES OF THE CIRCULATORY SYSTEM. I. DISEASES OF THE PERICARDIUM. PericJirditis 615 Acute Plastic or Fibrinous Pericarditis 615 iSero-librinous Pericarditis 618 Purulent Pericarditis 623 Hemorrhagic Pericarditis 624 Adhesive I'ericarditis 624 Hydropericardiuin 626 Hemopericardium .• 61^ Pneumopericardium ''2' II. DISEASES OF THE HEART. Endocarditis 628 Simple Acute Endocarditis 628 I'lcerative Endocarditis . . f,32 Chronic Endocarditis 636 Aortic Incompetency 639 Aortic Stenosis 645 Mitral Incompetency 647 Mitral Stenosis 653 Tricuspid Incompetency 657 Tricuspid Stenosis 660 CONTENTS. 9 T-A'.V. Pulmonary Incompetency 001 Pulmonary Stenosis 002 Combined Forms of Cardiac Diseases 002 Cardiac Thrombosis 070 Hyperti-ophy of the Heart 077 Dilatation of the Heart 084 Myocarditis 090 Acute Myocarditis 090 Chronic Myocarditis 091 Diseases of the Coronary Arteries 695 Degenerations of the lieart 690 Fatty Degeneration - ■ 090 Fatty Overgrowth - - 098 Fatty Infdtration 699 Brown Atrophy 700 Calcareous Degeneration =• • 700 Amyloid Degeneration 700 Hyaline Degeneration 700 Cardiac Aneurysm 700 Rupture of the Heart 701 Minor Affections of the Heart 702 New Growths 702 Parasites 702 Misplacement 703 Floating Heart 703 III. NEUROSES OF THE HEART. Palpitation '^03 Tachycardia ™2 Brachycai'dia jy' Arrhythmia . 1^^ Auricular Fibrillation ^10 Auricular Flutter ■■ ^H Stokes-Adams Disease l}" Angina Pectoris ...>...... '1" IV. CONGENITAL AFFECTIONS OF THE HEART. Arrested Development 716 Fetal Endocarditis . 716 V. DISEASES OF THE ARTERIES Acute Aortitis • 718 Arterial Sclerosis . 718 Aneurysm 723 Aneurysm of the Thoracic Aorta 724 Aneurysm of the Abdominal Aorta • 732 Aneurysm of the Pulmonary Artery • 733 Aneurysm of the Coronary Arteries . > 734 Aneurysm of the Celiac Axis 734 Aneurysm of the Splenic Artery ■ 734 Aneurysm of the Hepatic Artery = 734 Aneurysm of the Superior Mesenteric Artery 734 Aneurysm of the Inferior Mesenteric Artery 734 Aneurysm of the Renal Arteries 734 Arterio-venous Aneurysm 735 Congenital Aneurysm 735 PART VII.— DISEASES OF THE DIGESTIVE SYSTEM. I. DISEASES OF THE MOUTH. Stomatitis • 737 Catarrhal Stomatitis ^ > 737 Aphthous Stomatitis i^^ Aphtha Cachectica (Riga's Disease) = • '^^ Membranous Stomatitis = • •'^^ 10 CONTENTS. I Icerative or Fetid Stomatitis 741 Neurotic Ukeration 742 Parasitic Stoiuatiiis 743 La Perleche 745 Gangrenous Stomatitis 745 Mercurial Stomatitis 747 11. DISEASES OF THE TONGUE. Glossitis 748 Acute Glossitis 74g Chronic Sujierficial Glossitis 749 Glossitis Desiccans 75O Lingual Psoriasis 75O Leukoplakia Oris 750 Angina Ludovici 75I III. DISEASES OF THE SALIVARY GLANDS. Hypersecretion 751 Xerostotna 752 Glassblowers' Month 752 Symptomatic Parotitis 752 Chronic Parotitis 75,3 IV. DISEASES OF THE TONSILS. Acute Tonsillitis • , , 753 Chronic Tonsillitis 758 V. DISEASES OF THE PHARYNX. Pharyngitis 761 Acute Pharvngitis 761 Membranous Pharyngitis 763 Chronic Pharyngitis 763 Acute Infectious Phlegmon of the Throat 765 Retropharyngeal Abscess 765 VI. DISEASES OF THE ESOPHAGUS. Esophagitis v 766 Acute Esophagitis 766 Chronic Esophagitis 767 Ulcer of the Esophagus 767 Carcinoma of the Esophagus 768 Rupture of tlie Esophagus 769 Neuroses of the Esophagus 770 Muscular Spasm 770 Paralysis of the Esophagus 771 Dilatation of the Esophagus 771 Esophageal Diverticulum 772 Stricture of the Esophagus 774 VII. DISEASES OF THE STOMACH. Methods of Diagnosis 776 Examination of the Gastric Functions 778 Physical or External Examination 782 Malposition of the Stomach 784 Gasiroptosis 784 Dilatation of the Stomacii 786 Inflammatory Diseases of the Stomach ... 790 Acute Catarrhal Gastritis 790 Toxic Gastritis 793 Diphtheritic Gastritis 794 Acute Suppurative Gastritis 794 Chronic Catarrhal Gastritis 796 Gastric Ulcer 804 Ilour-glass Stomach 808 Carcinoma of the Stomach 813 Hypertrophic Stenosis of the PylorUB 819 CONTENTS. 11 PAGE Benign Cirrhosis of Stomach 820 Hematemesis 8'20 Neuroses of the Stomach 821 Nervous Dyspepsia 8'21 Special Forms of Gastric Neuroses, Characterized by Marked and reculia/- Anomalies of Sensation, Motility, and Secretion 82;i Neuroses of Secretion 82;-> Hyperchlorhydria 82;-> Neuroses of Motility 820 Increased Peristalsis of the Stomach >^2fj Diminished Peristalsis of the Stomach , 827 Neuroses of Sensation 827 Cardialgia 827 Hyperesthesia of the Stomach «29 Anorexia 829 Hyperorexia 830 VIII. DISEASES OF THE INTESTINES. Methods of Diagnosis ^'^^ Enteroptosis "•-'f Intestinal Catarrh • ^•'■'' Diarrheas of Children • ' °43 Acute Gastro-intestinal Catarrh 843 Celiac Disease • 846 Phlegmonous Enteritis • 847 Croupous or Diphtheritic Enteritis • 847 Sprue (Psilosis) • 848 Cholera Morbus 848 Intestinal Infarction 850 Intestinal Ulcers 850 Duodenal Ulcer 850 Follicular Ulcers ■ ■ 853 Stercoral Ulcers • 8-53 Simple Ulcerative Colitis • • 853 Solitary Ulcers 854 Diffuse Catarrhal Ulcer .^ - • 854 Cancerous Ulcer ; Tuberculous Ulcer ; Amebic Ulcer 854 Appendicitis 854 Chronic Appendicitis ^ 865 Typhlitis . . . _ ; 870 Intestinal Calculi • 870 Intestinal Obstruction 871 Stenosis of the Duodenum 877 Carcinoma of the Intestine 877 Habitual Constipation 880 Dilatation of the Colon 883 Coloptosis ■ 884 Intestinal Auto-intoxication 884 Neuroses of the Intestine 886 Secretory Disturbances 886 Mucous Colic o . c 886 Sensory Disturbances » 887 Enteralgia • _ 887 Diminished Intestinal Sensibility 888 Disturbances of Motility 888 Nervous Diarrhea 888 Enterospasm 889 Constipation 889 IX. DISEASES OF THE LIVER. Anomalies in Shape and Position 891 Jaundice 892 Catarrhal Jaundice 892 Other Forms of Jaundice 896 Acute Infectious Cholecystitis ■ 896 Chronic Cholecystitis 897 12 CONTENTS. PA«K Caliulinis ( holorvstitis 898 Chronic ObstriKtioii of the Duct by Gall-stones VIOO Obstruction of tlie Common Duct 900 Ubstrui'tion of tlie Cystic Duct 902 More Keinote Efteots of Gall-stones 902 Carcinoma of the Bile-ducts 900 Stenosis of tlie Bile-ducts 907 Icterus Nei>natortini 909 Vascular (Circulatory) Affections of the Liver 909 Anemia ..." 909 Hyperemia 910 Acute Hyperemia 910 Passive Hyperemia 910 Diseases of the Portal \'ein 911 Thrombosis and Kml)olism 911 Suppurative Pylephlebitis 91l! Stenosis 914 Artections of the Hepatic Blood-vessels 914 Atrophy and Hypertrophy of the Liver 914 Hepatic Inliltrations and Degenerations 91.") Amyloid Infdtr.ition 915 Fatty Liver 917 Fatty Infiltration 917 Fatty Dcgenenition 918 Perihepatitis 919 Acute Perihep.'ititis 919 Chronic Perihepatitis 921 Ab.sce.ss of the Liver 922 Acute Yellow .\ trophy 927 The Liver in Phosphorus-poisoning 929 Cirrhosis of the Liver 931 Carcinoma of the Liver 989 Other New Growths in the Liver 944 X. DISEASES OF THE SPLEEN. Dislocation of the Spleen , 945 Splenic Hyperemia 946 Splenitis 94() Amyloid Degeneration of the Spleen 948 Morbid Growths of the Spleen 949 Rupture of the Sjjleen 949 XL DISEASES OF THE PANCREAS. Acute Pancreatitis 949 Hemorrhagic Pancreatitis 949 Suppurative Pancreatitis 951 Gangrenous Pancreatitis 952 Chronic Pancreatitis 953 Pancreatic Hemorrhage 954 Carcinoma of the Pancreas 955 Other Tumors of the Pancreas 957 Pancreatic Cyst 957 Pancreatic Calculi - 958 XIL DISEASES OF THE PERITONEUM. Acute Peritonitis 959 Peritonitis in Children 963 Localized or Partial Peritonitis 963 Chronic Peritonitis 967 Ascites 970 New Growths in the Peritoneum 975 Carcinoma of the Peritoneum 975 Other Tumors of the Peritoneum 977 Fibromata and Lipomata 977 CONTENTS. 13 PART VIII.— DISEASES OF THE URINARY SYSTEM. I. DISEASES OF THE KIDNEY. I'AfJR Mobility of the Kidney •^"■'^ Circulatory Disorders of the Kidneys !:»H2 Active Hyperemia ' 9*^^ Passive liypv^remia 9H3 Embolic Infarctions *^H.S Special Pathologic States of the Urine *JS4 Plematuria '^4 Hemoglobinuria ^So Albuminuria 987 Proteinuria 990 Indicanuria 991 Pyuria 992 Chyluria 9'.i:3 Choluria 9<)4 Urobilinuria 995 Glycosuria 9'Jo Acetonuria, Diacetonuria, and Oxybutyria 998 Lithuria ■ • 999 Oxaluria 1000 Phosphaturia 1001 Leucinuria and Tyrosinuria 1002 Cystinuria 1002 Various other Conditions 1003 The Nephritides 1005 Morphologic Constituents of the Urine in Eenal Disease 1005 Dropsy of Eenal Disease 1007 Uremia 1008 Amyloid Kidney 1012 Nephrolithiasis 1014 Acute Nephritis ._ 1020 Acute Interstitial Non-suppurative Nephritis 1026 Emulsion-albuminuria 1027 Chronic Nephritis (Exudative) . . ." 1027 Chronic Nephritis (Non-exudative) 1032 Pyelitis • • • _ .... = . 1040 Hydronephrosis 1043 Perinephric Abscess 1046 Cystic Kidney 1048 New Growths of the Kidney 1049 II. DISEASES OF THE BLADDER. Cystitis ' • • 1051 Acute Cystitis 1052 Chronic Cystitis • • lOoo Neoplasms of the Bladder 1056 Vesical Hemorrhage 10'^^ Neuroses of the Bladder 1058 Irritability of the Bladder 1058 Neuroses of Micturition 1060 PART IX.— DISEASES OF THE NERVOUS SYSTEM. Introduction • 1063 General and Topical Diagnosis 1074 I. DISEASES OF THE PERIPHERAL NERVES. Neuralgia 1077 Tic Douloureux 1079 Neuralgia of the Neck and Trunk 1081 Neuralgia of the Extremities \0S\ Neuritis 1084 Progressive Neural Muscular Atrophy 1088 Neuromata 1089 14 CONTENTS. PAfiE Diseases of the Cranial Nerves lUDO Diseases of the Olfactory Nerve ]0i»0 Diseases of the KetiiKi, Optic Nerve, and Tract IdlU Diseases of tlie Motor Nerves of the Eyeball UUt') Diseases of the Fiftii Nerve 1011!) Di.seases of the Seventh or Facial Nerve 1100 Diseases of the Auditory Nerve 1104 Meniere's Disease 1105 Diseases of the (ilosso-pharyngeal Nerve 1106 Diseases of the Pneuniogastric Nerve llOfi Diseases of tlie Spinal Accessorv Nerve 1110 Torticollis ' 1110 Paralysis of the Spinal Accessory Nerve 1112 Diseases of the Hypoglossal Nerve 1113 Diseases of the Spinal Nerves 1114 Diseases of tlie Cervical Plexus 1114 Diseases of the Brachial Plexus 1114 Diseases of the Lumbar and Sacral Plexuses 1117 II. INFLAMMATION OF THE MENINGES. Inflammation of the Dura Mater 1118 C Chronic Hydrocephalus 1190 External Hydroceplialus 1190 Internal Hydrocephalus 1190 Acute Delirium 1192 Senile Dementia 1194 V. DISEASES OF BRAIN AND CORD. Multiple Sclerosis 1195 Pseudosclerosis and Diffuse Sclerosis 1198 Cerebrospinal Syphilis 1198 General Paralysis of the Insane ...... 1198 VI. GENERAL AND FUNCTIONAL DISEASES. Infantile Convulsions 1202 Epilepsy 1204 Migraine . 1209 Acute Chorea 1211 Huntingdon's Chorea 1213 Paramyoclonns Multiplex 1214 Electric Chorea of Dubini 1215 Dysbasia Lordotica Progressiva 1216 Tic 121« General Tic 1218 Saltatoric Spasm » 1219 Paralysis Agitans .... 1219 Other Forms of Tremor 1221 Tetany 1221 Periodic Paralysis 1224 Hysteria 1224 Neurasthenia 1235 Traumatic Neuroses 1242 Psychasthenia 1242 Occupation-Neuroses 1243 Acromegaly 1244 Adiposis Dolorosa 1247 Amaurotic Family Idiocy 1248 VII. VASOMOTOR AND TROPHIC DISORDERS. Angioneurotic Edema 1249 Raynaud's Disease 1250 Erythromelalgia 1252 Acroparesthesia 1253 Neuralgia Paraesthetica ...... 1254 Scleroderma DifFusum 1254 Morphea 1256 Ainhum 1256 Progressive Hemiatrophy of the Face 1256 PART X.— DISEASES OF THE MUSCLES. Myositis 1259 Infectious Myositis 1259 Progressive Ossifying Myositis 1260 Muscular Dystrophies 1260 Pseudohypertrophic Muscular Paralysis 1261 Hereditary Muscular Paralysis 1261 1 6 CONTENTS. PAUK Scapuloliiimeial ur Juvenile Type 1262 F;uiapuloliuniei-.il Type 1202 Myotonia Atrophica 1263 Artlirilif Miis»ular Atrophy 126:> Muscular Atrophies 12tj4 Mus<^u1ar Hypertrophy 1264 Thomsens l>is*.-aW 12t)4 Mvatouia Cou^ienita 1266 Mya>thenia(;ravis 1267 PART XI.— THE INTOXICATIONS; 0BE5ITY; HEAT-STROKE. The Intoxirations 1-68 Alcoholism , 1268 (iinger and Cologne-water Inebriety 1275 Morphinism I'-i^o Plumliism l-~8 Am-nicism l-'80 Mercurialism 1282 FoiMl-int'ection and Ptomain-poisoning 1283 (irain- and Vegetable-poisoning 128o Obesity 128" Ailituisis Tuberosa Simplex 1292 Heat-stroke 1293 Index - - -1299 PART i. INFECTIOUS DISEASES. TYPHOID FEVER. {Enteric Fever; Abdominal Typhus; lleo-typhoid ; Nerven Fieber.) Definition. — An acute infectious disease of which the definitive cause is the specific bacillus of Eberth (bacillus typhosus). It is char- acterized, pathologically, by hyperplasia and sloughing of Peyer's patches and the solitary follicles of the intestines coupled with parenchymatous changes in the principal viscera, and clinically by its gradual onset, peculiar temperature-curve, swelling of the spleen, rose-colored spots, diarrhea, tympanites, sero-reaction, and a liability to certain complica- tions (intestinal hemorrhage, perforation, etc.). The disease is a bacter- emia, and typhoid infection is no longer an anatomic entity, and does not always produce typical typhoid fever. History. — Although known beyond the reach of tradition, typhoid fever was clearly distinguished from typhus at a comparatively recent date. Louis of Paris in 1829 proposed the term typlioide^ but it re- mained for Gerhard of Philadelphia to discriminate typhoid from typhus fever as the result of his own precise clinical observations. His account of the disease was ably corroborated by the writings of E. Hale and James Jackson, Sr. (1838, 1839). Later, Shattuck of Boston and Jenner of London made important contributions to the subject. Shattuck's experiments on typhus and typhoid fevers at the London Fever Hospital in England, and Alfred Still^'s studies of the former affection in Dublin and Naples, and of the latter in Paris, in- creased greatly our knowledge of these diseases. As a result of the labors of the above-mentioned American authors the true nature and identity of typhoid fever were appreciated in America at an earlier day than in either France or England. Briefly, the decade from 1840 to 1850 witnessed the overthrow of erroneous notions concerning the similarity of typhoid and typhus fevers, on the one hand, and the establishment of their points of dissimilarity on the other. Pathology. — The lesions produced by typhoid fever may conve- niently be divided into two groups : (1) Primary lesions, due to the direct effect of the special bacillus upon the lymph-follicles of the intestines, the mesenteric and other lymph-glands, the gall-bladder, and the spleen. Typhoid septicemia without localizing lesions is also a rec- ognized form of the disease. (2) Secondary lesions, due chiefly to the 2 17 18 INFECTIOUS DISEASES. indirect effect of the typhoid bacillus and secondary infection, for the occurrence of -wliich the essential lesions furnish the golden opportunity. (1) The primary morbid changes in the Peycr's patches and solitary glands of tlie intrstincs are divided, usually, into four stages: (a) The Stage of Infiltration. — The lymph-follicles become engorged (hyperplasia), particularly Peyer's glands in the ileum and near to the valve, and, to a lesser extent, in the lower part of the jejunum. Fre- quently the solitary glands in the small intestines, the colon, and rarely the rectum, become similarly infiltrated. In mild cases a few Peyer's patches in the lower part of the ileum arc alone the seat of infiltration and subse([uent changes. The follicles are grayish- white in color, and may project from 3 to 5 mm. or more. Rarely the solitary glands, which vary in size from a mustard-seed to a large pea, also become promi- nent and show a bold attempt at pedunculation. The histologic chan;/es at first consist in a marked dilatation of the capillary blood-vessels, which later are more or less compressed (as a consequence of cell-infiltration), giving to the follicles their whitish, anemic appearance. The cellular elements partake of the nature of lymph-corpuscles. Some of these cells are larger and are epithelioid in character, with ten or more nuclei. The mucosa and muscularis ad- jacent to the glandular structures may be similarly infiltrated. From the eighth to the tenth day the stage of infiltration terminates either in resolution (rare) or in necrosis and sloughing. Tlie infiltrated cells may undergo granular or fatty degeneration, followed by absorption. This process — resolution — during its progress produces pitting of the swollen follicles. In consequence of these minute points of necrosis the plaques now present a characteristic reticulated appearance (plaques a surface reticulde). When resolution occurs accompanied by destruc- tion of the follicles, small hemorrhages may take place into the glandu- lar structure. These hemorrhages may occasion pigmentary deposits in the follicular depressions, giving rise to the so-called " shaven-beard " appearance. (h) Necrosis or Sloughing. — In all save the milder grades of cell- infiltration the hyperplasia of the lymphatic tissue cannot subside before necrosis occurs. The latter process results partly from compression and choking of the blood-vessels by the cell-proliferation, and partly from the direct action of the typhoid bacillus, leading to so-called anemic necrosis. Thus, necrotic crusts (sloughs) are formed, Avhich are gradually separated and cast off. While not all of the glands of Peyer which are the seat of cellular infiltration undergo subsequent necrosis, as a rule those situated in the lower portion of the ileum do, and show the process in its completest development. The depth to Avhich the necrosis extends is quite variable. It may involve only the most super- ficial layers of the mucosa, or it may extend in depth till it reaches, or even perforates, the outer or serous coat ; but usually this work of destruction does not dip below the submucosa or muscularis. The necrosed portions become detached — a process that proceeds from the periphery toward the center — leaving behind the typhoid ulcer. The stage of necrosis and sloughing begins betAveen the eighth and tenth days, and ends on or about the twenty-first day. (c) Stage of Ulceration. — The size and shape of the ulcers corre- TYPHOID FEVER. 19 spond exactly to the necrosed areas in these respects. A singh; gland of Peyer generally presents several ulcers of irregular outline separated by strips of mucous membrane. Rarely, the entire pla(iue is implicated, in which case a large oval ulcer is the result, and at the lower end of the ileum the ulcers often coalesce until they almost encircle the bowel. The ulcers of the solitary glands assume a rounded form. The character of the floor of the ulcer will vary with the character of the intestinal coat which forms its base, though usually it is clean and smooth. The edges are usually irregular, engorged, soft, and frequently overhanging. In the lower segment of the ileum ulcers may be numerous, and in about 25 per cent, of the cases the typhoid ulcers are found in the largo intestines — ^'. e., in the cecum and colon. Hemorrhage usually results from erosion of a vessel — an accident which is occasioned by the separation of the sloughs — but small bleed- ings may take place from the swollen, hyperemic edges of an ulcer. Perforation of the bowel occurs in a small percentage of cases (about 6 per cent.). J. A. Scott has pointed out two varieties : (a) Circular, pin-point in size, due to a perforative necrosis (common), and {b) a large aperture (as the result of extensive necrosis) ranging in size from the finger-tip to 3 cm. in diameter. The perforations may be multiple, though they are usually single. The small, deep ulcers are more apt to lead to complete perforation than larger ones, and the site of the orifice is usually in the course of the lower third of the ileum. The lesions of peritonitis invariably follow. Perforation of the large boAvel is exceed- ingly rare. Exceptionally, the appendix is the seat of ulcer. Localized abscesses have been found under these circumstances. During the stages of necrosis and ulceration a catarrhal state of the mucosa of the intestines exists. The diarrhea which usually accompanies typhoid is ascribable, in part at least, to the catarrhal state of the large bowel. (d) Healing follows promptly upon the formation of the ulcer. At first a granular tissue covers its floor. The mucous membrane is replaced, including the glandular elements and epithelial layer, and, as in the stage of necrosis and sloughing, so the healing process advances inward from the border of the ulcer. Indeed, it is this process that dislodges the necrotic crust. Occasionally, ulcers are seen extending in one direc- tion while healing in another. The cicatrix formed by the healing of an ulcer presents a smooth and often pigmented surface. The stages thus far described do not, strictly speaking, follow one another, since two or more may be illustrated at once by a group of ulcers occupying the intestine. When death occurs during a relapse fresh ulcers are observed by the side of those partially healed. The Mesenteric Q-lands. — Changes in the mesenteric glands occur simultaneously with those in the intestines, and those situated opposite to the lower third of the ileum, the portion of the bowel showing the most extensive ulceration, are most profoundly involved. Hyperemia, and later swelling due to cell-infiltration, are among the earliest changes, and correspond with the lesions noted in the intestines [vide supra). The mesenteric glands exhibit great variations in size, ranging, as they do, from that of a pea to a hen's egg. Their color appearance is a gray- ish red. Resolution commonly occurs, but, if it does not, then necrosis of the central portion (due, most probably, to the same causes that 20 INFECTIOUS DISEASES. produce necrosis of the intestinal lymph-follicles) occurs. Le Conte* believes that perforation of the capsule of the trlands, when it occurs, is due either to the presence of the staphylococcus or streptococcus or to thrombosis of the larger vessels of the mesentery outside of the glands. Still other glands become hyperemic and swollen (retroperitoneal, bron- chial) ; but these usually tend toward resolution. T/ic S/'lt'e)i. — With rare exceptions the spleen becomes enlarged in typhoid fever. At first hyperemic, the tissue then grows soft and gran- ular, and at times is almost diffluent on section. Infarction is not a rare occurrence and may lead to suppuration. Keen has searched the litera- ture and found only 9 cases of abscess. In rare instances, either spon- taneously or as the result of injury, the spleen may rupture, and the records of 2000 post-mortems at the Munich Pathologic Institute furnish 5 cases. Perisplenitis rarely occurs (vide Spleno-ty|)lioid, p. 45). Gall-bladder. — The gall-bladder may show catarrhal inflammation, and rarely a croupous, diphtheritic, or ulcerative inflammation leading to perforation. Westcott has tabulated 30 cases of typhoid infection of the gall-bladder that resulted in perforation. Chiari's ^ and Fle.xner's^ figures show that typhoid bacilli are found in the gall-bladder in more than 50 per cent, of the fatiil cases. Chiarolanza* found that typlioid bacilli in- jected intravenously reached the gall-bladder in 17 out of 23 cases, enter- ing through the capillaries of the mucosa and submucosa. ( Vide Acute Infectious Cholecystitis.) Mallory has shown that the typhoid bacillus produces a toxin which causes proliferation of the endothelial cells along the line of absorption from the intestines, both in the lymphatics and blood-vessels. These cells increase in size and number, and manifest ])hagocytic properties. (2) Secondary Lesions due Chiefly to the Continued Fever and to Secon- dary Infections. — The lesions in other organs are of subsidiary importance, and are, for the most part, secondary in nature, though we cannot draw a sharp line of distinction between these and those that are primary. In the kidneys, pleura, pharynx, larynx and tonsils primary implantation of the typhoid bacillus may rarely occur (vide infra). The liver early becomes hyperemic, and later is softer and paler than is natural. Handford has described necrotic areas, and Wagner minute lymphomata. Rarely infarction and abscess occur. Mesenteric abscess and perforative appendicitis may be followed by pylephlebitis. The micro- scope reveals parenchymatous and granular degeneration. The cells con- tain an abundance of fat, whilst their nuclei have lost, in great part, their outline. The kidneys, like the liver, exhibit parenchymatous degeneration. They are somewhat pale-looking, are cloudy on section, and slightly swollen, and under the microscope granular and fatty degeneration of the epithelial cells of the convoluted tubules is observed. More rarely the lesions are those of acute hemorrhagic nephritis. Small areas of round-cell infiltration may develop late in the course of typhoid, and these may present an appearance similar to lymphomata or may undergo softening and suppuration, giving rise to miliary abscesses. The mu- cous membrane of the pelvis of the kidney is not infrequently the seat of a mild grade of catarrh, and, rarely, of diphtheritic inflammation. ' Jcmr. Am. Med. ^.s.sor., Oct. 22, 1904. ' Pr,ig. med. Woch., 1903, No. 22. ■' Johns Hopkins Hosp. Reports, vol. v. * Zlsohr./. Hygiene u. InJ'ectionskr., 1908, Ixii., 1. TYPHOID FEVER. 21 Typhoid cystitis is still more common, and the bladder may also be the seat of diphtheritic inflammation. Rarely orchitis is encountered. On making cultures from sections of the kidneys not a few observers have been able to demonstrate the presence of the specific bacillus of typhoid. In the lungs are found morbid lesions in nearly all cases of typhoid fever, and belonging to the essential pathologic processes is bronchitis, due to a congested and catarrhal state of the bronchial mucous mem- brane. The lesions of lobular pneumonia present a complicating con- dition in many instances ; those of lobar pneumonia also may be present, though less commonly. The so-called hypostatic congestion is often found, but is, I think, less frequent than is supposed by many authors. Embolic infarctions, having their origin in thrombi occupying the right side of the heart, are sometimes present. Gangrene may also occur. Pleurisy is rarely met with. It is generally of the plastic vari- ety, although empyema occurred in nearly 2 per cent, of the Munich cases. The initial lesion may be pleuritic. ( Vide Pleuro-typhoid, p. 45.) The larynx and the pharynx may manifest changes. Ulcers have been observed on the epiglottis and posterior wall of the larynx, and I have more than once seen them on the pharynx (jPharingo-typhoid). When situated in the larynx they may extend in depth till they reach the perichondrium, causing perichondritis, with or without edema of the larynx. Typhoid bacilli have been found in the ulcers (Eichhorst). Catarrhal, or even croupous, pharyngitis may occur, and a swelling of the follicles of the pharynx and base of the tongue is to be noticed in many cases. True aphthous changes, affecting the mouth and pharynx, may be present as a secondary event. The tonsils may present ulcers (Tonsillo-typhoid.) The mucosa of the stomach is sometimes congested, and may be the seat of typhoid ulcers, although this is rare. Perito7iitis is always found in fatal cases in which the bowel has been perforated. The condition is a general one, save in the rare instances mentioned below, and there is usually much fibrino-purulent effusion present. Diffuse peritonitis may be present without perforation, and results sometimes from a localization of the typhoid poison in the peri- toneum, from rupture of suppurating mesenteric glands, and from direct extension of intestinal inflammation to the peritoneum. The heart may be the seat of morbid changes. Acute endocarditis may be a very rare complication, while pericarditis occurs relatively more often — viz. in 14 of the Munich post-mortems before mentioned. Myocarditis is a common event, the cardiac muscle exhibiting parenchy- matous and, less commonly, hyaline degeneration, and the latter change sometimes leads to sudden rupture of the muscular fibers, with a fatal result (myocardite segmentaire). It is, however, a significant fact that in many instances, even of the severest type, the cell-fibers may show slight, if any, noticeable change. Out of 48 cases, 16 showed granular or fatty degeneration, and 3 a proliferative endarteritis in the small ves- sels (Dewevre). The arteries have, in a number of instances, been found to be the seat of two forms of arteritis (Barie) : {a) Acute obliterating arteritis and {b) partial arteritis. These conditions may affect the smaller ves- OO INFECTIOUS DISEASES. sels. particularly those of the heart, but they occur most commonly in the arteries of the lower extremities. Tiiron'ibi are found in the right chambers of the heart and in the veins — most fretjuently in the femoral, and less often in the cerebral, sinuses. According to Flexner, thrombi may be caused by auto-agglutination of the red cells. The vohmtarji muscles undergo parenchymatous and, occasionally, a hyaline change, though this is not a feature ])eculiar to typhoid feVer. The latter form of degeneration does not aftect the ^vhole muscle, but only certain libers, and, as a rule, the recti abdominis, the diaphragm, the adductors of the thigh, and the pectorals are the seats of the lesion. The parts affected are pale and possess a grayish, waxy lustre. Histolog- ically, the process implies the transformation of the muscular fibers, and especially the cement substance, into a homogeneous, pliable mass. Regen- eration of the fibers occurs during convalescence. Hemorrhages into, and rarely abscesses in, the intermuscular tissue occur. The nervous system presents no gross lesions, if we except menin- gitis, the latter occurring as a complication ; but it is exceedingly rare, having been present in only 11 of the 2000 Munich cases. In a few instances large cerebral hemorrhages have been met with, but these are apparently coincidental, while capillary hemorrhages into the cortex may be numerous. Meningeal hemorrhages may also occur. Slight edema of the cerebral cortex has been noted. The peripheral nerves are not infrequently the seat of parenchymatous change, with or with- out local neuritis, and the ganglia of the trunks of the vagi exhibit an inflammatory change w hich Levin believes is the cause of the laryngitis, pharyngitis, pharyngolysis, and arrhythmia sometimes observed. The hlood shows few important alterations. The red blood-corpuscles are relatively increased during the febrile period and markedly dimin- ished during convalescence, but the great loss of water during the former period and a reabsorption during the latter will explain these interesting facts (Henry). Leukocytosis is absent {vide infra, p. 40). Ktiology. — Bacteriology. — The bacterium which is the specific cause of typlioid fever was discovered by Eberth, whose researches were later confirmed by the investigations of Gaffky and others. G-eneral Characters. — It is a short, thick bacillus, about three times as long as it is broad, with rounded ends (Fig. 1). It is motile, due to the presence of cilia, and when stained, exhibits vacuolations that have been mistaken for spores. It is easily stained with all the anilin dyes. Cliaracteristic Growth. — Upon gelatin plates it develops in grayish translucent colonies with irregular borders and ridged surfaces. Upon agar the growth is not characteristic ; upon the potato, especially if it has been rendered slightly acid, it forms a perfectly transparent growth that is only evident as a slight apparent increase of moisture upon the surface, and as offering a greater resistance to the point of the needle when scraped across it. It neither coagulates milk, li(juefies gelatin, nor produces indol. The organism never forms spores. Moreover, the bacillus has no greater powers of resistance than the ordinary bacteria. Experimental T3nplioid. — Inoculated into lower animals, the bacillus frequently causes fatal results without producing the lesions characteris- tic of typhoid in iiuman beings, although occasionally typical typhoid ulcers have been found. The susceptibility of lower animals, though nor- TYPIIOW FEVER. 23 I i "-- ■' V Fig. 1— Typhoid bacilli with flagella; X 1000. mally slight, can be increased by preliminary injections of saprophytic bacteria, this result having been obtained by Alessi when he exposed animals to the gases produced by _^ putrefying matters. It has been .^^^ *** "^v,^ found that the ulcerative intestinal lesions produced by the inoculation of the bacilli or their toxins in large quantities into the blood of rabbits may also be caused by other bacteria, including the bacillus coli commune. Metchnikoff,^ however, has adminis- tered foods contaminated with weak dilutions of bacillus-infected feces to chimpanzees ; they contracted char- acteristic typhoid fever. Usually, in making a hacteriologic diagnosis the typhoid bacillus is to be differentiated from those organisms that morphologically resemble it and present almost identical characteris- tics upon various culture-media, such as the bacillus of Shiga, paracolon bacilli, and the bacillus coli communis. These organisms can now be separated from the bacillus of Eberth, bacteriologists having pointed out the fundamental differences between these related forms. Smith and Tennant, in a study of the 1898 epidemic of typhoid in Belfast, failed to find typhoid bacilli in the water-supply, but were able to isolate vari- eties of the bacillus coli communis. The real poison of typhoid fever is most probably a ferment (?) secreted by the bacillus — typho-toxin ; and Brieger has extracted the latter agent, finding that it produces the fever, nervous symptoms, and the other manifestations characteristic of the affection. Distribution in the Body. — The bacillus has been found in the intes- tinal tract, the lymph-glands, the contents of the intestine, the spleen, the liver, the gall-bladder, the rose-colored spots, the blood, and the bile. The bacillus typhosus is demonstrable in the stools (in about 50 per cent, of the cases), the urine (Wright and Semple), the sputa, the vomita, milk, and the sweat. The bacillus typhosus is most abundant in the duodenum and jejunum; it is practically constant in cultures made from the mucosa of the stomach (Jiirgens). Less commonly it has been found in foci of suppuration and in exudations (pleural, endocardial). The Bacilli Outside the Body. — The bacilli cannot maintain a perma- nent existence outside the human body. From time to time, however, the conditions indispensable to the growth and development of the ty- phoid germs prevail, and corresponding with such periods of time more or less extensive epidemic outbreaks of the disease may occur. It is known that the typhoid bacilli may retain their vitality for from seven to fourteen days in water, disappearing from the same on account of the presence of saprophytes ; but an epidemic or an endemic of typhoid fever implies persistent contamination of the drinking-water. Multiplication of the bacilli may take place in water, in milk (very rapidly), and in the soil, where they preserve their vitality under favorable conditions (for eleven months — Robertson). Freezing does not kill them, as they may ^ Jour. Amer. Med. Assoc, April 16, 1910. 24 INFECTIOUS DISEASES. live in ice for several months (Prudden). Thej have been discovered in infected Avater, but they are thorouirlily destroyed by boiling. Predisposing Causes. — {a) Q-eographic Location. — In temperate zones typhoid fever prevails constantly to a greater or less extent, and is the most important infection. It has been shown in recent times to be comparatively common in the tropics (c. g., India) as "well as in many cold latitudes (Iceland. Norway). It exhibits an appalling prevalence and fatality in armies in the field. For example, in the Spanish-American war one-fifth of the soldiers in the national encampments suffered from the disease, with 1580 deaths ; while in the South African war the British army lost 7991 men from typhoid fever and only 7582 died of wounds. {l)) Seasons exert a decided influence upon the frequency of the occurrence of typhoid. According to the statistics of Murchison, Bart- lett, Osier, Hirsh, and others, the time of greatest liability to typhoid fever is during the late summer and the early autumn (August, Septem- ber, and October). The remaining summer and autumn months yield a relatively larger number of cases than the winter and spring : again, in winter more cases are met with than in the spring, which furnishes few- est number of cases. After hot and dry summers typlioid fever is espe- cially apt to be prevalent, and, according to Baumgarten, a relatively large amount of dust in the atmosphere may disseminate the typhoid germs. Epidemics, however, may occur at any season. [c] Condition of the " GS-round Soil." — Pettenkofer and his disciples contend that when the standing water in the soil reaches a high level fewer cases occur, and when it falls to a low level or below the mean height the cases become more numerous. This dictum, however, has not as yet been conclusively proven Avith reference to many localities. The poisoned foci, may be more eifectively drained by the springs and streams, since the latter contain an increased quantity of solid matter when the ground-water is low. Epidemics of typhoid fever, however, occur repeatedly without regard to the condition of the ground-water. {d) Age. — Typhoid fever may occur at any age. It is, however, espe- cially frequent among young, robust individuals between the ages of fifteen and thirty j-ears. Later in life it becomes progressively less fre- quent, though cases have occurred at or beyond the seventieth year. Young children are not exempt, and cases among them are of rather frequent occurrence, if we except those under one year of age. When contracted late in pregnancy typhoid may be congenital (Freund and Levy). The typhoid bacilli have been successfully cultivated from the fetus, and Moss^ and Fraenkel ^ have confirmed the observation that the Widal test can be obtained from the placenta and blood of the fetus. (e) Sex probably does not aff"ect the degree of liability in typhoid. (/) Individual Predisposition. — This may be acquired or inherited. An instance of acquired predisposition is to be noted in the great sus- ceptibility which exists among persons who have recently moved from rural districts to cities. Thus, Louis found "that of 129 cases, 73 had not resided in Paris over ten months, and 102 not over twenty months." Defective ventilation, filth, overcrowding, and imperfect drainage increase susceptibility. There is evidence to show that the disease is on tlie in- crease in rural sections. Predisposition to typhoid may also be inherited. Most persons, however, enjoy natural immunity from the affection. * Joum. des Practiciens, Jan. 28, 1899. TYPlIOll) FEVER. 25 (//) Intestinal Catarrh. — Cases of influenza with catarrh of the gastro- intestinal tract may be followed by typhoid fever. (A) Nervous Influences. — Great miental excitement and overwork. Immunity. — The occurrence of typhoid fever confers an approximate, though not an absolute, immunity against subsequent attacks. In this connection two questions present themselves for ronsidoi'iitiou : (1) What are the methods of conveyance of the poison into the body ? IsoLated cases and epidemics of typhoid fever are alike to be attributed to antecedent cases of the disease, and this fact presupposes that the bacillus of typhoid leaves the body of the sufferer. It does so in the stools, the urine, and occasionally in the vomitus and sputum, i'ark states that examinations, both in Europe and America, show that fully 2 per cent, of persons who have had typhoid fever are typhoid bacilli carriers. Hutchinson's^ investigations show that 8.3 per cent, of typhoid fever patients are excreting the causal organisms when discharged from the hospital, while 6.3 per cent, of these do not continue to be infective for more than one month from that time. A few of them pass infected urine, but most, infected feces. During the declining and post-febrile stages the urine is probably the most dangerous excretion containing bacilli. Finally, one in every five hundred healthy adults who have never knowingly had typhoid fever is a carrier through contact with in- fection. It would seem that there are several periods of " effectiveness " and "ineffectiveness" (the latter coinciding w'ith the early months of the year) of typhoid bacilli carriers. According to the Germans, the most common soui'ce of the bacillus is a patient or chronic carrier, the latter causing about 10 per cent, of the cases. Conradi claims that four times as many women as men become chronic carriers. Typhoid bacilluria may persist for a long time after apparent recovery. The dejecta and the urine, which are the principal sources of infection, may be conveyed to well persons by — (a) Infected Drinking Water. — In most instances the poison is trans- mitted from those affected wdth the disease to those in health through the drinking-water supply, as shown by many epidemic outbreaks in which the mode of origin has been traced. Wells, storage reservoirs, springs, and rivers may become contaminated and cause an epidemic. In the spring of 1885 a most deplorable epidemic occurred in Plymouth, Penna., a town of 8000 inhabitants. At first the nature of the affection was not recognized, and before it ceased to appear 1200 persons were affected, with 130 resulting deaths. This epidemic was investigated by Shakespeare and L. H. Taylor, and was found to have arisen from a single case of typhoid occurring in a house on a hill which sloped toward the water-supply of the town. This patient was ill during January, February, and March, while the ground was frozen and covered with snow, upon which the dejecta were thrown. On March 25th there was a considerable rainfall, followed by a sudden thaw, and the water ran at once through the various surface channels into a brook, which in turn emptied into the reservoir. On April 10th other cases of the disease appeared, and those citizens who obtained their water from other sources than the infected reservoir escaped. The recent outbreaks at Maidstone ^ Medical Chronicle, Jan., 1912. 26 INFECTIOUS DISEASES. (1897) and at Butler. Pa. (1903), are equally convincing and instructive as regards the causative iniluence of a contaminated water-supply. (h) Infected milk fre([ucntly conveys the poison. It may become pol- luted by water which has been used either to Avasb the cans or for diluting purposes, or the bacilli may be transferred to milk by the unclean hands of the milker. iS^umerous instructive epidemics, originating in infected milk, have been reported. E. B. Bigelow has reported a milk-borne ejudemic which was traced to one male bacillus-carrier, and involving 20-t cases. The occurrence of numerous cases among children suggests contaminated milk. Solid forms of food (salads, celery, fruits) may be contaminated by infected water or dust or by the fingers of the nurse or the patient. During the late Spanish-American Avar the typhoid bacilli may have been conveyed from the latrines directly to the victims or to the kitchens and mess-tables by swarms of flies. Vaughan^ confirms this view, and has also observed that " officers w^hose mess-tents were protected by means of screens suffered proportionately less from typhoid fever than did those whose tents were not so protected." He believes that fecal matter containing the typhoid germ may adhere to the fly, and be mechanically transported, and further suggests the possibility of the bacilli being carried in the digestive organs of the fly, and deposited with its excrement. H. W. Conn has shown that oysters while being ftittened or freshened may become infected with water polluted by sewage, and Foote has shown that the typhoid bacillus will not only retain its vitality in the salt water in which the oysters are fed, but that it will live even longer in the oyster itself. Phillip Mai'vel has reported a small epidemic (comprising a total of 72 cases) due to infected oysters that occurred at Atlantic City during the months of August, September, and October of 1902. Newsholme" attributed one-third of a total of 56 cases of typhoid to the eating of raw shell-fish. (c) Contagion or Direct Transmission. — This necessitates direct con- tact with the typhoid stools. It affords a ready explanation for contrac- tion of the disease by internes and nurses who attend to the stools, the bed- and the body-linen of the patient, and by laundresses, who are affected with great relative frequency. Out of 1500 cases treated in the Johns Hopkins Hospital, 31 were contracted in this manner (Futcher). (d) " Ground-soU." — The typhoid poison which leaves the body must undergo development in the ground-soil before it is potent to cause the disease in others (Pettenkofer). The former great prevalence of typhoid in Munich was due to pollution of the soil (Childs). (e) Sewer-gas. — The recent researches of Bergey and of Abbott show that sewer-gas, ^^cr se, cannot cause typhoid fever. (/) Sand-storms. — Tooth states that sand-storms may contaminate articles of food with the bacillus. (^) The hands of chronic carriers may be the medium of transference. Courmont^ claims that dogs are typhoid bacilli carriers. (2) Through what channel or channels does the bacillus enter? (a) In the vast majority of the cases the bacilli are swallowed. In the stomach they meet with the acid gastric secretions, which often destroy them. The alkaline juices of the small intestine, however, furnish every condition necessary for their further growth and development. They 1 Phiia. Med. Jour., June 9, 1900. « 5,.^ ^/g^ j^;^,.^ june g, 1895. ^ Bulletin de P Academic de Medecine, Paris, June 28, 1910. TYPHOID FEVER. 27 penetrate the mucosa and attack primarily tlie solitary follicles and Peyer's plaques. Next they invade the mesenteric glands, reaching the circulation, spleen, liver, and other organs a little later. (i) The possibility that the bacilli may reach the blood-stream through the respiratory organs must be conceded ; and hence the added possi- bility that they may set up initiatory lesions either in the tonsils, lungs, or pleura, passing thence into the circulation, must also be granted. Yaughan inclines to the opinion that the bacillus may be inhaled in the infected dust by troops on the march. Complete desiccation, however, soon destroys the typhoid germ. Primary localization of great severity may also occur in the kidneys and cerebrospinal meninges, giving rise to special clinical varieties {vide infra). {c) Typhoid Septicemia. — By this is meant a general infection with the bacilli without localized lesions. The special mode of infection is not clear. Brion and Kayser * conclude from extensive bacteriologic and clinical studies that typhoid fever may start as a lymph-and-blood aiFec- tionr (possibly entering by way of the tonsils). {d) Typhoid infection predisposes the system to secondary infections with various bacilli (streptococcus, staphylococcus, bacillus coli commune, pneumococcus). The portals of entrance for these micro-organisms are various (e. ^., respiratory tract, lymphatics). Clinical History. — I. Incubation. — The average duration of the period of incubation, or the time between the introduction of the poison into the system and the appearance of the first active symptoms, ranges from ten days to three weeks ; this interval may rarely be shorter, although oftener it is somewhat longer. During this period the patient may experience no deviation from health, but in most cases there are prodromal symptoms, such as languor, loss of appetite, nausea, headache, neuro-muscular pains in the back and limbs, a disinclination to exercise, etc. These symptoms last from a few days to a week or more. 11. General Symptomatology and Course. — On account of the peculiar temperature-curve in typhoid fever its course falls naturally into three periods — the stage of development ; the acme or fastigium (correspond- ing to the height of the disease) ; and the stage of decline or deferves- cence. It is convenient to speak of the various weeks of the affection when referring to these stages. Thus, the first week represents the stage of development {stadium incrementi), the second and third weeks (in cases of average severity) the fastigium, while the fourth week in the typical form (the third week in mild cases) corresponds to the third stage {stadium decrementi) of the disease. (a) Stage of Development. — The invasion, as a rule, is gradual, the symptoms being chilliness and feverishness, with increase in the severity of the prodromal symptoms. Typhoid fever rarely starts in with a dis- tinct rigor. At or about this time nose-bleed may betray the nature of the disease. The symptoms just described are quickly followed by a prostration sufiiciently well marked to compel most patients to take to their beds. From this latter event is usually dated the onset of the aifec- tion. It is safer, however, to regard the time of occurrence of the above- mentioned symptoms (elevation of temperature, with its attendant discomforts) as the time of onset, since many patients continue in their avocations for days after the first symptoms appear. The onset may be ^ Deutsches Archivf. klin. Medicin, last indexed, vol. xlv., p. 1S32. 28 INFECTIOUS DISEASES. marked by symptoms resembling influenza (Bunce). In my experience ciises in which general pains, including backache or slight pharyngitis, are seen at the onset are not rare. Again, invasion may be usiiered in by various nervous symptoms {e. g., convulsions, in children) or marked pulmonary features, especially those of severe bronchitis. With the progress of the initial period the symptoms usually increase in severity ; the fever rises day by day, terrace-like, till, at the end of four or five days, the second stage, or fastigium, is reached. Anorexia, thirst, and headache are often marked, the skin hot and dry to the feel, the tongue coated, the sleep disturbed, and constipation is generally present. The patient may complain of sensations of chilliness alternat- ing with flushings of heat, and there is a slight cough. The puhe is somewhat quickened (from 90 to 110 per minute) and is full. The pht/sical sig7is are not prominent. The abdomen is often slightly distended and tender; the spleen is found to be swollen. The associa- tion of splenic enlargement and dry bronchitis point to this disease. (b) Fastigium, or the second stage, commences on the fourth or fifth day, and lasts, in typical cases, about two weeks. During the first week of the fastigium (the second of the disease) the general symptoms become more marked. Thefei'er remains high, the evening temperature usually reaching 103° or 104° F. (40.° C), and exhibits the continued type. The pnlse is accelerated, but not dicrotic. The headache disappears, and mental dulness and slowness are conspicuous, but there may be mild delirium, particularly at night. There is a dry cough and the physical signs indicate more or less extensive bronchitis. The tongue is coated and may become dry, the belly is somewhat swollen and tender, and diarrhea replaces constipation. The spleen is decidedly enlarged, and about the eighth day of the disease a number of roseate spots appear on the trunk. During the latter part of this week a grave or even fatal condition may be developed as a result of intense nervous or pulmonary symptoms, intestinal hemorrhage, or perforation. During the second week of the fastigium (the third week of the dis- ease) the marked general symptoms already noted persist in severe types of the aflFection. The j^ulse varies from 110 to 130, and is now often dicrotic, while the temperature may approach the remittent type. In addition this period furnishes most of the untoward complicdtions (lobu- lar pneumonia, hypostatic congestion of the lungs, intestinal hemorrhage, perforation, peritonitis), and in the absence of serious local complications grave general conditions may be presented. The duration of this stage varies with the severity of the type. (c) Stage of Decline or Defervescence. — At the end of the second stage, and about the twenty-first day of the disease, in favorable cases the fever begins to decline, and with it the other general and local .symptoms gradually disappear. This is followed by true convalescence. In protracted cases, however, the fourth week of the disease may present much the same clinical indications as the third, and these may even be intensified. Frequently an aggravated type of the typhoid state is now superadded, the symptoms being stupor, muttering delirium, subsultus tendinum, a rapid, feeble pulse, a dry, brown tongue, marked diarrhea, greatly swollen belly, and an involuntary discharge of feces and urine. Inflammatory complications may add to the perils of the condition. In not a fcAv cases the febrile period is prolonged into the fifth, and TYPHOID FEVER. 29 rarely into the sixth or even the seventh week, and the fever observed when defervescence is retarded presents an irregular type. 1 have else- where reported a case in which it lasted not less than seven weeks.' About this time recrudescences and relapses may occur in typical cases. Different epidemics of typhoid fever, however, vary so greatly in their clinical characteristics as to make it impossible to include all cases in any outline of the course of the disease that might be attempted. III. Chief Clinical Features in Detail. — (a) Course of the Fever. — During the stage of development (the first four or five daysj the temper- ature usually rises in " step-ladder " fashion. The evening exacerbation is on each day from a degree and a half to two degrees higher than on the preceding, and the same is true of the morning remissions. A glance at the temperature-charts (Figs. 2 and 3) will show that the morning remissions touch a level from one-half to one degree lower than the preceding evening registers. This stage is rarely met. When the fastigium is reached, the evening temperature may be 103°, 104°, or 105° F. (39.4°-40.5° C), and is usually thus main- tained, with the slight morning remissions. The tide-like character of fever-curve seen in the initial period is absent. Often, during the latter half of the fastigium (the third or fourth week of the disease) the morning fall of temperature becomes decidedly greater. According to my own observation, the height of the fastigium is reached a day or two after its onset or at the end of the first week of the affection. Marked morning remissions are a favorable indication. On the other hand, and contrary to the general rule, the morning temperature may be higher than the evening, forming a somewhat unfavorable symptom. Morning temperatures of 104° F. (40° C.) or over are indicative of a serious type. In many instances of mild grade the evening temperature at no time exceeds 103° (39.4° C), but oscillates between 100|° and 102|° F. (38.1°— 39.2° C). In cases of average intensity the morning remis- sions touch 102°-102f° F. (39.2° C), and the evening exacerbations reach 104-1 04f° F. (40.3° C). When the temperature rises above 105° F. (40.5° C.) hyperpyrexia exists. Ampugnani made studies of hourly charts from 200 cases of typhoid fever, and found the maximum tem- perature to occur between three and six o'clock in the afternoon, and the minimum between four and eight o'clock in the morning. The duration of the fastigium exhibits a wide range and is dependent upon a variety of conditions — e. g. the degree of mildness or severity of the type, the presence or absence of complications, etc. In cases of a mild character it lasts from a few days to one week ; in cases of average severity, from ten days to two weeks; in the severest forms, from two to four weeks. In typical cases the end of the fastigium marks the beginning of the last stage (that of defervescence), and during this period the tempera- ture falls by lysis. Measured by days, it declines by degrees, both the morning and evening temperatures being often one or two degrees lower than on the preceding day. Thus is formed a more or less regu- lar step-like line of descent. To this general rule there are two nota- ble exceptions : From the beginning of the period of defervescence the morning remissions may strike the normal point, while the evening ex- ^ "A Case of Typhoid Fever; numerous Intestinal Hemorrhages, the Amount of od Lof Recovery, Blood Lost being Seventy-eight and one-half Ounces ; and Obstinate Vomiting, with r," International Clinics, vol. i. 5th series, April, 1895, p. 29. TEMP. CEN" riGRADE ^ ■ i :'■''■ 5:J"-: : -. - ^ Ss - _ 1- , ; ,:,'''!' r". i ! 1 -??■ '^ M= 3T T u> 1 (±ii 1 H= ' s^ _,S3:4±±. _ _ _ _ » liJ X --S.X'^W' 1 o. a [ 1 HrtllSiJ I — :-— :-S::S±: V 1 111 1 ■ ;a - - -g,. 'c"" "1 rpri m ' D _ ^ ■"- ^ - - - - -U 1 1 J^^ ^ ■ 1"* = ■ Q - - - -t- -44-4- - ~^~-'-- » 111 TTTT "SSr^ "PTt >• ■ i 'r^, ' JJTr=H z 1 !-=d"Jt u 1 1 i=» o ■*=HrTLLL uj irfci — in •Ha. — :...s:' .- rSiiiiS":::" uiiiii'iii;:;" " " "" ^ rrpH Jt _ <— ,. ■<1- n CN — o o o o ll3HN3aHVd o a\ -1 CO -t dwii 1 "^ TEMP. CE — O Oi ^ t fO MTiGRADE 00 r^ iC - -- ZS- - $::..: ; : 1- . -- . - -- _ :: B = :"T'"" '" '" a (/5 - -- "';; j2 i ■^~--» ~~s LU - - h- _ . - i :^ - - .- 1 1 ^ ^ ■ 5-1 : _: : "' ' r =^ X :::!::::- UJ n^^~ _ 1 1 u . 5 :::::::::::::::^g_ __^-rf=P= X. X ^SZ-L .Ui^ 1 : ' i O - - -^ —-T-^^— '- jT - u. ■ - J ' .-^^^J 1 j ^ . _]Xx.,_L •^ ' ■- -J 1 w ^ J ! _ ~^'r'»^ i ■ : 1 1 . .-. . .: :::::: s UJ ^^^ ■ ' ; . 3-] 1 3 Q -^ ;±==- T .. = - = = ^ £ -IT ;S^ TT"' h- = ^j;_.4_.,. __XL.--^ (■) ' ' ~ "f 1 1- -=:-| 1 III ^ -^ ^ ^ : -- ::!:;!":" : 55 : :::::: ^ -=?=: ~ "- 1 1 I 1 1 I 1 IT) T^ ro CS o o o o 1 113HN3aH — o o> -i 00 * O O C3l 1 Ol ^ vd^iAisr f "^ TYPHOID FEVER. 31 acerbations become less and less marked, until they also touch the normal. Under these circumstances the temperature-curve resembles somewhat that of the quotidian intermittents, and rarely the tertian fever-curve obtains. In comparatively rare instances the morning tem- perature shows a deeper remission on each successive day, while the evening temperature remains high for several days, when it also declines. This period lasts from one week to ten days — a longer time than the initial stage with its ascending type of fever. In the severe and protracted forms of typhoid fever there occurs between the second stage (fastigium) and the tliird stage (defervescence) another, to which Wunderlich has given the name of the " ambiguous period." This lasts from a few days to a week or more, and is charac- terized by a striking diurnal range of temperature, with marked irreg- ularities. It is probable that it is sometimes produced by an auto- intoxication. Abnormal Course of the Fever. — The pyrexial peculiarities yet to be pointed out are less usual than the foregoing, although of sufficient frequency of occurrence to demand a brief description. The first stage varies but little from the regular course described above. A sudden elevation of temperature, however, is seen in those cases that begin with a severe rigor, accompanied by pneumonic, catar- rhal, and gastro-intestinal symptoms. Pepper and Stengel have reported seven cases with acute onset, and Moore, of Dublin, states that the whole course (since 1889) has become more typhus-like than formerly. In the lightest forms the fastigium may be practically absent, defervescence setting in upon the first day of the fastigium. There is also a class of cases in which, throughout the greater part of their course, the fever is distinctly intermittent or remittent, and in which careful blood-examination fails to disclose the plasmodium malarice. The same form of temperature-curve is seen in those rare instances of typhoid fever which occur in subjects previously infected with malaria. These two classes of cases run a favorable course as a rule. Sudden deep temporary drops in the temperature may occur during the fastigium. (1) This may take place during the early part of the fastigium without obvious cause. (2) Intestinal hemorrhage almost invariably produces a sudden, and sometimes a great, fall of tempera- ture. Osier has reported a case in which a drop of 10° F. (5.5° C.) followed melena. The blood does not appear in the evacuations of the patient for six to twelve hours or more after the temperature has begun to fall ; and hence a critical decline of temperature during the latter part of the second and the third week of the disease suggests that hemor- rhage has probably taken place. (3) The occurrence of jjeritonitis is marked by a sudden and considerable fall of temperature. (4) In the female, abortion or premature delivery occurring in the course of typhoid fever produces a decided lowering of the temperature. (5) Collapse of the circulation sometimes occurs Avith a notable remission of temperature — an ominous association of events, and one which I observed in two cases occurring in females in the Medico-Chirurgical Hospital. In one of these cases two such periods of collapse occurred, and in the other three, though both finally recovered under prompt and continuous stimulation Occasionally hyperpyrexia is observed in typhoid 32 INFECTIOUS DISEASES. fever, and most freiiuently just before dissolution, when the thermometer may register 108° or even i09° F. (42.7° C). A fresh rise with marked irregidarity of temperature may occur during the latter part of the fas- tigiuni or the period of decline, and is often dependent upon some local complication (late pneumonia, parotitis, etc.). The stage of defervescence is sometimes much prolonged, though most frequently there is simply a slight evening elevation (99° to 100° F. — 37.7° C), the morning temperature being normal. The causes of retarded decline are, for the most part, obscure. I believe that many of them are ascribable to a mild grade of auto-intoxication, and in my hands a mild saline laxative has been the means of cutting them short in a number of instances. An examination should, however, be made for some localized intlammatory complication, though this is not always dis- cernible, as in the case of suppuration in the mesenteric glands. Sluor- gish typhoid ulcers, which refuse to heal promptly, may act as a cause of the slow decline ; they are often due to the post-typhoid anemia and exhaustion. Post-typhoid Elevations of Teynperature. — After both the evening and morning temperatures have become normal, fresh temporary eleva- tions (102° or 103° F.— 38.8° or 39.4° C.) frequently appear. They are, as a rule, unassociated with any other symptoms, and at the end of a few days the temperature falls rapidly to the normal. These are termed recrudescences, and are to be distinguished from true typhoid relapses. They are probably produced in various ways — by errors in diet, constipation, mental emotion, excitement. ''There are cases in which the presence of the fever seems to be really a nervous phenomenon " (Osier). It is most common in children and in persons of a decidedly nervous temperament. Certain local secjuelae may cause post-typhoid fever, such as abscess and periostitis. Rarely during convalescence a sudden and marked elevation of temperature, accompanied or not by rigor, occurs, but it is usually of short duration and seldom is of serious import. I saw, with the attending physician, Dr. Modell, a case in which the temperature had been normal for six days, when rigors, fol- lowed by steep elevations of temperature, occurred several times and at intervals of thirty-six or forty-eight hours. These high temperatures were followed by a rapid decline to the normal and by sweating, leaving the patient profoundly exhausted. Subsequently the convalescence was slow, but uninterrupted. Afebrile Typhoid. — As the term indicates, typhoid fever may run a course attended with all of the characteristic symptoms save only the fever. Cases of this kind are of great rarity. (h) Skin. — The eruption is highly characteristic, and usually decides the diagnosis. It makes its appearance on or about the eighth day, and sometimes a little later. Occasionally it does not appear until the tenth or twelfth day of the disease. It consists of distinct, rose-colored, and slightly elevated papules, having a rounded or lenticular form and a diameter varying from one or two to three lines. The papules are almost invariably found upon the trunk, and especially upon the upper part of the abdomen and the lower part of the thorax, to which regions they may be wholly confined. They may, however, be absent from the usual seats and present elsewhere, so that the sides of the trunk, the TYPHOID FEVER. 33 back, and the thighs should always be inspected. They disappear upon pressure, but reappear when the pressure is removed. These rose-colored spots last three or four days, and appear in successive crops, each one being made up, usually, of a few spots — a half-dozen to a dozen. Rarely the eruption is abundant on the trunk, even extend- ing to the extremities and head; but there is no direct correspondence between the extent of the eruption and the severity of the cases. Occa- sionally the spots are entirely absent — a condition most frequently met with in children, and less often in elderly persons. Other eruptions are often present, and their negative diagnostic value must be kept in remembrance. Minute pearly vesicles (sudamina) may appear. They are limited to the abdomen, the axilla, and to the inner surface of the thighs as a rule, and are in great measure due to profuse sweating. A scarlet-colored erythematous eruption sometimes appears at a com- paratively early period in typhoid fever. Urticaria and purpura are rarely seen. Out of 250 cases of typhoid fever among the soldiers in the Spanish-American war treated in the Medico-Chirurgical Hospital two manifested purpuric spots. Extensive ecchymoses may occur, but are rare, and merely symptomatic of the hemorrhagic diathesis. Cutane- ous hoils and abscesses due to secondary infection with the pyogenic cocci are a comparatively frequent and late development in the course of the disease. Peliomaia typhosa in the form of little bluish subcutic- ular spots (the " t^ches bleuatres " of the French writers) may appear; but they are not related specially to typhoid fever, and in a recent case of my own were undoubtedly due to pediculi. Giangrene, chiefly of the lower extremities, has been noted in 214 cases (Keen), and is due to the diffusion of the bacilli and their toxic products, to an obliterating endarteritis, thrombosis, or embolism. Profuse siveats form a conspicuous symptom in many epidemics of the disease, with or without accompanying fits of chilliness or rigors, and constitute the sudoral form of typhoid fever (Jaccoud). Some of these cases resemble ordinary intermittents. Edema of the skin may be observed and is due most frequently to anemia or cachexia, though sometimes to nephritis. A local form of edema affecting the leg is not uncommon, and for this form thrombosis of the femoral vein is chiefly responsible. A peculiar " musty " odor is exhaled from the skin in some instances of typhoid fever. The patient assumes the dorsal decubitus and is exposed, particularly in cases of prolonged duration, to the danger of the formation of bedsores. They are most prone to occur on the nates and the heels, and, once started, they are apt to spread till they attain to large dimensions, with extensive undermining of the skin. The condition is now serious. During and after the con- clusion of convalescence the hair falls out, but, fortunately, it is invari- ably renewed. The nails sometimes become roughened and brittle, while transverse pale lines or ridges can usually be observed in them, marking the impairment of nutrition during the disease {vide Relapse). Jaundice, due to a variety of causes, is a rare symptom, and generally does not come on until the middle of, or until late in. the disease (Da Costa) (c) Digestive System. — The symptoms referable to the gastro-iutes- tinal canal, though not very striking in most cases, are of the utmost 3 34 INFECTIOUS DISEASES. importance and interest because of their direct connection with the pathognomonic lesions of typhoid. Beginning with the intestinal canal, and thence proceeding to the symptoms presented by the stomach, spleen, liver, throat, and mouth, will be a natural and convenient order. At the onset of typhoid fever constipation is the general rule, and this may persist to the end of the illness, though more commonly a moderate diarrhea appears. Osier ^ in the Johns Hopkins Hospital, however, met an initial diarrhea in 322 out of 829 cases. During the second week of the affection the stools number, on the average, from two to four or more daily. It is only in comparatively rare instances that ten or more movements per diem occur, and the severity of the diar- rhea depends largely upon the degree of catarrh, particularly of the large intestine. When, however, the ulcerative process is chiefly limited to the colon, it is an important factor in the production of the diarrhea. Indeed, in those instances — not altogether rare — in which there is urgent diarrhea of a dysenteric character, the ulcers are especially marked in the colon, with diphtheritic inflammation of the surrounding mucosa. Involuntary discharge of the feces may occur. The stools present a characteristic yellow appearance, suggesting by their color and consistence a comparison with pea soup. They are usu- ally either fluid or of the consistence of jelly, and are offensive and of an alkaline reaction. On standing they separate into two layers^r-an upper, liquid, cloudy layer, and a lower, thick yellow, sedimentary layer, in which, on macroscopic examination, remnants of food and grayish yellow fragments (necrotic crusts of Peyer's plaques) from a half to an inch in length may be detected. Microscopically, they have been found to contain undigested particles of food, epithelial debris, blood-corpus- cles, crystals of triple phosphates in abundance, and innumerable bac- teria. Laboratory experimentalists are able to demonstrate the pres- ence of the typhoid bacillus in the dejecta. Tympanites, mainly affecting the colon, is a common though rarely a striking feature, and cases of a quite serious nature are observed in which the abdomen presents a concavity throughout the entire illness. The latter is less unfavorable, by far, as a symptom than excessive tympanites, which interferes with both the respiration and heart action. Tympanites is apt to be most marked in serious cases which have diarrhea as a promi- nent symptom, though the latter may not even be present. It is due to the generation of gas from decomposing food, and to the arrest of peri- staltic movements in consequence of degeneration of the muscularis of the intestines. Pain is absent in the majority of cases, and when present is not intense, save in rare instances. Pressure upon the ileo- cecal region usually causes a gurgling noise, but, although this symp- tom is commonly present, it is not characteristic of the disease. There is generally also a slight degree of tenderness of the abdomen under pressure, most marked in the right iliac fossa, and lience, in all proba- bility, due to the presence of ulcers in this region. Absence of tenderness, however, is not a safe indication of the absence of extensive ulceration. Extreme sensitiveness generally denotes peritonitis (often without per- foration), although the symptom may be marked in constipation. Intestinal hemorrliage occurs in from 4 to 7 per cent, of cases, its 1 Philada. Med. Jcnini., October 15. 1900. TYPHOID FEVER. 35 frequency varying with different epidemics. The hemorrfiages appear almost invariably during the latter part of the second and third week, being caused by the opening of blood-vessels during the necrotic or ulcerative process. The amount may be small, or it may be from 1 to 2 or 3 pints (0.5-1.5 liters), or even more. In one of my own cases the total amount of blood discharged from the bowel was nearly 5 pints (2.5 liters), and yet the patient recovered. The blood presents a dark hue, and that which is passed last may be tarry. Roman has exam- ined the feces in 50 cases of typhoid fever with a view to the detection of occult bleeding. Blood was found in 14 cases, and of these, 7 were severe, 3 moderately severe, and 4 slight. The significance of intestinal hemorrhage is always grave. On the other hand, recovery is possible even if the hemorrhage be copious and oft-repeated; and in general terms .'t may be said that death super- venes in from 30 to 40 per cent, of all cases. R. G. Curtin has recorded 60 cases, of which 46.6 per cent, died; he argues that cold applications to the skin and the necessary disturbance in giving a cold bath tend to produce melena. It occurred in more than the usual pro- portion of cases under my care during the Spanish- American ^ar, probably owing to the fact that the men were conveyed from the various distant camps to the hospital. A fatal result may occur as the direct effect of a profuse hemorrhage. When death does not follow immediately, the signs of collapse and of anemia appear ; yet intestinal hemorrhage sometimes exerts a favorable influence, stupor and delirium quickly giving place to consciousness. When typhoid fever occurs in the hemorrhagic diathesis, hemorrhage occurs from various outlets. Perforation, which almost invariably produces fatal diffuse peritonitis, is the accident most to be dreaded. It does not bear a fixed relation to the severity of the affection. According to Fitz, who tabulated 4680 cases of typhoid fever, there is a mortality of 6.58 per cent, from perforation of the bowel. Scott's statistics, embracing 9713 cases from English, Canadian, and American hospitals, give a mortality of 3.6 per cent, from perforation. It is much more common in males than in females, and appears in a ratio of about 71 to 29. Age has a decided influence, the complication occurring oftenest between ten and forty years of age, while in children it is rare. It may occur at any time in the course of typhoid fever, but it is most common between the second and fourth weeks of the disease. In the cases analyzed by Fitz perforation was found in the ileum in 81.4 per cent., in the large intestine in 12.9 per cent., in the vermiform appendix in 2.5 per cent., and in the jejunum in 1.29 per cent. The accession of hyper- tension of the pulse is indicative of approaching perforation. The acci- dent is usually announced by the sudden advent of acute pain in the abdomen, quickly followed by the symptoms of collapse; and the fact that diffuse peritonitis, following perforation, may develop insidiously must be recollected. The abdominal muscles become rigid, sensitive to touch, and later tympanites develops. Fluctuation can sometimes be elicited. On percussion splenic and hepatic dulness is often absent, but hepatic dulness is also wanting when the distended intestines lie in front of the liver. Shifting dulness in the right flank may be an early sign. The collapse of the circulatory system is evidenced by the pinched features, 36 INFECTIOUS DISEASES. hollow cheeks, vomiting, and the small, frequent pulse. A rising leuko- cytosis is a valuable diagnostic symptom. Crile found a rise in the blood- pressure in cases. Wilson has emphasized the importance of an early diagnosis and of immediate resort to operative intervention. The instances that develop independently of actual perforation usually assume the local, or circumscribed form of peritonitis ; they are occasioned in various ways — e. g.^ by direct extension of the inflammatory process from the intestinal ulcers, primary localization of the virus in the peri- toneum, and rupture of the mesenteric glands. The condition presents corresponding areas of tenderness under gentle, and especially under pro- longed, pressure, but it is difiicult to diagnose intra-intestinal states. Generalized peritonitis may succeed the circumscribed variety. A. McPhedran* calls attention to a serous peritoneal effusion (ascites) and to the physical signs of exudate in the peritoneal cavity. The mesenteric lymph-glands may soften or suppurate {vide Pathol- ogy), and, as before mentioned, may be the exciting cause of a recrudes- cence, or they may rupture and cause diffuse peritonitis. The Spleen. — With few exceptions the spleen is enlarged in ty- phoid fever, the edge usually being palpable below the margin of the ribs, on or before the commencement of the fastigium. It generally goes on increasing in size till near the beginning of the third week, and lessens during the latter part of the third and fourth weeks. Swelling of the spleen is sometimes absent after a copious intestinal hemorrhage and in elderly typhoid subjects. When the tympanites is excessive, we can in most cases satisfy ourselves of its existence or non-existence by cai'eful palpation. Suppurative infarcts or softening of the spleen may start a peritonitis. Rarely spontaneous rupture of the organ may occur, which is manifested by intense pain in the splenic region. Bryan reports a case and has collected 24 others from the literature. The Liver. — A slight swelling of the liver can sometimes be detected. Among the least frequent complications is jaundice (vide .supra) ; it may be due to cholangitis, to abscess, and to gall-stones. Cholecystitis caused by the typhoid bacillus (vide Pathology) may arise during the attack or long after complete recovery. In most cases the lesions are catarrhal, but they may be suppurative, in which event perforation followed by peritonitis may occur. Calculous cholecystitis is frequently caused by the typhoid bacilli, but may not manifest itself for a variable number of years. Suppurative pylephlebitis, secondary to perforative appendicitis, may be a complication. Multiple abscess may occur. The Stomach. — The stomach presents no characteristic symptoms. Of the anorexia enough has been said, })Ut during convalescence the appe- tite returns, becoming even voracious. Nausea and vomiting may occur during any stage of the disease, but are most common at the beginning. When they appear as late symptoms they are probably excited either by a typhoid ulcer or by peritonitis. Nausea is often traceable to other causes — e. g., to errors in diet, or to the use of irritating medicaments, but vomiting also occurs from unknown and inevitable causes. It may become a grave symptom. Hiccough is a rare but serious symi)tom. Hematemesis has been observed, although practically unknown. The Pharynx. — Tlie pharynx frequently shows 'catarrhal irritation, 1 Cleveland Med. Jour., June, 1911. TYPHOID FEVER. 37 and the patient may complain of dryness or a burning sensation in the throat. Actual sore throat, may be present at the time of onset, asso- ciated with a diffuse erythematous rash, suggesting scarlatina. The To7isils. — There is a special form of typhoid — tonsUlo-typhoid or pharyngo-fyphoid — in which there appear upon the tonsils peculiar patchy elevations, whitish in color, which undergo subsequent ulcera- tion. It is not improbable that these lesions result from the local action of the specific bacillus in an unusual situation. Thrush, affecting the mouth, throat, and even extending to the esophagus, not infrequently arises as a complication. The tongue is heavily coated, as a rule, with a yellowish-white fur ; later it clears off near the edges and tip, while the center becomes dry or brown and sometimes fissured. The lips are also dry, sometimes fissured, and often covered with dry, black crusts (sordes). Ulcerative stomatitis may occur if the mouth be not kept clean. Under these circumstances secondary lesions evincing unpleasant and even serious symptoms may also arise in organs more or less remote from the mouth, and among these is parotitis, which is most probably caused by the staphylococcus or streptococcus reaching the parotid gland by way of Steno's duct. The condition is betrayed by such symptoms as pain, redness, and finally by fluctuation, with an elevation of the bodily temperature. It is a late-appearing develop- ment, and is usually unilateral, though it may be bilateral. Suppura- tive otitis media, a rarer complication, arises in a similar manner, the pathogenetic agents reaching the ear through the Eustachian tube. {d) Respiratory System. — As pointed out in the section on Pathology, bronchitis is almost invariably present, but in the majority of instances the cough is slight. The condition is recognized by the existence of numerous sibilant r^les. Very rarely is it a striking feature in the early stage of typhoid fever, and then, except this fact be remembered, room for error of diagnosis exists. Moreover, in cases that are im- properly treated the bronchial secretions are apt to accumulate, and a well-marked bronchitis may be the result. It may be said, however, that, as a rule, bronchitis does not assume a severe type in cases which receive proper attention from the beginning, provided the patient be not unusually stupid or unconscious. When the nervous phenomena are pronounced, and the patient maintains the dorsal decubitus, bron- chitis of a severe grade and affecting the smaller bronchi is almost in- evitable. The occurrence of an intense generalized bronchitis is also favored by conditions such as corpulence, advanced age, and emphysema. These cases are apt to lead to lobular infiltration — aspiration-pneumonia. Lobular pneumonia may take on a putrid nature and the consoli- dated area may become gangrenous. As a sequel, pleurisy with efl"usion or empyema may originate in consequence of the infiltrated lobules being contiguous to the pleura. If the lobules occupying the periphery of the lung become gangrenous, perforation of the pleura, leading to pyopneumothorax., may result. As pointed out by Gordinier and Lartigau,^ in the majority of instances of typhoid pleurisies the aspirated fluid has been found to be purulent in character. Lobular pneumonia may be attended with hurried breathing or troublesome cough. ^ Am,Qr. Journ. Med. Sci., January, 1901. 38 INFECTIOUS DISEASES. More commonly, the local symptoms are in abeyance, and this is espe- cially true of the severer cases which are attended with profound nervous prostration and more or less unconsciousness. Sole reliance is to be placed upon the results of a physical exammation, which should be repeated daily. Points or surfaces of dulness, near the bases of the lungs, are found on percussion. Fine moist rales, heard in every direc- tion, and especially marked toward the bottom of the thorax, form a characteristic sign. A certain diagnosis of lobular pneumonia demands the combined presence of both the circumscribed dulness and moist rales. Lobar pneumonia is a not uncommon complication. In a small per- centage of cases it develops early, and is most probably the result of a special concentration of the poison in the lungs, giving rise to the so- called pneumo-iyphoid fever {vide infra. Varieties). These cases are often mistaken for primary lobar pneumonia. Their onset may or may not be marked by a rigor, but it is usually more gradual than that of primary lobar pneumonia. At the end of the first week or thereabouts the pulmonary symptoms gradually abate, while those characteristic of typhoid (enlarged spleen, roseate spots, etc.) come to the fore. Wagner, Leichtenstein, and Aufrecht entertain grave doubts as to the existence of a pneumo-typhoid. I have, however, had under my care a case in the Medico- Chirurgical Hospital that was proven by the Widal reaction. Lobar pneumonia more often develops as a late complication — in the second or third week, or even during convalescence — but it is not at- tended by the usual phenomena (rigor, cough, rusty expectoration, intense chest-pain), and hence may be easily overlooked. The temperature may be either quite elevated or at times only moderately so. Lobar pneu- monia, the complication, is principally due to the pneumococcus. The diagnosis is to be made from the physical signs, together with the pecu- liar temperature-curve, Avhich may present marked irregularities. Pul- monary infarction and abscess of the lungs are occasional complications. Hypostatic congestion of the lungs, due to enfeeblement of the cardio- pulmonary circulation, is a frequent concomitant, appearing in the third week of the disease. It is generally bilateral, and is promoted by the effects of gravitation. It is almost always associated with more or less edema of the lungs. The subjective symptoms, including fever, are usually negative, Avhile the objective signs are those of partial or com- plete consolidation of the bases (defective resonance or dulness, broncho- vesicular breathing, with moist rS:les). Miliary tuberculosis rarely develops as either a complicating affection or, it may be, as a sequel. Of 249 autopsies in fatal cases of typhoid fever only four showed acute tuberculosis to have been associated.^ Laryngitis, indicated by hoarseness, is an occasional complication. The laryngeal ulcers may extend in depth to the perichondrium, and promote that grave condition, perichondritis, leading to necrosis of the cartilages with edema of the glottis and stenosis. A third form of laryn- geal complication is that in which the muscles are deprived of their function because of paralysis (Gibb). Epistaxis appears early in some cases and is a valuable diagnostic symptom. It may also occur during the fastigium, particularly toward ^ " The Eelation of Typhoid Fever to Acute Tuberculosis," Amer. Jour. Med. Sciences^ May 4, 1904, by the writer. TYPHOID FEVER. 39 its close, when it is of no diagnostic, but of grave prognostic, significance. In a case I saw with the late Dr. Snively it led to a fatal issue. (e) The circulatory system presents no characteristic symptoms. The heart-sounds are but little affected, as a rule. In cases of asthenic type and in severe typical instances the first sound of the heart may grow quite feeble and ultimately resemble the second (embryocardia). Under these circumstances a soft systolic murmur may be faintly heard along the left border of the sternum. Among occasional complications pre- sented by the heart is pericarditis, and still less frequent is endocarditis. Myocarditis is more common. The sudden development of circulatory collapse in the course of typhoid fever, as previously noted, may be due chiefly to myocardial inflammation ; and there may be a brief though alarming derangement of the heart action, due to functional disturbances. The pulse is accelerated, but not, as a general rule, in proportion to the height of the temperature until late in the affection. Its average rate is from 84 to 108. The temperature, moreover, may be of average height, while the pulse is normal or only slightly quickened throughout; and hence the increase in the pulse-rate cannot be due solely to the ele- vation of temperature. As before intimated, the extreme debility which comes on during the third week in severe cases may have, as one of its manifestations, a very rapid pulse, reaching to 160 or more (the so-called running pulse), and with or without marked irregularity. Slight irreg- ularity is sometimes observed, either during the height or decline of the afiection, but as a rule proves of no serious consequence. Marked tem- porary accelerations are often caused by undue exertion or mental excite- ment. The lowered arterial tension is shown by a dicrotism of the pulse — a non-characteristic symptom^ however, since it is well marked in other acute infectious diseases, although less commonly. During convales- cence the pulse often becomes abnormally slow (brachycardia). Per contra, less commonly, the pulse-rate is increased during convalescence. I have found the systolic arterial pressure during the fastigium to range from 110 to 125 mm. Hg. (Riva-Rocci instrument); it declines further late in the disease. The fall in the diastolic pressure is proportional. During convalescence the blood-pressure again rises, reaching the normal in from two to four weeks. Venous thrombosis occurs in 1 per cent, of all cases (Murchison). Its most frequent seat is the left femoral, and the next most frequent the right femoral vein, and it is the immediate result of cardiac weak- ness, except perhaps in those rare instances that arise early in typhoid. In most cases there is, doubtless, more or less phlebitis, and the bacilli have been found in the thrombus. The condition may be bilateral. Coming on, as it usually does, during convalescence, it manifests itself by swelling and edema of the extremity affected. There are pain in the thighs and calves, and tenderness over the course of the vein, and often over the calf of the leg as well. It causes Jever of a moderate grade and irregular type. In the course of from two to three weeks the swollen member may be reduced to its normal dimensions. This complication is usually not serious, but occasionally clotting extends into the pelvic veins, and into the vena cava, thence even into the right auricle, inducing fatal syncope, and sudden death has resulted from the detachment of emboli. 40 INFECTIOUS DISEASES. The thrombus may undergo suppuration, leading to systemic septic infection. Thrombosis and emboUsm in the arteries, with renal, splenic, and pul- monary infarcts, may be encountered in typhoid fever. The large or small arteries may become obliterated, either by em- bolism or thrombosis, in extremely rare instances, but whether the throm- bosis under these circumstances is brought about by a peculiar condition of the blood which favors clotting, or by a localized arteritis, is not definitely known. If, as is usual, the femoral artery be involved, the blood-supply to the foot and leg is cut off and gangrene of those parts must follow. The condition may be bilateral. It may be detected WEEKS I 11 III IV V VI VII VIII IX X WEEKS yooi 'I ' 90^ J ■^si:;:::::" _ :::: ' 80< 70% --- - . _.L^ ^/_ __.<^___ ■ ■■- : — r ::"_:: :;;;:;._;:;;? 6Q% .- - -..J .... 50% ,.._«,.-., _ __ ___ 2 000 000 - "-- ±- ;::::::::n:;:;;?::::::" 40^ 30^ 20<(; lOOjt 90% BQ% 10% 60% 50% W% 30% Fig. 4— Chart illustrating the hlood middle curve, hem changes oglobin ; n typhoid jwer curv fever : upper e, white corpu; curve, red corpuscles; ^cles. early, owing to the absence of a femoral pulse, before the signs of gan- grene appear. The condition is highly dangerous. The blood presents certain changes, some of which are valuable for diagnostic purposes. The red corpuscles may be relatively increased in number during the febrile period, owing to loss of water {e. g., profuse sweats, diarrhea). There is, in most instances, little or no decrease in the number of red corpuscles till the end of the second week. They are markedly diminished, as a rule, during convalescence, the oligocythemia bearing a close relation to the severity of the disease. There is a greater relative decrease in the amount of hemoglobin than in the number of red corpuscles. The number of white corpuscles remains at or a little below the health standard until late convalescence, when it sinks to a moderate degree — furnishing a count of about 2000 per c.mm. [leukopenia). This fact is an important aid in the differentia- tion of uncomplicated typhoid fever from leukocytotic affections. Leuko- TYPHOID FEVER. 41 cytosis, however, occurs in typhoid, with hemorrhage and perforation, and especially in connection with " large ahscesses, phlebitis, peritonitis, pneu- monia, pleurisy, periostitis, cystitis, and cliolecystitis " ('J'liayerj. Tran- sient leukocytosis occurs after cold baths. Naegeli ^ found an early neu- trophilic leukocytosis of moderate degree which rapidly decreases. In the second stage neutrophiles and lymphocytes are still further decreased, the former at last disappearing, while the latter begin to increase again, and so continue until defervescence. During the decline of the fever the neutrophiles reach their minimum, the lymphocytes are greatly increased, and the eosinophile cells gradually return to their normal number. After the disappearance of the fever a lymphocytosis may occur. 'We blood- characters in typhoid are shown in the accompanying chart (Fig. 4j. (/) Nervous System. — The persistent headache that is almost always present is among the most prominent symptoms during the first week, but it diminishes steadily during the early part of the second, as a rule. It affects the temporal, occipital, and cervical regions, and when the onset is comparatively sudden, pain in the back is also a more or less conspicuous feature during the first few days of the illness. In a small class of cases, however, the effects of the typhoid bacilli or their toxins are manifested solely in the nervous system from the very onset. In such there are violent headaches, retraction of the head, rigidity, pho- tophobia, and muscular twitchings (rarely convulsions) — all of which symptoms indicate meningitis. The diagnosis of meningitis as a com- plication must be made with extreme caution, since, no matter how com- plete the clinical picture may be, the post-mortem examination usu- ally reveals a total absence of meningeal inflammation. It must be recol- lected, however, that the lesions may be wholly microscopic. Vertigo may accompany the headache, but it seldom outlasts the latter. Before delirium manifests itself wakefulness and restlessness at night are very annoying, and later the same symptoms may be observed associated with the delirium. In cases of moderate severity mental dulness, and even uctual hebetude, are almost invariably present. Questions are apt to be answered inconsistently and in monosyllables. Delirium is frequent in the severer cases. It is, however, not an uncommon event for those of moderate severity to be free from this symptom throughout the attack. It is, as a rule, most marked at night or at some time when the patient is left alone. His delusions may impel him to attempt to leave his bed, but more commonly there is mild or noisi/ delirium, with more or less restlessness. He may lie somnolent, soliloquizing in a loud whisper (muttering delirium), and this so-called typhomania may gradually give place to actual coma to- ward the close of the middle period of the disease. In not a few cases — mild or severe — coma is developed suddenly, and is often a mortal symptom. Still another unfavorable sign is a picking at the bed-clothes or a grasping at imaginary objects (carphologia). The delirium may assume an hysteric type, the patient usually ex- hibiting the saddest emotions, and if he be an alcoholic he may be seized with delirium tremens. In a case of typhoid fever that I saw with Dr. S. W. Morton hysteric delirium developed during early conva- lescence, but did not last more than twenty-four or thirty-six hours. ^ Deutsche Archiv/iir klin. Med., Band Ixvii., Hefte 3 n. 4. 42 INFECTIOUS DISEASES. The motor nerves also present notable disturbances in association with the sopor and the forms of delirium previously described. Slight twitchings of the muscles of the face and extremities are quite common, and when they affect the tendons of the wrist and fingers the term suh- sulhis tendinmn is applied. The lips, tongue (especially when pro- truded), lower jaw, and even the extremities, are often in a state of con- stant tremor. During this motor irritability the reflexes are increased, but when profound coma comes on they are either largely diminished or totally abolished. The toxins of the typhoid bacillus, acting poisonously upon the nervous centers, are undoubtedly the cause of the nervous symptoms in typhoid. Nervous complications and sequeJce may arise. Chief among these is paralysis, which is most probably due to neuritis. The lesion may involve one, two, or more nerves, and in this way we may have either a paralysis of one limb or, more rarely, a true paraplegia. Aphasia may be a sequel, particularly in children. Hemiplegia., due to hemorrhage or a localized encephalitis, may occur either as a complication or sequence of the disease. Following typhoid fever, the patient may ex- hibit evidences of mental enfeeblement, and even insanity where a pre- disposition to this condition has existed; and insanity is relatively more common after this disease than after any others belonging to the same class. I have seen four instances, all of which recovered, while Osier has seen five, four of which ended similarly. It is in most cases, as pointed out by Wood, a confusional insanity, due to exhaustion and impairment of the nutrition of the nerve-centers, while in a smaller contingent it takes the form of a true melancholia. After the conclusion of typhoid, as well as during its course, neuralgia afi"ecting the occipital and other cranial nerves is not infrequent. Great hyperesthesia of the skin and muscles is common during convalescence, attacking the lower extremities by preference (Striimpell). The so-called " typhoid spine " (Gibney) has also been observed, and consists in an acute inflammation of one or more vertebrae following typhoid. The chief symptoms are pain in the back and hips of a lancinating character. The point of origin appears to be the small of the back ; thence the pains extend paroxysmally up and along the spine and to the abdomen. They subside gradually, leaving the back weak and painful on attempts at turning in bed, etc. Plantar and other skin-reflexes are increased, and the knee-jerks are preserved. G. E. de Schweinitz has described at length the ocular complications and sequelce of typhoid fever. Affections of the conjunc- tiva and cornea and retinal hemorrhage are perhaps the most frequent, although optic neuritis and affections of the uveal tract also occur. (^) The Urinary System. — Urine. — The urine is lessened in quantity and high-colored, with an increased specific gravity up to the arrival of the stage of decline. About this time, and rarely earlier, it grows light in color, larger in quantity than the normal, and the specific gravity is relatively diminished. Both urea and uric acid are increased during the earlier stages, and sometimes throughout the attack, while during convalescence both are diminished. On the other hand, the chlorids are diminished during the active stages of the disease and in- creased during its decline. Afebrile albuminuria is quite common, and the sediment may show an excess of renal epithelium, a few blood-cells, . and occasionally renal casts. TYPHOID FEVER. 43 Acute nephritis may develop as a complication in the earlier or later course of the disease, and can be recognized to a certainty only by a thorough appreciation of the urinary phenomena. The urine is dimin- ished in quantity, being often scanty, and there may be retention. It contains characteristic morphologic elements (albumin, casts, blood, and epithelium). The development of the typhoid state in this affection is rendered much more probable in the presence of this complication, and, moreover, uremic symptoms often put in an appearance at this juncture, and then the situation is really serious. Acute nephritis may arise at one or other of three different periods, and its significance varies with the time of onset : {a) at the beginning of the fever, when it often obscures the true nature of the malady. This is the nephro-typhoid of the German authors, and will be referred to hereafter {vide infra, Varie- ties) ; (h) in the early part of the fastigium or the second week of the disease. Coming on at this time — an event which I have observed in two instances — it is probably to be ascribed to the local effect of the toxin upon the renal tissues. Both of my own instances proved fatal, and in both an autopsy was refused. Wagner^ has had 5 cases of recovery in succession, but the high mortality mentioned by Amat — 10 deaths in 12 cases — is the more common experience, (c) Acute nephritis may arise as a sequel of typhoid, when there is almost invariably associated a de- cided edema. In this category of cases recovery is to be expected. The diazo-reaction of Ehrlich is a valuable aid in diagnosis, but may be present also in acute phthisis, meningitis, measles, pneumonia, yellow fever, and other fevers. To obtain it two other solutions {a and h) are needed : We mix 1 part of solution (a), which consists of a 0.5 per cent, solution of sodium nitrite, with 50 parts of solution (6), which con- sists of 2 grams of sulfanilic acid, 150 c.c. of hydrochloric acid, and 1000 c.c. of distilled water. To this an equal volume of urine is added, and the contents of the test-tube are then thoroughly shaken. A layer of ammonium hydrate is now superimposed, and at the line of contact a ruby or pink ring develops. A more reliable change, however, is a rose- red (pink) hue of the foam. Says Cummins, " Upon employing a dilution of 1 : 150 other conditions are eliminated (except a small percentage of tuberculous cases)." It is present in about 70 per cent, of the cases. The reaction begins about the beginning of the second week, sometimes later, and lasts usually until defervescence is well advanced. A brownish ring is given by normal urine. Diabetes mellitus is, in extremely rare instances, developed after typhoid. Hematuria has also been observed as a symptom of the hem- orrhagic diathesis. There is a post-typhoid, diphtheritic pyelitis in which the pelves and calices of the kidneys are the seat of membranous exudation, and later of erosion and ulceration. The urine generally contains blood and pus. Simple vesical catarrh may rarely result from catheterization for re- tention. Typhoid cystitis, in which the bacilli are found in pure culture in the urine, is not rare [vide p. 53). It occurs principally in patients who are predisposed by local conditions. Orchitis, epididymitis, spermatocystitis, prostatitis, and ovaritis are ^ Deutsch. Archivfiir klin. Med., Bd. xxv. and xxxvii. 44 INFECTIOUS DISEASES. occasional sequels. Blumenfeld collected 69 cases of orchitis ; it gen- erally develops suddenly during convalescence. (It) The Joints. — Typhoid, septic and rheumatic arthritis may occa- sionally arise as a complication. The first is usually mon-articular (par- ticularly in the hip) ; the last two comvaowXy polyarticular. Keen has collected "in all 84 cases involving the joints." (<) The Bones. — Periostitis, due to injury and muscular strain and often leading to necrosis, is a not rare sequel of typhoid. The favorite seats are the tibia and ribs, though in a case of my own at the Philadel- phia Hospital it affected the os calcis. Ebermaier found the bacillus typhosus in the pus from 2 cases of suppurative post-typhoid periosti- tis, although other bacilli (streptococci, staphylococci, pneumococci) are at times associated. Osteomyelitis may also occur. Keen has collected . 216 cases in which the bones were attacked. (y) The Muscles. — As in the case of the heart, so the voluntary muscles exhibit hyaline degeneration ; also abscesses, in consequence of secondary infection or of infection with the typhoid bacillus itself. Typhoid abscesses likewise result from perforations of the gut. Associated Acute Infectious Diseases. — Malarial fever may be com- bined with typhoid, though the relationship is not a vital one. In an analysis of 2122 cases of malaria typhoid fever was associated in 8.^ Many instances of so-called typhoid-malarial fever, however, would be shown to be pure typhoid by a careful blood-examination. Pseudo-membranous inflammation, as above intimated, may occur in the naso-pharynx, larynx, gall-bladder, and genitals. Measles, scarla- tina, and chielken-pox have also been known to arise in the course of, or during convalescence from, typhoid fever. Erysipelas is a rare secondary affection coming on either during the height of the affection or (more frequently) after its close. Typhus fever may be associated with typhoid, but this is rare. Clinical Varieties of Typhoid Fever. — These are numerous, and may grow out of peculiarities manifested during the course of the affec- tion, as may be observed not only in different epidemics, but also in the same epidemic. The groups of cases described here have reference par- ticularly to the degree of severity of the type, which varies between the wide limits of extreme mildness on the one hand and extreme severity on the other. The course of the disease may also be modified by the occurrence of one or more of its manifold complications. (1) The Mnd or Rudimentary Form (Typhus Laevissimus). — Of this variety many cases occur, and especially among children. The spleen is almost always enlarged, the roseate spots are sometimes present, while the temperature is moderately elevated and often partakes of the same character as that of true typhoid. The fever, however, may pursue the remittent type. Complications presented by special organs are usually absent, but grave accidents (intestinal hemorrhage, perforation) are not impossible. The diagnosis is always difficult, owing to the feeble development of the characteristic symptoms, and in the total absence of the latter is out of the question ; but the recognition is assured if a casual connec- ^ "The Complications of Malaria," Journal of the American Medical Association, vol. xxiv., p. 919, by the author. TYPHOID FEVER. 45 tion between them and typicnl cases can be shown to exist, and if the Widal test gives a positive result. (2) The abortive form has a sudden onset, and is often marked by fits of shivering. The characteristic features of the disease (enlarge- ment of the spleen, abdominal symptoms, rose spots, etc.) appear earlier than in the usual type, and soon become quite well marked. The fas- tigium is short, and the temperature, from the seventh to the twelfth day of the illness, declines by a prompt lysis, with profuse sweating. With the rather rapid fall of temperature there is a no less rapid im- provement in every other leading symptom. Convalescence is speedy. (3) The Ambulatory Form (Latent or Walking Typhoid). — The pa- tient continues to walk about, either experiencing but slight disturbance or being unwilling to take to his bed. Such cases do not come under the care of the physician in many instances. Others, on account of debility, anorexia, diarrhea, and other vague symptoms, finally consult their physician, who may discover the presence of all the characteristic features of the disease. A third contingent, belonging to this form, continue to move about, or even to follow their usual vocations, till seized suddenly with profuse intestinal hemorrhage or general diffuse peritonitis following perforation. (4) The afebrile is an exceedingly rare form of the affection — in this country at least. Liebermeister, however, has met with a number of cases at Basle, the symptoms being lassitude, depression, headache, neuro-muscular pains, anorexia, slow pulse, furred tongue, constipa- tion or diarrhea, with enlargement of the spleen and roseate spots. These cases are often confined to bed, and there are occasional attempts at evening exacerbations of temperature (100.5° F. — 38° C). (5) Severe or Grave Forms. — These may be dependent either wholly or in great part upon the degree of virulence of the typhoid poison. A profound intoxication of the system, as shown by high temperature, violent nervous symptoms, and great prostration, is noted. The grave types may arise in the course of cases of average severity from the de- velopment of serious complications. Again, to serious forms belong those cases that begin with the characteristic symptoms of a localized inflam- mation — e.g. the cerehro-spinal form., in which the nervous symptoms greatly predominate at the onset; the nephro-typlioid (before alluded to). in which the preliminary symptoms are those of acute Bright's disease ; the pnewno -typhoid [vide supra)., which begins with the manifestations of a more or less frank pneumonia. Pleuro-typhoid. — The cases begin as an acute pleurisy, and are fol- lowed, soon or late, by the diagnostic evidences of typhoid fever. Tala- mon ^ distinguishes these cases from simple pleurisy by the intensity and continuous course of the fever, by the general depression, headache, and vertigo, and by the sleeplessness. Eiselt^ has described a special form under the name spleno-typhoid, in which the spleen is enormously en- larged without characteristic intestinal lesions. Perisplenitis with adhe- sions may be noted. The sudoral form and tonsiUo-fyphoid (before de- scribed) also belong to this category. The fever is often of remittent type. ^ Iji Medecine moderne, Paris, 1891. ^ La Semaine mediccde, August 27, 1891. 46 INFECTIOUS DISEASES. Typhoid septicemia may present the grave symptoms of an extreme intoxication, often merging into the typhoid state. Visceral and cuta- neous hemorrhages may be superadded. Cases of hemorrhagic typhoid fever have been reported by A. A. Eshncr and T. H. Weiseuberg* and others. They are probably due '' to a condition of systemic intoxication and septicemia " (Nicholls and Learmouth). Many circumstances con- nected with the individual influence decidedly the general course of the affection, and these are based upon such factors as age, habits, etc. (6) Tyrlioid Fever in Children. — The onset is rather more abrupt than in the adult, and certain prodromal symptoms are rarely present (epistaxis, chilliness). On the other hand, bronchial and nervous symp- toms are often quite pronounced. Again, during the fastigium some of the usual typhoid features may be missing — e. g. diarrhea and tympan- ites — while the eruption may either be slight or absent. The dispropor- tion between pulse-ratio and temperature is less marked than in adults (But- ler). Intestinal hemorrhage is rare and perforation almost never occurs. (7) Typhoid Fever in the Aged. — The course of the aifection presents no regular type. The temperature is not as high as usual, but there is marked adynamia and serious danger from certain complications, such as pneumonia, nephritis, coma, cardiac exhaustion, and the like. The diagnosis is difficult, owing to the prominence of the nervous and pulmonary symptoms on the one hand, and the frequent absence of the more characteristic symptoms of typhoid on the other. Diagnosis. — Unless all the chief characteristic features be pres- ent with a clear history, it is a golden rule not to make a positive diag- nosis. Obviously, then, the physician at the first visit, often about the close of the first week, cannot, in many cases, diagnosticate typhoid with absolute certainty. If the case have been a typical one, the history of the gradual development of the disease, marked by such symptoms as languor, anorexia, headache, dulness, slight chills, increasing fever, and sometimes nose-bleed, will be obtained, and justify a strong suspicion of typhoid. When, in addition, diarrhea and the objective symptoms, splenic enlarge- ment, dry bronchitis, tympanites, gurgling, with tenderness in the ileo-cecal region, are present, the diagnosis of typhoid is made highly probable. After the lapse of a few days — the beginning of the second week — the roseate spots usually appear. The most certain method of making an early, positive diagnosis is by an examination of the blood for the bacillus typhosus. Mabee and Taft^ have described the method of making blood-cultures from the ear, and found that in early cases of typhoid (/. e., within the first week) an accurate diagnosis in from 90 to 100 per cent, is easily possible. Says Peabody,^ while blood-culture in ox bile is the earliest indication, at a later stage, when the organism can no longer be isolated from the blood, the agglutination reaction {vide infra) is usually present. In obscure cases the occurrence of intestinal hemorrhage or a characteristic decline by lysis is helpful. To show a casual relation between an obscure case and one that is clearly typhoid leaves little to be desired. The diagnosis should include the particular stage of the disease. Briefly, the most trustworthy diagnostic features are the gradual onset, peculiar temperature-curve (made up of the " step- ^ Amer. Jour. Med. Sci., March, 1901. ' Boston Med. and Surg. Jour., June 1, 1908. TYPHOID FEVER. 47 ladder" stage of development, the continued type of the fa.stigiurn, and the decline by lysis), enlarged spleen, the rose-colored spots, cultural experiments, and the sero-reaction. tSerwrn-diagnosis. — The results of the investigations of Pfoiffer and, later, those of Grliber and Widal have given us a specific sero-reaction. Johnston recommends the following technic : The blood is obtained upon a clean glass slide from a needle-prick of the ear or finger of the suspected case. It is allowed to dry, and is then carried to the laboratory. A loop of bouillon-culture of genuine typhoid bacilli is placed upon a clean cover-glass, and to this is added a large loopful of a watery solution of the dried blood-specimen. The cover-glass is in- verted over the concavity of a hollow slide and sealed at the edges with melted vaselin. Under the microscope, with a high-power dry lens or with a one-twelfth oil-immersion lens, a rapid clumping of the bacilli in the hanging drop can be observed,^ and their motions cease almost instantly. Diagnostic Value. — There is a general consensus of scientific opinion as to the great clinical value of the Widal reaction. The large statis- tics of Kneass and Stengel, based on 2283 cases, coupled with more recent available figures, show the presence of the reaction in 95.2 per cent., and no reaction in non-typhoid cases in 98 per cent. A, C. Ab- bott^ reports that, according to the records of Widal reactions in 4154 cases, the error does not exceed 2.8 per cent. Of 230 cases examined, 219 gave a positive result (Anders and McFarland^). In 128 of these cases this result was obtained prior to the appearance of the rose spots, or before the eighth day ; in 36 cases the first reaction occurred during the second week ; in 45, between the seventeenth and twenty-first days of the disease ; in 8, not until the twenty-fifth day, and in 2 cases as late as the twenty-eighth day. Interfering Conditions. — In the first place, a previous attack of typhoid fever may produce a reaction. In 39 cases of pure typhoid tested at periods of from one to eighteen months after defervescence, 13 reacted positively (Cabot and Lowell). It may be possible for the scene to be dominated by some other morbid process (tuberculosis, etc.). Kraus * found that a complicating pneumonia caused the Widal reaction to disappear. On the other hand, the reaction may be present in Weils disease and in meat poisoning when the Bacillus enteritidis (Gartner) is present. Again, exceptional cases occur with no reaction throughout. Brill has reported 17 cases of this sort ; in such cases^ however, the ex- amination must be repeated until after convalescence is completed. Conradi^ has discovered a new method of cultivating typhoid bacilli. A small amount of blood is obtained by lancing the ear; this is inocu- lated into a small sterile bottle of bile, to which a little peptone and glycerin has been added. After sixteen hours the bile is reinoculated onto lactose-litmus agar. A positive diagnosis can be made in thirty hours. 1 Medical News, Nov. 14, 1896. 2 p^^7„, j/g^/, jowr., Feb. 25, 1899. 3 Phila. Med. Jour., April 8, 1899. ^ Zeit. f. Heilk., Bd. xxi., H. 5. ^ Miinch. med. Wochensehr., 1906, vol. liii, p. 1654. 48 INFECTIOUS DISEASES. Chantemesse ' suggests an ophthalmic test, but the cutaneous reaction is a more simple test and "gave positive results in every case in which it was employed" (Deehan). C B. Burke ^ has described a new reflex sign. Prendergast proposes a new typhoid fever test consisting in the injection with a fine hypodermic needle of a few drops of a suspension of dead typhoid bacilli of the strengtli of less than 5,000,000 per c.c. No reaction occurs in tyjdioid infection, but in the non-typhoid patient a well-marked area of redness around the injection develops within twenty- four hours. The cases that begin Avith the well-defined local inflammatory lesions previously referred to (tonsillo-typhoid, pneumo-typhoid, pleuro-typhoid, nepliro-ty])hoid) cannot be recognized at the outset. The same local inflammatory conditions may, independently of typhoid fever, be com- bined with a genuine typhoid state. In all instances of typlioid fever in which, at the time of onset, localization occurs, the degree of fever and prostration are apt to be out of pi-oportion to the local symptoms, and the former are apt to continue after the subsidence of the latter. A careful observation of the symptoms after the first week will usually detect undoubted symptoms of typhoid. The Widal test decides these cases. Blood-cultures if made early will also set the diagnosis at rest. The bacilli may be obtained from the stools and urine. Differential Diagnosis. — (1) Typhus fever (rarely met with) is to be dif- ferentiated by its appearance as an epidemic, by its sudden onset, by the deeper stupor, the besotted expression of tlie features, the injected con- junctivae, the contracted pupils, the appearance on the fourth day of macula; which are transformed into petechit« ; by the shorter course, the termination by crisis, and the absence of the Widal reaction. (2) Acute miliary tuberculosis is to be differentiated from typhoid fever by the greater frequency of the pulse and respirations, the cough, and in some instances by the expectoration ; by the diff'use cyanosis and the presence (sometimes) of choroidal tubercles. Blood-exaniinations may show leukocytosis, but the large mononuclears are not increased as in typhoid fever. There is an absence of the temperature-curve, the pulse, the characteristic eruption, and the Widal reaction and abdominal symp- toms of typhoid. In doubtful cases lumbar puncture and blood-cultures should be undertaken, as tubercle or typhoid bacilli may be found. (.3) Malarial fever may assume the continued form of fever — e. g., the festivo-antumnal type, in which chills may be absent — and there are typhoids that affect both remittent and intermittent malarial fevers. Malaria can be differentiated from typhoid fever only by the detection of Laverans hematozoa in the blood. Should tjipho-malarial fever be suspected and the typhoid symptoms be unequivocal, the finding of the malarial organism would establish the diagnosis and diff'erentiate the hybrid from pui-e typhoid. (4) Relapsing fever is distinguished by its abrupt onset, with rigor, high fever, pain in the epigastrium ; by its brief duration, termination by crisis, and the occurrence of a relapse at the end of a week ; by the absence of the characteristic eruption and the sero-reaction of typhoid. The finding of the spirilla discriminates relapsing fever. (5) Meningitis. — In striking contrast with the specific typhoid symp- ^ Progressive Medicine, March, 1910, p. 1S6. ^New York Med. Jn>jr., Deo. 16, 1911. TYPHOID FEVKR. 49 toms, meningitis exhibits marked hyperesthesia, intolerance of light and sound, exaggerated reflexes, and often muscular rigidity before the stage of eifusion ; also restlessness, peevishness (unlike the dulness ob- served in typhoid patients), vomiting, and constipation {vide Acute Miliary Tuberculosis). The temperature maintains a lower level on the average, and is more irregular in type than in typhoid; the pulse is more irregular, and the nervous symptoms assume greater prominence in the earlier stages, particularly headache and delirium. On the other hand, true typhoid symptoms are wanting in meningitis. (6) Tuberculous meningitis gives a characteristic- previous or family history, occurs in young subjects, and the tendon and cutaneous reflexes exhibit wide variations as to intensity, within brief periods and through- out the whole attack. An examination with the ophthalmoscope may reveal choroidal tubercles. The Widal reaction is missing. (7) Catarrhal enteritis in children, with prominent abdominal symp- toms, may simulate typhoid fever very closely. In the former the symptoms are all gastro-intestinal, save perhaps the occurrence of slight febrile disturbance and certain nervous phenomena, while typhoid fever manifests a wider range of symptoms (some of which are peculiarly its own — notably the greater prostration, more marked fever, enlargement of the spleen, the sero-reaction, and the characteristic eruption). In young children the last-named symptom may be either wanting or atypi- cal, in which case the existence of enlargement of the spleen coupled with other phenomena, particularly the Widal reaction, will suffice. (8) Salpingitis on the right side may resemble typhoid. In the former there is usually a clear history either of antecedent vaginitis or of an abortion, and there exist special evidences of local peritonitis, but not the classic features of typhoid fever. A digital examination per vaginam^ however, is necessary to the certitude of diagnosis in salpingitis. The diagnosis between typhoid fever and typhoid pneumonia, influenza, ulcerative endocarditis, and appendicitis will be considered hereafter. Prognosis. — As in all other acute infectious diseases, so in typhoid, the prognosis depends upon three main considerations : (1) The severity of the type of the infection, which is indicated in great measure by the degree of fever. A temperature of 106° F. (41.1° C.) is a serious symptom, and, if maintained at this point for a few days, an almost certainly mortal one. I have not seen a single instance in which the temperature has touched 106° F. (41.1° C.) for two or three successive days that has recovered. If the temperature mounts to and keeps at 105° F. (40.5° C.) for more than three or four days, the prognosis should be made Avith due reserve. When the fas- tigium is much prolonged, even though the fever be not exceptional, the prognosis is usually grave; while, on the other hand, marked nocturnal remissions are of favorable omen. A sudden, deep fall, however, may imply danger (intestinal hemorrhage, collapse). The researches of Isaac Ott have taught us that, while high tempera- ture is an indication of danger in specific fevers, it is not always the cause of it. He regards high temperature as being only a part of an infectious process, and points out that the thermotaxic centers of the cortex may be so disordered as to alter the harmony between the heat-production and 4 50 INFECTIOUS DISEASES. heat-dissipation. I nder these circumstances a specific fever of severe form may be associated with a slight elevation of temperature. The power of resistance to the influence of high temperature is quite reliably indicated by the condition of the heart. So long as the pulse is regular and its rate does not exceed 110 or 120 beats per minute, the outlook is favorable. When, however, the pulse maintains an average rate of 1-JO or more — a condition with which there is usually associated some degree of cyanosis, pulmonary congestion, and edema — the outcome is to be regarded as doubtful. Collapse is apt to follow the occurrence of sudden complications (perforation, hemorrhage), but it may also arise causelessly. The absence of eosiuophiles from the blood-picture is an unfivorable prognostic sign. Serious types are also shown by certain nervous symptoms, such as wild delirium, stupor, and well-marked symptoms of motor irritation. (2) Circumstances of the Patient. — Certain individual peculiarities render the prognosis highly unfavorable. It is had in yery fat persons. In such cases there is a great danger of sudden collapse, and this fact also holds to a less degree with reference to subjects of certain chronic dis- eases (Bright's disease, heart disease, gout, emphysema). Age is an influential modifying factor. After puberty the gravity of the disease increases with increasing years. Indeed, it may be said that, as a rule, typhoid has an unfavorable prognosis in persons past forty years, for the reason that at this time of life there is an added liability to pulmonary complications and failure of cardiac reserve. In children (vide Clinical Varieties) the tendency to hemorrhage and peritonitis is reduced to a minimum, and the mortality is not over 1 per cent. The puerperal state renders a typhoid patient liable to many acci- dents and peculiar complications, and independently of pregnancy the disease is more fatal among females than males. CJironic alcoholism is apt to be complicated with delirium tremens, often preceded by pneu- monia. Such patients are also prone to heart-degeneration and ex- haustion. Environment aff'ects the prognosis, poor sanitary arrangements and poor attention greatly diminishing, and the opposite conditions greatly augmenting, the chances for recovery. Improved methods of treatment in recent years have efi'ected a decided lowering of the death-rate. Here it may be said that the average mortality rate of typhoid is from 8 to 10 per cent., as against 15 to 20 per cent, formerly. The death-rate was 2.3 per cent, lower among the inoculated South African soldiers than in the uninoculated. It must ever be remembered, however, that epi- demics differ widely as to their mortality list — a fact which makes a precise statement regarding the question an impossibility. (3) The third and last consideration is the presence or absence of dangerous complications and accidents. These have all been enumerated and their prognostic significance stated {supra). Merely to reiterate some of those that lend fresh peril to the typhoid patient, arranging them with some regard for the order of their relative gravity, may prove helpful to the student. They are — perforation with diffuse peritonitis, intestinal hemorrhage, lobar pneumonia, lobular pneumonia, sudden col- lapse (due to cardiac weakness), excessive tympanites (often with marked diarrhea), and hypostatic congestion of the lungs. TYPHOID FEVER. 51 Relapses of Typhoid Fever. A relapse is a repetition of all the characteristics of typhoid after the latter has run its course. As a rule, the return occurs from one week to ten days after the beginning of convalescence, though it may be either earlier or later ; and occasionally a relapse develops before the temperature has become normal (^intercurrent relapse). The cause of relapses is a reinvasion of the blood by the typhoid bacilli or their secre- tions from within the body, and the source of the bacilli is most probably the gall-bladder. The pathologic lesions differ in no essential way from those described as belonging to the primary attack, but the stages through which they pass are not quite so long. In the interval between the primary attack and the relapse there may be present suspicious features, such as a slight enlargement of the spleen, a trivial evening rise of temperature, an unnatural apathy or dulness, and a more profound prostration than is usual. In the majority of in- stances, however, there are no premonitory symptoms. The onset is rather more sudden, and rigors are more common, than in primary typhoid. The temperature, however, rises in the characteristic " step- ladder " fashion, reaching the fastigium in two or three days, and the same relative abridgment of the fastigium and defervescence is observed. It follows that a relapse has a shorter duration than a primary attack, and, indeed, it rarely exceeds two or three weeks. The temperature may, however, touch a higher limit in the relapse than in the primary attack ; but, with rare exceptions, when the primary typhoid is of aver- age or even greater than average severity, the temperature in the relapse does not reach an equal height. The characteristic rash appears earlier — from the second to the fourth day — and is somewhat darker and coarser than that of the first attack. The spleen swells rapidly. The intercurrent relapse sets in while the temperature is declining ; the fever again rises, and often ranges higher than in the primary attack. Diagnosis. — Upon the points that are distinctive of a primary attack of typhoid fever rests the important diagnosis between a relapse and a recrudescence (spurious relapse). The latter is usually attributable either to errors in diet, to undue muscular exertion, or to great mental excite- ment ; and, whilst it occurs during convalescence, it seldom lasts longer than one, two, or three days, and is not characterized by the diagnostic symptom-group of a relapse (peculiar temperature-curve, enlarged spleen, and specific eruption). The prognosis of relapses depends very much upon the severity of the primary attack, those following severe attacks being relatively milder than those that follow the rudimentary, primary attacks. The frequency of relapses differs widely in diflFerent epidemics. Hence the fact that the percentage of relapses as estimated by difier^ ent authors ranges from 3 to 15 per cent, need excite no surprise. The relapse may repeat itself once, twice, or even thrice, and two relapses occur in about 1 per cent, of the cases. In a case which I ^ reported three successive and typical relapses occurred. The pale line or ridge which was mentioned (vide Clinical History) as noticeable in the nails after typhoid occurs similarly after each relapse, and in the afore-men- tioned case of my own four distinct whitish, transverse ridges were noted. Da Costa has recorded five relapses in each of two cases. ^ 3fed. and Surg. Reporter, vol. xlvii., p. 66. 52 INFECTIOUS DISEASES. Recurrences. — By this term is meant successive attacks separated by longer or shorter intervals after complete recovery from the primary attack." Typlioid fever usually bestoAvs lasting immunity, but this is not an invariable rule. Eichhorst has studied 600 cases, and found that in •28 of the number (4.7 per cent.) a second attack occurred. Soldiers -who are subjected to typhoid fever, commonly give a history of previous attacks (D. Parker). I have seen a number of typical recurrences of typhoid fever, in two persons, the intervals having been five and eight years re- spectively. Very rarely three separate attacks have occurred in the same individual, and a second is usually milder than tlie first attack. Treatment. — (a) Prophylaxis. — The municipal authorities possess in thorough filtration a power that can be used to advantage. For example, in A^ienna, by purification of the -water-supply, the death-rate in typhoid fever was reduced from 12.5 per 10,000 to 1.1 per 10,000. It has been well said that typhoid bacilli do not naturally inhabit water and milk, but man is their natural host, hence the primary source of the bacilli. Let us make sure that every typhoid bacillus is killed immediately on leaving every host and the disease is at an end (McCrae). The best means that can be employed during the attack, with a view to limiting the spread of typhoid, is disinfection^ and the following de- scription comprises its essential points : Disinfection in tyjdioid may conveniently be divided into (a) that of the excreta (stools, urine, vomitus, and sputum) ; (b) of the bed and its coverings ; (c) of the patient and the sick-room. While all of these subdivisions are of the greatest importance in the treatment of a case, the disinfection of the excreta (a) is perhaps most carelessly performed, and hence the importance of the statement that all stools and urine voided by the patient, as well as the vomitus and sputa, should be promptly treated as follows : The excreta should be received in a vessel that can be thoroughly disinfected inside and out with any of the several standard solutions, of" which that of chloriiiated lime (strength, 6 ounces per gallon) is the most eifective and satisfactory. it is my custom to order that one pint of the chlorinated lime solu- tion be placed in the bed-pan (or other appropriate receptacle) befoi-e the discharges are received therein, and from one to two pints after. The whole is thoroughly mixed by stirring and shaking, care being taken that all solid masses are broken up. The vessel is then allowed to stand for three hours before it is emptied into the water-closet. Phenol is also efiicient and cheap. The stool should be mixed with about twice its volume of a 1 : 10 to 20 phenol solution and allowed to stand for several hours. Gwyn^ has given the following results of his investigations into the fjuestion of typhoid bacilli in the urines of typhoid fever patients: They are present in from 20 to 30 per cent, of the cases, and may be exceedingly numerous. The organisms may persist for months or years. For the disinfection of the urine in the bladder, urotropin is serviceable when administered by the mouth. Under no circumstances, however, should its administration permit the disinfection of the voided urine to be neglected. As an irrigation, Gwyn recommends mercuric- i Philada. Med. Jour., Jan. 12, 1901. TYPHOID FKVFJt. 5'^ chlorid solutions (1 : 100,000 to 1 : 50,000), To disinfect the urine, ''the best solutions are, plienol (carbolic acid) 1 to 20, in an amount equal to that of the urine, or bichlorid of mercury 1 to 1000 in an amount one-fifteenth that of the fluid to b(^ stf'riliz<;d. These )iiixture,s with the urine should stand at least two hours. " ^ (6) It should be an invariable rule to change the bed- -and body-linen daily, and as often as soiled. The mattress should be protected by a rubber cover, and this, together with the soiled linen and blankets, should be received in a sheet that has previously been dipped in a 5 per cent, solution of carbolic acid. The rubber sheets are to be washed with the carbolic-acid solution, but all other bed-clothes miist be boiled for half an hour. When the patient leaves the sick-room the mattresses are to be fumigated and aired daily for a week, and the rubber covers and bedsteads washed with a solution of mercuric chlorid (] : 1000). (c) After every stool the patient should be cleansed with a compress of cloth or cotton wet with a solution of mercuric chlorid (1 : 2000) or of carbolic acid (1 : 40). The bed-pan and hopper are to be similarly treated, and the cloths used immmediately burned. Fitz recommends that the feeding utensils be cleansed in boiling water after using. Since it is well known that many epidemics are directly traceable to the drinking-supply of water and milk, it is necessary that all water and milk used by the patient and other members of the household be boileu for half an hour before being ingested ; and if an epidemic be prevailing, the community at large should join in this precaution. In view of the significant rOle played by the bacilli-carriers, convalescents must be regarded as dangerous for a long time after apparent recovery. The patient should report to the physician for examination of the excreta until it is satisfactorily shown that no more typhoid bacilli are being passed. Isolation of Patients. — It is advisable to isolate typhoid cases as fiir as possible — e. g.^ in hospitals, to keep them in special wards ; in private families, in special apartments. There is incontestable proof that typhoid fever is feebly contagious.^ At the Johns Hopkins Hospital 1.81 per cent, of all cases are of hospital origin (Cole). / Prophylactic Inoculations. — Excellent results have followed the fre- ventive inoculation of healthy persons with typhoid virus. The striking results of antityphoid vaccination are shown by the Medical Corps of the United States Army, e. g., the Maneuver Division at San Antonio, Tex., in 1911 : Mean strength, 12,801 ; cases of typhoid fever, 1 ; deaths from typhoid fever, 0. The procedure of administration is as follows : " The initial dose is 500,000,000, and two successive doses of 1,000,000,000 are given at ten- day intervals. The antibodies develop in from five to ten days later, and are bacteriolysins, opsonins, and agglutinins, the last in large amounts. The last two measure the antibodies present, since their quantitative re- lations are quite constant. The increase in agglutinins is quite evident in four to five days ; the fall begins in six weeks and the normal is reached in fifteen months. The injection is given in the deltoid region, the skin being previously washed with tricresol solution and soap. The needle 1 Jour, of Amer. Med. Assoc, April 6, 1912, p. 1015. ^ Philada. Hosp. Report, 1891, vol. i., p. 149, by the writer. 54 INFECTIOUS DISEASES. puncture is closed Avith the compound solution of tricresol (cresol, 500 ; linseed oil, 350; potassium hvdroxid, 80; water, to 1000). Tincture of iodin may be substituted for the latter purpose, but the compound cresol solution for use in camps is the ideal method" (R. AV. Wilcox).^ Irwin and Houston successfully treated a case of persistent typhoid bacilluria by means of a .vaccine prepared from typhoid bacilli. (J) Treatment of the Attack. — (1) The general conduct of the case, including skilful nursing, is of paramount importance to the typhoid patient. He should be put to bed as soon as the indications point to this disease, and kept there continuously in the recumbent posture till the end of the attack. The sick-room should have a sunny exposure if possible ; should be cool and well ventilated, though free from strong currents ; and perfect cleanliness both of the room and of the utensils employed in the management of the case should be attempted. The bed should be provided with a woven-wire mattress, upon which should be placed one of hair. A rubber cloth is spread beneath the sheet, and the latter kept smooth in order to lessen the danger from bed-sores. A seriously ill patient should lie on an air-cushion or, better still, a water- bed, and to avoid bed-sores he should be instructed to turn gently to either side from time to time. His back, hips, and heels should be bathed frequently with a mixture of alum and salt in dilute alcohol. The use of the bed-pan and urinal is an absolute necessity. When a good nurse cannot be had, the attending physician must note in writing the directions regarding the disinfection of the excreta, bed-linen, and utensils, as well as regarding the exhibition of the food, medicine, etc. The mouth and throat should be kept clean, since by so doing we obvi- ate unpleasant and even dangerous complications (aphthous ulcer, thrush, parotitis, lobular pneumonia, etc.). If they arise, the nurse or attendant should w'ash the mouth and tongue several times daily with a solution of boric acid (3 per cent.), and the throat may be sprayed at equal intervals with a similar solution. A frequent moistening of the tongue and mouth, and particularly the lips, with glycerin and water (equal parts) gives great comfort when they are dry and parched. (2) An appropriate liquid diet should be employed, and the best article of food is milk, which it is well to dilute with plain water (or lime-water), since aerated waters are objectionable in that they some- times increase the meteorism. The daily quantity should not be less than three pints, and it is important that the stools be examined, since, if the milk be not thoroughly transformed, curds or (on microscopic ex- amination) numerous fat-globules will be seen, in which case a smaller amount should be given. If curds or fat are still seen, the milk should be peptonized. Experience teaches that milk is often better taken and better borne when a little brandy, coffee, or tea is added to it. When milk cannot be taken or digested in sufficient amount, either whey, sour milk, or buttermilk may be tried; and if these be distaste- ful, we may replace them (wholly or in part) by meat-juices or broths of various sorts, together with one of the standard infant's foods made with milk or water. Albumin-water, prepared by straining egg-white through a cloth and adding an ec^ual part of water, has given much satisfaction in my hands. It may be made pleasant to the taste by 1 Amer. PracL, March, 1912. TYPHOID FEVER. 55 flavoring with vanilla or lemon, and with meat-juice and Ijroth.s will often support a patient during the most trying period of tlie attack. High calorie feeding is advised by Shattuck, Robertson, Shaffer and Coleman, and others, e. g., a dietary made up as follows : a quart of milk, a pint of cream, six ounces of milk-sugar, eggs, toast, butter, cereals, potato, apple-sauce, and the like. There are typhoid su})jects Avho cannot (on account of vomiting, etc.) take per oram sufficient nourisliment to support life. In such cases we may supplement the usual method of feed- ing by rectal alimentation, when from 8 to 4 ounces (96.0-128.0) of pep- tonized milk, \ ounce (16.0) of meat-juice, and a little egg-white may be combined, and employed at intervals of four hours. In early convales- cence the patient may take milk-toast, well-cooked plain rice, entire eggs (diluted), or thin custai'ds. Solid food should not be allowed till the tem- perature has been at the normal grade for one week at least. In cases in which the fastigium tends to become prolonged with increasing prostra- tion, and those presenting the fever of exhaustion, the administration of soft food (eggs, finely scraped meat, well-cooked rice, plain) is often fol- lowed by improvement. Pure cold water has a positive value as a diuretic in this disease. Gushing and Clarke ^ used large quantities of water internally (a gallon or more in twenty-four hours), administering it in small quantities at fre- quent, definite intervals. The toxic symptoms and mortality were lessened. The internal use of water stimulates renal activity by raising the blood- pressure. (3) Stimulants are useful in about 50 per cent, of the cases. When the first heart-sound becomes weak or the vascular tone diminished, alcohol should be used regardless of the temperature. In severe types whiskv is the best form ; in milder ones some good wine, such as port, sherry, or madeira. It is well to begin with a moderate daily quantity, and then in- crease, if necessary, until the indication is fulfilled. If the patient so desires, we may use brandy instead of whisky, and it is usually toward the close of the second or during the third week of the disease that the indi- cations for the use of alcohol arise. It is not only the best spur for a flagging heart, but is of equal value in combating unfavorable nervous symptoms due to the typhoid septicemia ; and the time for commencing its use may be indicated first by the latter symptoms {e. g. delirium, coma, tremor). The quantity to be administered must be regulated by its efiects, since it may act injuriously, and even aggravate the symptoms, though this is seldom the case. Threatened collapse may be met by full doses of alcohol (^ ounce — 16.0 — every hour), combined with strychnin (gr. -^ — 0.004 — every three hours), exhibited subcutaneously till the depression has been counteracted. Effective doses of diffusible stimulants, as champagne, are useful during periods of sudden circulatory depression. The cardiac stimulants mentioned above may be further supported by the use of digitalis and sulphuric ether. Stengel has recommended hypodermic injections of 1 to 2 grains (0.0648-0.1296) of camphor dissolved in 15 minims (1.0) of sterilized olive oil as a cardiac stimulant in typhoid fever. (4) Hydrotherapy. — There is at the present day general agreement among medical authors that the best mode of treating typhoid fever is 1 Amer. Jour. Med. Sci., February, 1905. 56 INFECTIOUS DISEASES. by means of the cold hath, which was originally introduced by Currie, of London (more than a century ago), and reintroduced and ^^uccessfullv practised by Brand, of Stettin. The benefits oft'ered to the patient by this method are so great and varied that it becomes the duty of every physician who treats typlioid fever to be prepared to employ it. The beneficial influences of the baths are as follows: (1) They absorb the body-heat directly, thus reilucing the temperature and overcoming the ill effects of high fever, this action becoming more marked after a day or two of the treatment : (2) They improve the nervous symptoms, diminish- ing mental dulness, delirium, stupor, muscular tremors and twitehings, and inducing sleep ; (o) They strengthen the heart, thus obviating the danger of sudden circulatory collapse and the consequences of increasing cardiac weakness (hypostatic congestion of the lungs, venous thrombosis, etc.) ; (4) They stimulate the respirations, whereby the inspirations are deepened and the tendency to pulmonary complications greatly lessened, especially severe bronchitis, lobular pneumonia, etc. ; (5) The renal func- tion is invigorated, and as a result the elimination of typhotoxins by the kidneys is increased (Roque and Weil) ; (6) On account of the cleanliness of the skin which they ensure, bed-sores rarely occur ; (7) They may shorten the stay in the hospital or sick-room, but not the stay in bed, except, perhaps, in the lighter types. L nquestionably, the good efiects of this method receive striking con- firmation from statistical reports which have been prepared by Brand, Osier, Jiirgensen, and others abroad, and by Baruch, Wilson, and others at home. According to the warmest European advocates of the method, the mortality is less than 0.5 per cent. The results among American clinicians give an average mortality of 7.3 per cent. During five years 408 cases have been treated by the bath-n:!ethod in the Royal Victoria Hospital, Montreal, with a mortality of 4.4 per cent. The tub is to be brought to the bedside of the patient, and in hospital practice both bed and tub should be screened while the bath is in progress. After removing the night-dress and placing a large napkin around the loins, the patient should be lowered into the bath by a sheet held at each corner by an attendant (and, if seriously ill, with the least pos- sible disturbance), and there carefully supported and held while in the bath. If sleeping, the j^atient must be awakened and the bath de- layed for ten or fifteen minutes. Young subjects and adults in light cases of the disease may be handled properly by two persons, but I do not approve of allowing the patient to step fi'om the bed into the bath, however light the case. While in the bath the skin-surface, particu- larly that of the back and limbs, is constantly rubbed by the attendants, in order to stimulate the peripheral circulation and as far as possible to avert chilliness and discomfort. The head of the patient rests upon a rubber air-cushion. At first he should be kept in the bath five to eight minutes ; later, ten or fifteen minutes, according to the severity of the case. The head and face are bathed at once from a basin, and a cold compress is applied to the forehead, and, if prominent nervous symptoms be present, often associated with high temperature, water at 70° F. (21.1° C) or lower should be poured from an elevation of about six inches upon the head and nape of the neck several times during the bath. The ears must be stopped with cotton when douching is practiced. ^9 58 INFECTIOUS DISEASES. If while in the water the patient complains bitterly of the cold or is very restless, a stimulant may be administered — f5J (32.0) of whiskey, diluted — and if this fails he must be lifted into bed and further stimu- lated. If he be very young, highly sensitive, or elderly, it is best to place him at the commencement in water of a temperature of 85° or 90° F. (29.4°-32.2° C), and then gradually cool it down to 80° F. (26.6° C). After he has become accustomed to the bath he may be immersed in water at the temperature of 80° F. (26.6° C), to be re- duced to 75° F. (23.8° C.) or even 70° F. (21.1° C), below which it is unnecessary to go save in the rarest instances. This is the gradually cooled bath of Ziemssen. In the rigid Brand method, which is, perhaps, less generally adopted at present than several years ago, the patient is lifted at once into a bath at 70° F. (21.1° C) and kept there for fifteen minutes. He is to be removed from the bath to the bed (previously pro- tected by a blanket and mackintosh), wiped off gently ; after which the sheet, blanket, etc., are withdrawn and he is covered with a fresh blanket. If now reaction be retarded, some hot broth or about an ounce of whisky should be administered and active friction applied to the back and extremities. The effect of the bath is best shown by the rectal temperature, which is taken half an hour after the conclusion of the bath, and again a half hour later if the patient be not asleep. Usually the temperature will be found to be two or three degrees lower than before the plunge - ■ ■ -^ Fig. 6. — Portable bath-tub in use. (see Fig. 5). In obstinate and severe cases the fall may be less than one degree, in which case it is advisable either to prolong the bath to twenty minutes or to reduce still further the temperature of the water. Protracted warm baths are highly recommended by Reisse and others when cold baths are badly borne or are unproductive of good results. In light cases the cold bath should be repeated every six or eight hours; in severe ones, every three or four hours, but more frequently than once in three hours is not advisable, even in the worst cases. Sufficient water to immerse the patient to the neck (about 30 gallons — 114 liters) should be used. During the night the patient should be allowed to sleep for six or eight hours if he can do so. There are a number of convenient and satisfactory portable tubs in the market, but that devised by Dr. C. L. Furbush of Philadelphia TYPHOID FEVER. 59 possesses certain leading advantages (Figs. G, 7). The frame is made of light wood, and when folded is 4 inches (10.1-06 cm.) in depth, 14 inches (35.546 era.) in width, and 5 feet 10 inches (1.778 m.) in length, so that it can be placed in a closet or beneath a bed. Less than two minutes are required to prepare the bath, which the patient receives while lying in bed. When in use the ends are fastened by brass pins hung on small chains, and these hold the frame in a fixed position. The tub proper is made of double-faced sheeting, reinforced in the middle, so as to resist the greatest amount of pressure. The Bides of the sheet have a casing through which is passed a wooden rod 4 feet 4 inches long (1.320 meters), and outside of this a margin of IJ inches (3.808 cm.) is left for the brass eyelets, through which passes a rubber cord which is covered with woven cotton. This cord, which is attached to the sheet, is held to the frame by special brass fittings along the lower sides of the latter. By the use of the cord and wooden rods we have an even tension on both sides, combined with ample resistance to withstand the pressure of the water. An ad- justable head-rest fits into the end of the frame. The wooden rod also enables the attendant to roll up the sheet quickly after the bath. Through the bottom of the sheet a 1-inch rubber tube is fitted with a stopper, and by means of this the tub can be emptied sooner than by a siphon. The frame is covered with ivory-enamel paint, and can be cleansed easily. The entire weight of the outfit is 25 pounds (11.33 kgms.). Fig. 7.— Portable bath-tub, folded. Brand recommends that the baths be commenced when the tempera- ture in the rectum reaches 102.2° F. (39° C). The height of the tem- perature, per se, is not to be invariably regarded as an absolute indi- cation for the employment of the cold bath, since the facts must be recollected that the essential effect is a stimulation of the nerve-centers Avhich preside over the organic functions (respiration, circulation). Baruch insists that the object of cold baths with friction is to sustain the nervous system and circulation rather than for temperature reduction. The contraindications to the use of baths are — (1) Intestinal hemor- rhage, which is in itself attended with danger and requires absolute quiet for a time (four days), when the baths may be resumed if there is no recurrence. (2) Peritonitis, the occurrence of which always excites 60 INFECTIOUS DISEASES. suspicion of perforation. Here, again, rest and all that the term im- plies must be procured. (3) Extreme Cardiac Weakness. — The excite- ment in the necessary handling of the patient connected with the bath might prove fatal, as I have witnessed in one instance. This condi- tion is sometimes met with in cases that come under observation at a late period, and in cases arising in aged and enfeebled subjects. (4) Cases that have progressed to an advanced stage (the third week of the disease) should not be immersed. Dangerous and even fatal collapse has been observed to follow cold baths under these circumstances. Substitutes for the Cold Bath. — The prejudice which exists against the cold-bath treatment — at least in America — sometimes proves insur- mountable. Again, there are many physicians who do not avail them- selves of the means at command for carrying out hydrotherapy. In consequence of these facts substitutes for the tub baths are quite com- monly in vogue. Among them, cold sponging of the body of the patient is often resorted to, though it secures for him trivial advantages as com- pared with those of the baths. If this method be employed, the water should be of the temperature of the air of the room or ward. The limbs should be sponged and dried in succession, and then the trunk. When- ever the temperature reaches 102.5° F. (39.1° C) this measure is to be instituted, each sponging being continued until the desired effect has been produced (a reduction of the temperature of ]i° to 2° F. — 1° C), unless the patient gives signs of uneasiness, when it must be cut short. It may be repeated as often as required. To the water used equal parts of vinegar or spirits should be added. The efficacy of the cool sponging is enhanced by the simultaneous application of the ice-cap, either constantly or intermittently. If this method fails, as it often does in severe types, the cold pack may form a satisfactory substitute ; and I have found it of great use with children, in wliom the reaction after a cold bath is often delayed or imperfect. The patient is placed upon a cot previously prepared by spreading over it a blanket, which is in turn covered with a sheet doubled and wrung out of water of the required temperature — 70° to 80° F. (21.1°-26.6° C). The sheet and blanket are now Avrapped about the patient evenly, and he is left in the pack for a period varying from a half to one hour. Free diaphoresis generally ensues, and this aids in maintaining the fall of temperature. The effect, in most instances, is to reduce the body-heat two degrees or more, and the treatment may be repeated at intervals of three or four hours if needful. The wet sheet alone may surround the patient, and be sprinkled at short intervals with a watering-pot containing water at a temperature of 70° F. (21.1° C). In desperate cases ice-water enemata may be tried. If carefully administered they accomplish a reduction of the temperature by two or more degrees. Leiter's coils may be applied to the head, chest, or abdomen. Guaiacol has been used for its antipyretic effect by H. G. McCormick and others, from 10 to 30 minims (0.666-2.0) being applied to the skin surface. I have seen its use followed by rigors, hyperpyrexia, etc., but McCormick uses sufficient only to lower the temperature to 100° F. (37.7° C), and has thus avoided all ill effects. (5) Internal Antip3rretics. — The most reliable of this group of medic- TYPHOID FEVER. 61 aments (phenacetin, acetanilid, and antipyrin) are open to the serious objection that they depress cardiac power. F^inee heart-enfeeblernent, which may develop either gradually or suddenly, is recognized by present- day clinicians as a common danger-signal of the disease, the time lias come when the employment of coal-tar products should be discontinued. (6) Intestinal Antiseptics. — Unquestionably these neither destroy the bacilli nor counteract the ill effects of their toxins, since both become active after they pass beyond the intestinal mucosa ; but they are indi- cated in cases in which tympanites is a prominent manifestation. Some of the toxic substances occupying the intestines in this disease result from the acquired virulence of usually harmless organisms, and the amount of decomposable material is increased owing to defective hepatic and gastric secretions. Salol is broken in the intestinal canal into car- bolic and salicylic acids, and has proved capable of controlling meteiir- ism as nothing else has done in my hands. The dose is 2 to 3 grains (0.1296—0.1944) every three hours, preferably administered in capsule. With it I usually combine quinin in doses of 1 to 2 grains (0.0648-0.1296) each. Henry speaks in favor of thymol, and guaiacol carbonate has many advocates. Wilcox ^ urges that chlorin is capable of disinfecting the intestinal tract. Acetozone in daily doses of 15 to 20 grains is both an efficient and harmless intestinal antiseptic ; it should be dissolved in a liter of water, flavored with some one of the volatile oils, and taken in divided portions. Systematic lavage of the intestinal tract is advisable in excessive tympanites. In cases in which pronounced meteorism occurs the use of hydrochloric acid in small doses after each feeding is serviceable, since the secretion of this agent, which normally inhibits putrefactive changes, is lessened.^ Mild purgation Avith calomel, espe- cially in the earlier stages, is useful. Carbolic acid, iodin, sulphocarbolate of zinc, and other antiseptic agents have their advocates. Turpentine fulfils a leading indication. When the tongue is dry and brown, the abdomen distended, the general prostration marked, and often muttering delirium present — symptoms of the typhoid state — the use of this agent, together with alcoholics, constitutes the best mode of treat- ment. Of the rectified oil of turpentine, ITLv-x (0.333—0.666) may be ad- ministered every third hour until relief is afforded. (7) Curative Inoculations with Cultures and Serum. — In 1897 Boken- ham^ prepared an antityphoid serum from the horse. Chantemesse* has treated 1000 cases (using his own serum), with a death-rate of 4.3 per cent., while of 5121 patients who received routine treat- ment during the same period, 17 per cent. died. Hughes and Carter treated a number of cases with blood-serum derived from convalescent cases, but apart from a decided lowering of temperature the general course of the disease was not perceptibly modified. H. Forssman treated 20 cases with the typhoid serum of Kraus, and in those in which it was used early in the first week, the disease showed a mildness, which otherwise occurred only as an exception during the epidemic. M. W. Richardson,^ 1 Med. News, February 11, 1899. 2 See Therap. Gaz., April 15, 1900, by the writer. ^ Transactions London Pathological Soc, vol. xlix., p. 373^ ^Hyg. gen. et appliq., 1907, p. 577. ^ Boston Medical and Surgical Journal, Oct. 3, 1907. 62 INFECTIOUS DISEASES. from a study of specific therapy in 130 cases of typhoid fever "with Vaughan's non-toxic residue of the typhoid bacillus, concludes that it prevents relapses if inoculations are continued into convalescence. The value of vaccines for the following purposes must be conceded : "(1) As a means of prophylaxis ; (2) in suitable cases when continued during con- valescence, to prevent relapses ; (3) to combat local infections with the typhoid l)acillus, as, for example, bone suppurations which arise in the period of convalescence ; and (4) for the removal of the typhoid bacilli from the feces and urine in the case of typhoid carriers. " ^ Chantemesse, Walters and Eaton, Sadler, and others report marked reduction of the mortality-rate of this disease under vaccine therapy. All observers, however, agree that very severe cases show no improvement. The dosage has varied greatly with different clinicians, e.g., Sadler found an initial dose of 1,000,000 to 2,000,000 killed bacilli injected subcutan- eously most beneficial, followed by a smaller dose every four or five days. •' On the other hand, Walters and Eaton used doses of 100,000,000 to 500,000,000 bacilli."- W. Broughton-Alcock states that the living sensibilized bacilli should be preferred. (8) Treatment of Individual Symptoms and Complications. — Headache. — Early in typhoid the headache demands relief. Absolute rest and cold to the head frequently suflSce. Depressant analgesics are to be avoided so far as possible, although it sometimes becomes necessary to resort to them. At such times those least objectionable are to be selected. I have found that a mixture containing sodium bromid (gr. x to xv — 0.6480 to 0.9720) and the deodorized tincture of opium (TTliij to v — 0.1998 to 0.3330) in each dose, given at intervals of three or four hours, exercises a striking palliative influence. In occasional instances the above mixture fails, and then phenacetin (gr. ij to iij — 0.1296 to 0.1944) may be substituted for the opium in the same combination. Insomnia. — The cold baths or other measures calculated to relieve the headache often procure for the patient refreshing sleep. It is im- portant not to allow him to go too long without sleep, since this tends to the development of a pronounced "typhoid state" and its concomi- tants. When the agents recommended for the headache fail, I employ morphin hypodermically in small doses (gr. -J^ to \ — 0.004 to 0.008) during the evening hours with excellent results, withdrawing the remedy so soon as decided amelioration of this symptom has taken place. Codein, sulfonal, and, more recently, veronal, trional, and chloralamid, have proved useful. Chloral is certain in its action, but I have abandoned its use, since it apparently produced circulatory collapse in two instances. Delirium. — Since the introduction of the Brand method delirium rarely calls for special medication. I have observed, in common with others, particularly during the advanced stages, that in cases in which the circulation was feeble and in which typhomania was a prominent feature, the administration of stimulants with a free hand completely dispelled the nervous phenomena. If alcohol fails, ether (iTtx — 0.666 — at a dose) may be given hypodermically, and repeated in one or two hours if necessary. To combine with the arterial some nervous stimu- ^ Journal of the American Medical Ass^ocintinn, Dec- 10, 1910, by the writer. 2 Editorial, .lonr. Amer. Med. Assoc, June 29, 1912, p. 2035. TYPHOID FEVER. 63 lant (musk, valerian) will be found serviceable, particularly in cases in which the delirium assumes an hysteric type. Of" special value are the bromids, hyoscin hydrobromate, the persistent use of ice to the head, and the agents suggested for the headache and insomnia. Vomiting is rarely troublesome. Its chief cause is the irritation of the gastric mucosa, from improper diet or medication. After the re- moval of the cause, the use of ice in small pieces by .swallowing affords relief. If vomiting occur during the period of development, minute doses of calomel, combined with sodium bicarbonate, may be prescribed with good effect. If it occur during the fastigium, the amount of milk taken should be reduced by one-half, peptonized, and then diluted, preferably with lime-water. If the patient experience a strong aversion to milk, it must be suspended temporarily and albumin water and broths substituted. Dry champagne may be administered simultaneously. Ex- cessive irritability of the stomach calls for rest of the organ for a period of twenty-four hours, the patient being meanwhile supported by rectal alimentation and subcutaneous medication. Diarrhea more than any other single symptom claims special attention. Two to four movements daily do not constitute diarrhea and do not de- mand treatment. It may be caused by overfeeding or by improper food —as shown by the stools, as a rule — in which case regulation of the diet is curative. It is often due to ulcerated and catarrhal lesions of the intestines, and particularly the large. Unquestionably, intestinal anti- septics which possess the property of insolubility are most valuable. Astringents may be combined with the latter or given separately. The subjoined formulae have yielded good results in my own hands : !^. Betanaphtol, 3j (4.0) ; Bismuth, subgallat., 3ij (8.0). M. et ft. capsulse No. xxiv. Sig. One every two or three hours. ^. Plumbi acetat., gr, xxiv (1.555) ; Phenylis salicylat., 3ss(2.0). M. et ft. capsules No. xii. Sig. One every three or four hours, as required. Large doses of bismuth (gr. xxx — 2.0) every third hour are useful. Late in typhoid fever, when the ulcers are fully developed, opium is of service ; it tends to arrest the peristaltic action which keeps up the diarrhea and favors the spread of the inflammation to the peritoneum. When distention is increased by the use of opium it is to be omitted. I have recently observed brilliant results from the use of rectal injections of an astringent solution (tannic acid 1-2 per cent.), alternated with an anti- septic solution (salicylic acid 1-2 per cent.), each given once daily. Constipation is to be relieved by simple enemata of soapsuds every second day. Calomel may be used in the early stage of dynamic cases. Its employment may be followed by symptoms of a milder type than are ordinarily encountered. If constipation exists during the third week, ac- companied by an oscillating temperature-curve, saline laxatives in small but repeated doses may cut short the attack. Or, 64 INFECTIOUS DISEASES. Tympanites. — This is sometimes a most distressing symptom, and treatment should be commenced early. As a remedy for tympanites tur- pentine is excellent and richly deserves a trial, but it does not, as some claim, influence the general course of the disease. When employed for this symptom alone I prefer to apply it in the form of stupes over the abdomen, although when, as is frequently the case, the gases occupy chiefly the large bowel, turpentine enemata should be given. Irrigation of the colon with the normal saline infusion has recently proved most effective in relieving excessive tympanites. Eserine, gr. yj-^^, every third hour, administered hypodermically, sometimes proves efficient. The meteorism is often increased by the milk taken, and a change of food to meat-juices and albumin-water may be tried. Hemorrhages. — The bowel-movements, if the hemorrhage has been copious, must be allowed to pass into the draw-sheet. The ice-bag (sus- pended if possible) should be applied to the right iliac region, and ice ireely given by the mouth. Morphin, to control peristalsis, must be given, and, by preference, hypodermically. It may be supplemented by full doses of the acetate of lead. Cases in which slight oozing appears from time to time require turpentine. Adrenalin chlorid is serviceable, and Cnrtin ' derived advantage from the use of suprarenal extract in cases in which there was general hemorrhage. The amount of food should be greatly restricted, and in serious bleedings abstinence from food for from twelve hours to three or four days is to be observed. When feedings are resumed, a teaspoonful or tw^o of cold milk (repeated every two hours) may be given during the first twelve hours, then gradually increased in amount. For severe hemorrhages, saline infusion, either by the method of intravenous injection or by hypodermoclysis or entero- clysis, is to be strongly advised. The saline solution not only raises the blood-pressure in the vessels, but it also has a hemostatic action. The proper strength is 8 : 1000, and from 10 c.c. (3 fluidrams) to one-half liter may be employed if the collapse is marked, and repeated several times in the course of a day. Rectal injections may be somewhat larger. McCrae^ advises calcium lactate in doses of 20 grains a day ; it may be given subcutaneously, if rapid action is desired, in a 1 per cent, solution. Calcium salts are indicated where the coagulation time is slow. In case the blood gives a poor agglutination reaction, phlebotomy to the extent of about 10 ounces (according to the physical condition of the patient) may be tried. On the other hand, Avith the patient in extremis, trans- fusion may prove effective. Peritonitis. — Operation for perforation offers some hope of cure, and with the progress of convalescence the chances of recovery from this acci- dent improve. Deaver regards the acute development of pain and gen- eralized abdominal rigidity" and tenderness as an urgent indication for immediate celiotomy. Keen's statistics show that between twelve and twenty-four hours after perforation is the most favorable time for opera- tion, this period giving 30 per cent, of recoveries. Le Conte^ holds that it should be immediately undertaken. Rarely, appendicitis supervenes in typhoid fever. It demands prompt removal of the appendix. 1 Prnc.epdincjH Fliila. Co. Med. Soc, Nov., 1902. ^Jour. Amer. Med. A.tsoc, Sept. 19, 1908. ^Jour. Amer. Med. Assoc, Nov. 8, 1902. TYrilOID FEVER. 65 Lobar Pneumonia. — Its treatment, when a complication, ■will be con- sidered hereafter [vide Secondary Pneumonia). Pneumo-typhoid requires the same measures, until the true typhoid symptoms arise, as primary' adynamic pneumonia {vide p. 126). The hypostatic congestion of the lungs is to he met by heart- stimulants and by frequently changing the position of the patient. Bronchitis. — No special measures are necessary when the bron- chitis is confined to the larger tubes, as in typical cases, while, if diffuse, its management is like that of h-onclto-rrneumnnia {vide p. 559). Laryngitis. — For this condition counter-irritation should be tried; and if this fails, a small blister may be applied below the angle of the jaw on either side. For edema of the larynx scarification and the inhalation of steam are useful measures. Then, should suffocation become imminent, tracheotomy should be performed without delay. Operation "gives a mortality of only 55.5 per cent." (Keen). Bed-sores. — The preventive measures have already been considered, but the smallest bed-sore demands active treatment. It is to be kept clean and dusted with a powder composed of equal parts of boric acid, calomel, and bismuth ; if sluggish, with a powder made up of aristol and iodoform. Thrombosis of the femoral vein is best treated by elevating the part and keeping it at perfect rest. An ointment composed of equal parts of unguentum ichthyol (12 per cent.), lanolin, and unguentum belladonna, may be applied along the course of the affected vessel thi'ice daily. (9) Management of Convalescence. — Some of the points connected with this subject have already been discussed {diet, time for getting up, etc.). I may add that should a recrudescence occur the patient should be kept at rest in the recumbent posture and a return made to the liquid forms of food. Often a moderate laxative serves a good purpose, particularly if an indiscretion in diet have been committed. The ulcers may not be healed, though the temperature may have been normal for a week or ten days ; hence the patient should not be allowed to stir about for a period of two weeks after the temperature has become normal. At first his movements should be slow ; he may soon, however, be allowed to exercise gently in the open air during seasons of favorable weather. Mental excitement is to be avoided. Occasionally during convalescence the diarrhea persists, being due to colonic ulceration, and is best treated by restricting the diet to milk and other light forms of albuminous food. The patient must be confined to bed. Medicinal treatment by the oxid of zinc internally and the use of astringent and antiseptic rectal injec- tions, as before indicated, usually proves successful. Constipation is best relieved by simple enemata. Most patients require tonics. «We should begin with a vegetable salt of iron in combination wifh a simple bitter {e. g., infusion of gentian), and later an inorganic salt of iron, with quinin and strychnin, may be used. Relapses are to be treated as primary attacks. QQ INFECTIOUS DISEASES. Paratyphoid Fevers. This term is applied to a group of affections that closely simulate typhoid fever clinically, but are due to different niicrobic cause. Pathologfy. — The anatomic clumges are simply those of septicemia with splenic swelling and occasionally non-specific ulcers in the intestine. H. Gr. Wells and L. 0. Scott ^ have summarized the pathologic findings of 5 cases of paratyphoid and concluded that its pathology is different from that of ordinary typhoid. In 3 cases reported the ulcers resemble those of dysentery rather than those of typhoid ; there are slight, if any, changes in Peyer's patches or the solitary follicles. The mesenteric glands show alterations, and focal necroses have been noted in the liver. Ktiology. — The disease is not a unit, but is probably caused by several members of the colon family. These organisms possess proper- ties intermediate between the bacillus typhosus and the bacillus coli communis. Longcope^ and others have found the paracolon bacillus; Ruxton, the paratyphoid bacillus, which is closely related to the bacillus typhosus. The paratyphoid bacillus is regarded as ubiquitous in certain parts of Germany. The predisj^osinc/ factors and soui'ces of infection are about the same as for true typhoid fever. Sacquep^e and Bellot traced an epidemic comprising 19 cases to a cook (paratyphoid carrier). Minertz * claims paratyphoid to be an entirely different disease from typhoid, his experience confirming the fact that infection is derived from meat, espe- cially pork, and not from human sources. Bainbridge* holds that meat- poisoning and paratyphoid fever are distinct diseases. Symptoms and Course. — Typical cases usually manifest features that should arouse suspicion of their true nature. Brill has contrasted the diagnostic featui^es of true typhoid fever and these allied conditions. The incubation-period is somewhat briefer and the onset more abrupt than that of true typhoid. After three or four days of malaise the temperature rapidly rises to 104° F. (40° C.) or over, replacing the characteristic step-ladder curve. Mental dulness and apathy develop earlier and are marked. The initial headache is more intense, and constipation is common, although diarrhea is also observed. Brion's figures show diarrhea in 18 per cent, of the cases and melena in 5 per cent. The spleen is enlarged and rose-colored spots may appear, but the Widal reaction is absent. The duration of paratyphoid fever may be short, and the temperature decline by rapid lysis or crisis, or it may be long. Convalescence is also less protracted. J. H. Pratt refers to the frequency of complications (4 per cent.) ; they differ but little, either as to incidence or character, from those of typhoid fever. Relapses occur. Diagnosis. — A bacteriologic diagnosis is essential. Cultures of paratyphoid bacilli can be obtained from the feces, urine, rose-spots, although i^teferably from the blood of the veins. The various subtypes of paratyphoid bacillus may be distinguished from one another by agglu- tination (Bielyaeff). It is necessary to test simultaneously the action of serum upon the typhoid bacillus and upon the paratyphoid bacillus obtained from the patient. Swan ^ suggests that if a bloo) diphtheritic. It is pro})able, hut not proved, that all of the cases of" bacillary dysentery are due to a common micro-organism — the Shiga bacillus (Bacillus dysenteriai). The classification of catarrhal dysentery, therefore, still rests upon its clinical and pathologic manifestations, although many, if not all, of the cases as shown by the observations of Vedder and Duval ^ are etiologically identical with epidemic tropical dysentery. Flexner's statistical studies indicate tliat the Bacillus dysenterijB (especially the so-called " Flex- ner-Harris '' type), can be isolated from the intestinal discharges, and the intestinal mucosa of " a large percentage of children suffering from the diarrheal diseases prevailing along the Atlantic sea-board of the United States during the summer months."^ (a) Catarrhal Dysentery. {Sporadic Dysentery.) Pathology. — The solitary follicles are affected chiefly, and are the seat of hyperplasia, folloAved by necrosis, with the formation of small ulcers. This is common in children. There may be a purulent inflam- mation of the entire mucosa, w^ith more or less erosion of the surface, and superficial ulceration exists. In both forms the lesions are mainly con- fined to the large intestine, though the ileum is sometimes implicated. Special Btiology. — The catarrhal form of the disease is the one most commonly met in the United States, and is to be classed Avith acute dysentery ; it may accompany some of the acute infections (scarlatina, malaria, typhoid fever, tuberculosis), and is seen in institutions. Clinical History. — There may be prodromes., lasting one or two days, which take the form of a mild gastro-intestinal disorder (anorexia, slight pains in the abdomen, followed by diarrhea). The characteristic symptoms are mild colicky pains in the abdomen, followed by discharges from the bowel, which at first number from three to six daily. Soon they become frequent and are accompanied by straining and tenesmus, and now their number ranges from ten to no less than one hundred or more per day. Indeed, the desire to go to stool may be almost constant, and the rectum is the seat of intense burning sensations during and after each evacuation of the bowel. The character of the discharges varies with the diflfereut periods of the aff'ec- tion. During the first thirty-six or forty-eight hours they are feculent (sometimes scybalous masses), rather copious, and intermingled Avith some mucus and blood. For the next four or five days the stools are scanty, measuring from 2 drams (8.0) to \ ounce (16.0), and are made up of a sero-mucous fluid or of a muco-purulent material with blood. The chief constituents of the stools are mucus, blood, and pus, any one of which may preponderate. Microscopic examination of the usually glairy stools shows red blood- corpuscles, numerous leukocytes, generally large, oval or round epithe- lioid cells containing fat-2;]obules, vacuoles, and bacteria (especially those connected with putrefaction). A few shreds (portions of necrosed mucous membrane) may appear ^ Jour. Exper. Med., Feb. 5, 1902. ■* Studies from the Rockefeller Institute for Medical Research. Reprints, vol. ii., 1904, p. 134. 74 INFECTIOUS DISEASES. from time to time in the dejecta. At the close of the first week, and a little later, the discharges become less frequent and the amount of mucus and blood diminishes. The stools are now of a greasy brown or dark- green appearance, fecal matter reappearing in them, and soon they are again fully formed. Other Symptoms Referable to the Alimentai^y Tract. — The tongue has a greasy coating — moist at first, dry later — and at last may become red and glazed. Anorexia is present, with excessive thirst, and vomit- ing may rarely occur. There will usually be tenderness over the line of the colon, but there is an absence of tympanites. The general symptoms are Avell marked only in the severer types. The patient is debilitated, sometimes even collapsed, as shown by the small, frequent pulse, cool skin-surface, the rapid wasting, and weak, hoarse voice. The temperature is not much elevated, though it may touch 103° or 104° F. (39° or 40° C), and the curve is an irregularly remittent one. Diagnosis. — This can easily be made upon the intestinal features and from the character of the stools — frequent, small, slimy (or bloody) discharges, accompanied by distressing tenesmus. Differential Diagnosis. — Symptoms simulating dysentery may appear in the course of certain rectal affections, such as strangulated hemor- rhoids, syphilis, and epithelioma. In these conditions there is a different history and the symptoms of proctitis are less acute, while a physical ex- amination of the rectum will settle the diagnosis in doubtful cases. Prognosis. — The duration of mild cases is from eight to ten days, and in severe types from three to four weeks. The prognosis varies ac- cording to the type of the affection ; but commonly this is not aggravated and recovery is to be expected. Occasionally, however, the disease is threatening to life. Serious nervous symptoms (delirium followed by coma) may develop and cause a fatal termination. When death occurs it is usually due to exhaustion, and is seen particularly in persons previously enfeebled by disease or in the very young and the aged. Complications influencing the prognosis are exceptional. This variety probably does not occur in extensive epidemics ; but it prevails in tropical and sub- tropical countries, and also throughout Europe and North America. (6) Diphtheritic Dysentery. (Acuie Tropical Dysentery.) Definition. — An intestinal inflammation (usually colonic), accom- panied by a croupous, or true, diphtheritic exudation. It is epidemic in Japan, but prevails Avherever large numbers of persons are closely associated, as in armies, asylums for the insane, ships, and the like. Pathology. — In mild grades a grayish-yellow, croupous exudate appears upon the inflamed mucosa, with a necrosis of the epithelial layer that is often limited to the top surface of the folds of the colon. In other instances the diphtheritic infiltration involves all the layers of the bowel, which now becomes greatly enlarged, its mucous membrane being converted into a yellowish-brown, thick, elastic mass, sometimes extending along the entire length of the large intestine. The changes may be confined to the circumscribed areas (flexures of the colon and DYSENTERY. 75 rectum), and thick sloughs may be cast off, leaving behind ulcers of cor- responding size and depth. The morbid changes in some cases are prin- cipally ulcerative in character, simulating those described under Catairhal Dysentery (vide p. 73), Indeed, the pathologic unity of" the various forms of bacillary dysentery would appear to be almost established. Bacteriology. — The distinctive pathogenic agent is the Bacillus dysen- terice discovered by Shiga ^ during his investigations into Japanese dys- entery. Flexner found the same organism. Duval, Harris, and Flexner have described different races of the Bacillus dysenterifje, showing that decisive criteria of difference are observable, which separate this organism from the Bacillus typhosus. The Bacillus dysenteriae is not normally found in the intestines. The Shiga bacillus, however, " is inactive to blood-serum from typhoid cases, but reacts with serum from dysenteric cases to which bacillus typhosus does not respond" (Flexner). It may be that a number of bacilli which closely resemble one another, yet dif- ferent, are capable of causing epidemics of true dysentery. PfuhP found dysentery bacilli in the intestines of soldiers returned from China one year after the initial attack ; this persistence may have a bearing on the geographic distribution of bacillary dysentery and its spread in the United States since the Spanish- American war.. Mode of Conveyance. — Messrs. Ryder, Richards, Peabody, Can- avan, and Southard studied an institutional epidemic in which the first case was probably an introduced probable carrier ; they believe that the epidemic was due to flies, and that occasional cases of dysentery depend mainly on contact-infection with the products of intramural carriers. Clinical History. — The affection usually has an acute onset, and one characterized by an appearance simultaneously of severe local and general symptoms. There may be an initial ehill, and there is fever, which rises rapidly, together with a marked and early appearing pros- tration and delirium. The fever-curve is of the irregularly remittent type and its range is somewhat higher than in the catarrhal form of the disease. The pulse is greatly accelerated and tends to become erratic both as to rhythm and volume. Active delirium is common and may alternate with or merge into coma. Severe abdominal pains are com- plained of, and the discharges may be numerous, containing shreds and large sloughs, or even tubular pieces, of false membrane. When these elements are present in the stools, the latter are of a dark-brown color, emitting a fetid odor, and generally containing more or less blood and mucus. The dejecta are more hemorrhagic, as a rule, than in the simple, catarrhal variety. Tenesmus may be intense. There is an absence of polynuclear leukocytosis in this disease. The physical signs are often prominent. The belly in most instances is greatly distended, and on pressure very tender — signs due to the fact that the lesions are situated chiefly in the large bowel. The diagnosis rests upon the intestinal symptoms and the character of the dejections, associated with a grave general condition suddenly developed. As accessory factors to the recognition of this variety are the finding of the false membrane in the dejecta, and the appearance of the cases in an epidemic form. An absolute diagnosis demands either the isolation of dysentery bacilli from the dejecta (which, however, are 1 Ceniralbl. f. Bakf. u. Parasitenk, 1898, xxiv., Nos. 22-24. 2 Munch, vied. Wochen., Feb. 11, 1902. 76 INFECTIOUS DISEASES. rarely present in mild cases and durinn; the first days of the disease) or the agglutination reaction of the blood-serum, and this serves to dift'ei-en- tiate bacillary dysentery from allied maladies, including typhoid fever. Complications. — These are both numerous and varied, and include perforation of the gut followed by peritonitis, either localized or general- ized (according to its seat) : also pleurisy, endocarditis, pericarditis, parotitis, "anasarca, phlebitis, and nephritis" (Rumford). Hepatic abscess is never observed (Shiga). The prognosis is almost wholly unfavorable. The principal element of danger is the profound toxemia, which rapidly leads to fatal asthenia in cases in which the stools consist of a blackish fiuid with a horribly fetid odor and of bits of gangrenous masses (Duncan). Shiga states that the toxemia is most marked in cases in which the lesions are located high up in the intestine, and that the disease is most fatal in winter. The numer- ous complications also exercise a lethal tendency. Occasionally recovery follows, though more frequently the disease takes on a chronic course. Secondary Diphtheritic Dysentery. Here the lesions are similar in kind, but less intense, as a rule, than those of the primary form. This variety is met with as a terminal con- dition in not a few acute and chronic diseases : it often occurs in pneu- monia (Bristowe), and less commonly in typhoid fever. Among chronic affections, upon which this condition may become engrafted, are nephritis, organic disease of the heart, and pulmonary tuberculosis. No characteristic symptoms attend upon its invasion. There may be slight diarrhea — two or four liquid stools daily — but it is not often ac- companied by tormina and tenesmus, and the discharges rarely contain any noticeable amount of blood, mucus, or shreds of pseudo-membrane. Secondary diphtheritic dysentery often induces fatal asthenia. Sequelae of Bacillary Dysentery. — In all forms a relapse is likely to occur, each attack increasing the liability of the patient to sub- sequent ones. Moreover, in persons who have recovered from acute dysentery we often observe a disordered digestion and irritability of the bowels. Rarely, chronic nephritis follows dysentery. The most inter- esting sequel, however, is paralysis, which occurs mainly in the form of paraplegia (S. Weir ]\Iitchell). Stricture of the bowel is rare. Treatment. — Prophylaxis. — This embraces isolation and a thorough disinfection of the discharges, which contain the specific germ of the disease, as soon as passed. The drinking-water during the epidemic prevalence of dysentery should be thoroughly boiled, and healthy per- sons sliould avoid cathartics, the use of improper food, or such as stimu- lates intestinal peristalsis, while an unhygienic environment (overcrowd- ing, etc.) is to be corrected as far as possible. Shiga recommends that the dead bacillus emulsion (heated at 60° C. for thirty minutes) and a specific immune serum be injected simultaneously. One injection pro- duces active immunity and the author tested the method on about 10.000 men in the district of Japan '• where epidemic dysentery prevails most seriously, and was able to diminish the mortality in the district from 20 to 30 per cent, to about zero." All sufferers from dysentery must be kept in bed, and should occupy a well-aired apartment. The diet should consist of milk, whey, and light animal broths dur- ing the period of active intestinal symptoms. The blandest articles only , DYSENTERY. 77 are either acceptable to the stomach or aHowable in the diphtheritic vari- ety, as Mellin's food (especially for children), egg-white, and zoolak, in small portions. During convalescence a return to the usual dietary is gradually to be niado. All food should be given lukewarm. Alcoholic Stimulants. — With the development of asthenia and cardiac failure stimulants must be employed, as in other acute infectious diseases. Diphtheritic dysentery calls from the very outset for free stimulation. The diffusible stimulants (e. g., champagne) are often invaluable. Strych- nin and digitalis (hypodermatically) may be required. Medicinal Treatment. — If scybalous masses be passing, a dose of castor oil should be administered. It is well to convert dysentery into diarrhea. Measures to deplete the mucosa of the intestine and at the same time in- hibit undue peristalsis are most effective, as magnesium sulphate. Dram doses may be given every hour or two, until the stools contain fecal matter and no more blood or mucus. In the later stages purgatives are attended with baneful effect. Ipecacuanha has long been, and still is, regarded as possessing a specific influence in cases of dysentery. Its administration is usually preceded by a dose of opium (laudanum or morphin) which is given when the stomach has been empty for a few hours. Most authors rec- ommend that large doses — gr. xx to 3j (1.29 to 4.0) — should be admin- istered ; but it is probable that a small dose — gr. -g- to ^ (0.010 to 0.016) every half hour — is quite as effective ; and in children the smaller doses are to be preferred and will be found to be quite efficacious. Other remedies should also be employed, and among these opium is particularly beneficial in combination with ipecacuanha or in the form of Dover's powder, which contains both agencies. Three chief symptomatic indi- cations are met by the opium — pain, restlessness, and undue peristalsis — and to obtain the best effects from the opiate it should be adminis- tered in the form of morphin hypodermically. In cases in which tenes- mus is an unusually distressing feature §in opium suppository (gr. ij — 0.1296) or laudanum (iTLxxx — 2.0, by enema) exercises a beneficial effect. Bismuth in full doses is useful (3ss— j — 2.0-4 every two hours), and I have frequently found the combined use of Dover powder, bismuth subnitrate, and salol of signal service. Cunningham, Stengel, and others have reported curative effects from the employment of sulphur ; and Richmann prescribes the following powder : ^. Sulphur sublimat., . gr. xviij (1.20) ; Pulv. Doveri, gr. v (0.33). M. ft. chart. No. i. S. To be taken every fourth hour. Antiseptic substances by the mouth for the purpose of disinfecting the intestinal canal and favoring the healing of the ulcerated surfaces after the removal of the necrotic pseudo-membrane, such as benzo- naphtol (gr. xl-lx — 2.592-3.788 — in the twenty-four hours in divided doses), salol, opium, and silver nitrate are among the remedies of choice. The naphtol preparations being insoluble should be given in capsule and the silver nitrate in pill form one hour after food. Iodo- form in a pill or capsule in doses of i^ to 3 grains (.032 to .194 gm.) has been much lauded. Bose and Vedel employed in 4 cases intravenous injections of sodium chlorid, 7 : 1000 being the maximum strength. 78 INFECTIOUS DISEASES. The injections should be made early, and repeated, so that they will de- velop sustained general reaction and a modification of the general condi- tion which can lead to recovery. Care should be taken as to the quantity used and the rapidity with which it is injected (^ to 3 ounces each minute should not be exceeded). Kendall advises de.xtrose infusions (25 per cent.) in normal saline solution ; this tends to restore the normal dextrose. Antiseptic irrigation of the bowel would be, if properly carried out, a curative measure, since liy this means we may destroy the distinct micro-organisms. Unfortunately, the bowel is frequently so irritable as to seriously interfere with this mode of medication. Preliminary to their use we may also employ cocain in the form of a suppository, or a small quantity of a solution of cocain (4 per cent.), or a laudanum enema (Tflxxx — 2.0, in starch-water), after which a large injection may be tolerated if administered slowly and the flow be interrupted at inter- vals. Among the best agents are silver nitrate (gr. ss-j — 0.032-0.064 — ad 5J — 32.0), tannic acid (1 to 2 per cent.), salicylic acid (1 to 2 per cent.), and mercuric chlorid (1 : GOOO). I have for a number of years been in tlie habit of employing these astringent and antiseptic solutions alternately, administering each once daily. Kuzmitzky,' MacDonald, and others have obtained good results with rectal injections of a tepid solution of potassium permanganate (1 : 4000) twice daily. The temper- ature of the water should, at first, range from 100° to 110° F. (37.7° to 43.3° C), and subsequently this may be reduced. The patient during the administration of the enemata should assume the dorsal position, with the hips well elevated, and he should be turned from side to side during the injections. The existence of great irritability of the bowel may be met by using two catheters side by side, one of them serving as an outflow. Kruse^ has produced a serum and has treated 100 cases with 8 deaths. Shiga has also discovered a serum of which he injects one dose of 10 c.c. in mild cases. In cases of medium severity, a second dose of 10 c.c. is injected after from six to ten hours, while in severe cases, a daily dose of 20 c.c. is repeated for two or three days. The mortality of dysentery under the use of this serum is reduced to less than one-half from that obtained from medical treatment. Local means, in the form of hot fomentations, light poultices, and turpentine stupes, often afi"ord much comfort. The various complications must be met by appropriate treatment, as under other circumstances. Chronic Dysentery. This form of the disease almost always succeeds an acute attack. A. Bassler thinks that " chronic dysentery due to the Bacillus coli conuuuiiis " seems warranted. Pathology. — In most instances the large intestine is still the seat> of ulceration. Some of the ulcers show no signs of healing ; in others this process is going on ; while in still others it is completed and puckered cicatrices are presented. The ulcers are deeply pigmented, as is the unnlcerated mucosa, which often presents a slate-gray or blackish color. The submucous and muscular coats are hypertropliied, as a rule, with occasional narrowing of the lumen of the bowel, and cystic degeneration of the intestinal glands is sometimes observed. In a small percentage 1 Woenno. Med. Jour., Nov., 1902. ^ Deutsch. Med. Woch., .Jan. 1 and l.=l. 1903. DYSENTERY. 79 of the cases ulceration does not occur, the mucosa presenting an uneven, puckered aspect, due to deposits of fibrous tissue. Symptoms and Diagnosis. — Many of the most characteristic fea- tures of the acute form are either but feebly expressed or altogether wanting. This is particularly true of the tormina and tenesmus. Cer- tain elements found in the stools of the acute type (blood, shreds of pseudo- membrane, and tissue) are also rarely present. True dysenteric nymp- toms, however, may arise during acute exacerbations, with or without pain or tenesmus ; then from three or four to a dozen or more fluid dejections are passed daily. The latter are often frothy (when starchy articles of food are taken), composed chiefly of fecal matter and undi- gested particles of food and mucus ; and in severe forms blood and pus may be constantly present in the discharges. In many cases the stools are semifluid (pultaceous), and rarely they contain scybala ; or the rather frequent liquid or semifluid discharges may alternate with constipatifn. The lesions are then apt to be situated in the lowest portion of the large intestine. The character of the discharges is much influenced by the sort of food taken ; thus, when a mixed dietary is partaken of, they are thin, more frequent, and contain more undigested masses of food. Gas- eous distention of the intestines is often an annoying symptom. The physical signs are negative, save only tenderness over the colon. Associated symptoms referable to other organs are not without value in the diagnosis. The gastric digestion is poor, the appetite generally impaired (though variable), and the tongue is clean, red, and glazed, presenting the appearance of raw beef. There are progressive emacia- tion and asthenia, which eventually reach an extreme degree. The skin- surface becomes dry, harsh, and cool, the facies grim, the pulse exceed- ingly feeble, the mental faculties greatly weakened in the advanced stage ; and, as in the acute form so in the chronic, death is usually due to asthenia — with this difi'erence, that in the latter the end is reached more slowly. Peritonitis in consequence of perforation is rare. Differential Diagnosis. — The disease is to be discriminated from chronic diarrhea. In chronic dysentery there is the history of an antecedent acute attack, with the appearance from time to time of exacerbating periods when mucus, pus, and often blood are contained in the discharges. The latter are, at the same time, more frequent and apt to be accom- panied by more or less abdominal pain and tenesmus, and the presence of these features would serve to eliminate chronic diarrhea. From tuber- culous ulceration of the intestines it is distinguished by the absence of any history of tuberculosis, family or personal, and of tuberculous new growths in other portions of the body, particularly the lungs. The complications are the same as in acute dysentery, if we except the greater liability, due to the great and protracted weakness of the patient, to certain serious intervening diseases (chronic nephritis, tuberculosis, pneumonia). Ulceration of the cornea has been noted. The duration is long, the disease lasting for months or even years. Treatment. — This should be directed mainly to the local condition, and should consist in methodic irrigation of the bowel with a view to promoting the healing of the ulcers. Formerly it was sought to accom- plish the latter indication by the use of certain remedies internally, as silver nitrate, balsam of copaiba, bismuth subnitrate, etc., but the only preparation which I have found useful is the zinc oxid (gr. v-x — 0.324- 80 INFECTIOUS DISEASES. 0.648) three times daily. The hitter preparation is decidedly j^alliative, soiiK'times even curative. Intestinal irrt(/ation is to be tried, and various disinfectants and astringent remedies should be alternated as advocated in the acute form. Among individual remedies the silver nitrate (gr. ss-ij — 0.032- 0.129 — ad 3J — o2.0) every second day is doubtless the best. On interven- ing days antiseptic remedies may be used in solution, such as mercuric chlorid (1 : 6000) or salicylic acid (1 to 2 per cent.); and of other use- ful agents I may mention tannic acid, alum, acetate of lead, and creolin. I'rior to the use of any of the above-mentioned enemata the bowels should be Avell flushed Avith a large injection of tepid water, so as to remove the fecal and other irritating materials. The same details are to be observed in cariving out this mode of treatment as in the acute forms of dysentery, (jalluy ' has related the curative effect.-^ of large enemata of a solution of crystallized silver nitrate in distilled water, a scruple to a quart (1.296 per liter), to which 20 or 3') drops of laudanum have been added. Amelioration follows the thinl or fourth washing, but a course of sixty is recommended to secure permanent relief. The lower pai't of the rectum should be examined with the speculum, and appropriate topical applications made if ulcers in this situation be discovered. It has been suggested that to])ical therapy can be facilitated in chnniic cases by the production of an artificial anus, in the left iliac region, or an appen- dicostomy, but the value of the method is still doubtful. The dietetic treatment in chronic dysentery is of the utmost import- ance, and light forms of proteids are to be selected, to the exclusion of vegetable substances. Milk is excellent when it can be taken. It is well to examine the stools, and if on microscopic examination curds or numerous fat-globules appear, the amount of milk should be reduced or skim-milk substituted. Egg-white, meat-broths or beef-juice, whey, and even light, nutritious solids may be allowed. The patient should wear flannels next the skin, and, while open-air exercise is useful, it should be moderate. During inclement weather the patient should remain in-doors. I have known change of climate, with proper regulation of the mode of living, to be productive of rather brilliant results. Tonics and alcoholic stimulants are sometimes re(iuired to assist the appetite, digestion, and systemic strength, and among the most efficacious tonic remedies are iron, strychnin, mineral acids, and arsenic. CHOLERA (EPIDEMIO). {Asiatic Cholera; Cholera Algicla, etc.) Definition. — Cholera is an acute, infectious, epidemic disease, due to the spinllum of Koch (vibrio cholerse Asiatica?) ; and its characteristic symptoms are copious watery dejections, painful cramps, collapse, and sup])ression of the excretions. In some localities it is endemic. Historic Note. — During the Middle Ages cholera made deplor- able ravages, chiefly along the belts of the Ganges, and has probably been endemic in India for centuries. Only during the present century, ' " Radical Cure for Chronic Dysentery of Recun-ent Type," British Med. Joui-nal, No. 1779, p. 276. CHOLERA. 81 however, has the disease been widely known in Europe and America, and when it has appeared it has always been in the epidemic form. The march of epidemics has been from east to west, along the lines of com- merce and travel by land or sea, sometimes spreading over the entire globe. Space forbids an account of the progress of the various cholera outbreaks in Europe and America. It may be stated that there have been no distinct epidemic visitations in America since 1873. In India, Mecca, Java, China, and in the Philippine Islands numerous cases ap- peared during the winter, spring, and summer of 1902. Pathology. — The body is much emaciated, the features sharp and drawn, and the skin of the dependent parts presents a mottled appearance. A post-mortem rise of temperature often occurs. The tissues are dry, owing to the draining of the liquids of the body, and hence putrefaction is delayed. Rigor mortis comes on directly after death, is persistent, and the muscles often contract so as to cause the body to assume various uncommon positions. The Visceral Lesions. — The chief of these are confined to the intestinal canal, and depend largely upon the period of the disease at which death occurs. In the early stage the serosa of the small bowel is congested, presenting a roseate hue. The muscularis is relaxed. The mucosa is the seat of catarrh, being deeply injected, swollen, at times edematous, and often coated in the early stage with more or less tough mucus. Shortly the coils of intestine are filled with an almost transparent or slightly turbid liquid ('' rice-water "), and occasionally a small amount of clotted blood is seen. The solitary follicles and Peyer's patches are swollen, and, in rare instances, become ulcerated. Denudation of the epithelial lining — most probably a post-mortem change — is the rule, and ecchymotic spots are visible in the intestinal mucosa. If the patient has died late in the disease (stage of reaction), patches of false membrane may be found anywhere along the intestinal canal, although chiefly in the large bowel ; and this secondary croupous-diphtheritic process may attack other mucous surfaces (bile-ducts, vagina). The stomach shows changes similar to those found in the intestines. At first the mucosa is congested ; then, as the result of transudation, it becomes filled with " rice-water " material. At last the organ is empty and collapsed. The esophagus also exhibits analogous lesions. The spleen is small, as a rule, though if death occur late it may show some degree of enlargement with softening. The liver presents marked passive hyperemia and cloudy swelling, with minute spots of beginning fatty change. Desquamation of the epithelium of the cystic mucosa may occur and block the bile-ducts. The kidneys show important lesions, being enlarged from passive con- gestion, especially the cortex, and the capsule being somewhat adherent. They exhibit cloudy swelling and decided coagulation-necrosis. Desqua- mation of the epithelium in the urinifei'ous tubules is extensive. Micro- scopically, the histologic changes are those of acute nephritis in the cases in which death takes place in the advanced stage. The bladder-changes differ in no way from those of other mucous membranes. Its mucosa is congested, ecchymotic, and may show diphtheritic deposit. The ureters and the pelves of the kidneys may present identical appearances. The Circulatory System. — The pericardium is dry, the parietal layer being covered with an adhesive secretion, while the visceral layer is the 6 INFECTIOUS DISEASES. seat of eccbymosis. The heart is dry and anemic looking. The left ventricle is contracted, while the right is often distended with blood and soft clots. ( hitside of the heart the veins, including the cerebral sinuses, contain most of the blood. The blood is thick and its color dark, resem- bling '*the juice of huckleberries '; its specific gravity, albumin, and corpuscles are all increased, while its coagulability is decreased. Respiratory Organs. — The larynx, trachea, and bronchi are hyperemic, and at first covered with tenacious mucus ; later they may present ecchy- moses and diphtheritic processes. When death occurs before the stage of reaction the lungs are blood- less, collapsed, and the mouth of the i)ulmonary artery may be distended. If life is prolonged until the third stage, the lungs may show conges- tion and edema or pulmonary infarction. The post-mortem may now also exhibit the lesions of broncho- or lobar pneumonia. The brain and its membranes may be the seat of hyperemia, except when death takes place at a late period, and then the brain-substance niav be nim-e or less bloodless and edematous. etiology. — The causes are (a) specific and (b) predisposing, (a) The specific cause is the spirillum of Koch, which is found in the intestinal canal of persons ill of cholera. Recent investigations into the bacteriology of the affection show^ that almost uniformly the cholera vibrio is associated with certain bacteria, most commonly the bacillus coli communis. True cholera is a 7iitrite--po\sonmg, the result of the growth of the specific spirillum. Koch's organism is not found in any other disease. Its form is that of a slightly curved rod, and its length about half that of the tubercle bacillus, but it is thicker and sometimes has the form of the letter S (Fig. 8). The cholera vibrio is motile, its motility beinor due to a sins:le fiasrellum attached to one end. It has been grown successfully on media of various sorts {e.g. nutrient gelatine, forming coloi'- less colonies and liquefying the gelatine) and equally successfully inocu- lated upon inferior animals. The organism is found in a variety of positions — in the intes- tine, the dejecta (even quite early), and in great profusion in the pathognomonic "rice-water" stools. Kemp in his review has shown that the spirillum is often absent from the evacuations, and that in these cases the bacterium coli is usually present and sometimes streptococci. He be- lieves, however, that the apparent ab- sence is due to faulty technique. It may be seen in the stools and vomitus (rare) of well persons during epidem- ics, displaying virulent properties. Outside the body they preserve their vitality in river or well Avater or upon the surface of moist linen for sev- eral weeks. C. Friinkel studied them in flowing water, and in other epidemic outbreaks they have been found in the water used for drinking purposes. (h) Predisposing Causes. — (1) Locality. — Near to the sea-coast cholera is more common than in the inland districts or towns, and the frequency Fig. 8.— Comma liacilli irnmi the mouth); X 1000 (Gunther). CHOLERA. 83 of occurrence lessens with increasing altitude, this fact possibly being due to a gradual decrease in soil humidity and porosity. (2) Atmospheric Temperature. — The spirillum of cholera can only flourish in a warm climate; hence the disease is endemic in certain trop- ical and subtropical climates ; and hence also its epidemic prevalence is confined to temperate latitudes. (3) Seasons. — For obvious reasons it is more common in the warm than in the cold months, most epidemics, both in Europe and America, having occurred toward the close of summer and in the early autumn. Winter frosts usually arrest an epidemic. (4) Age, as a rule, has no decided effect. Old people, however, are very prone to the affection. Sex is without perceptible influence. (5) Debilitating Causes. — Whenever the private conditions correspond to rigid scientific requirements during epidemic outbreaks cholera becomes less prevalent and also less virulent. On the other hand, defective munici- pal sanitation, disregard of proper hygienic rules, intemperance, over- crowding, etc., all predispose markedly to the disease. (6) Mere attacks of intestinal disorder due to improper diet, cold, etc., are potent to disseminate the disease. Modes of Infection. — The spirilla leave the body with the stools, but the most frequent bearer of cholera-poison is the drinking-water. Natur- ally, the individual susceptibility varies greatly (many persons being even insusceptible), and yet the degree of contamination of the drink- ing-water and the virulence of epidemics are almost strictly proportion- ate. As an illustration, Vienna had enjoyed exemption from cholera for nineteen years — a fact attributed to the excellent quality of the drink- ing-water and to hygienic improvements. In the same city the mor- tality-rate in the more recent epidemics has been small (7 per 1000) for a like reason. On the other hand, in 1872 there occurred in a single commune (Hamburg), which had a polluted water-supply (the Elbe) and no filtration plant, 17,862 cases, with the enormous death-rate of 42.3 per cent. Koch holds that man, not noticeably diseased, is the real bearer and reproducer of the cholera vibrios. The choleraic poison may be conveyed with the water used for washing, cooking, and other purposes to other fluids imbibed by man (beer, milk, tea), and also to food-stuffs taken by him (lettuce, cresses, and other raw vegetables, fruits, meats, bread, butter). The organisms live and maintain their virulence on these articles of food from four to seven days at least. The infection may reach the esophagus with the water used for washing the mouth or teeth, or that used for washing the utensils, dishes, food-receptacles, etc. Again, the hands, commonly those of laundresses and nurses, may become soiled in the careless handling of bed-linen or garments worn by cholera patients or the stools, and convey the poison to the mouth or lips, to be carried into the stomach along with the drink or food. Healthy bacilli-carriers have been found in ships arriving from Mediterranean ports. Flies may trans- fer the infectious element to food-articles (Simmonds, MacKaig, and others). Cholera is not contagious from mere contact with those ill of the disease. It is not acquired by inhalation (Shakespeare), and, since desiccation rapidly kills the organism, there is little probability that the latter is air- borne. Nor is there any clinical evidence to show that the poison may 84 INFECTIOUS DISEASES. enter the system througli the .skin surfafo. rmbably the germs are s/raJ- lowed, and the acid gastric juice may then destroy them if tlie size of the dose of the poison is not too large, or they may ])ass into the intestinal canal and there manifest pathogenic powers. After the spirillum reaches the intestine, whether or not an attack is the result depends both u])on the size of the poisonous dose and upon the personal degree of in)muiiity. Oj)posed to the drinking-water theory of tliis disease is that of Pet- tenkofer, which contends that the spirilla found in the serous evacua- tions of cholera patients must enter an a])pr(ipriate soil and there undergo further development before becoming pathogenic. While soils possessing a certain degree of moisture and perviousness and contaminated with organic matter favor the growth and multiplication of the specific organ- ism, these telluric conditions are not essential, as is shown by the viru- lence of the stools when swallowed in ample quantity. Pettenkofer and l\ubino' claim that the fidly developed ])oison rises from the subsoil into the lower atmospheric strata as a miasm. Immunity is not conferred by a previous attack of cholera. Pfeiffer and Marx have proved the existence in the blood-serum of human beings of bactericidal bodies (not a true antitoxin) that cause rapid destruction of the cholera bacilli. To these anti-bodies is ascribed the " Pfeiffer serum reaction.'" by means of which the vibrios are diiferentiated from other micro-organisms. Pfeiffer and Marx have also shown that the virus of cholera can be effectively preserved by a 0.5 per cent, solution of car- bolic acid, and that it in no way impairs its immunizing properties. Clinical History. — The incubation period varies from a few hours to five days (average two to three days). During this prodromal period the patient is either quite well or (during the latter portion) exhibits certain local symptoms. These are occasionally nausea, a feeling of distress in the abdomen, increased peristalsis which may be visible or palpable, slight pain and tenderness, and either a mild or a decided diarrhea. The discharges are feculent, colored, and semifluid, or, more rarely, quite fluid, and may be quite copious. These symptoms may all be present, though oftener a few, and rarely a single one. is noted ; moreover, they are not distinctive unless seen during an epidemic and unless the patients have been exposed to the poison. Prostration may be marked and there may be slight muscular cramps. The so-called premonitory diarrhea may terminate in recovery at the end of from one to three days, or be followed by an attack of cholera. This has three stages. (1) Stage of Serous Diarrhea. — Tlie dejecta are generally painless, very frequent, odorless, copious, and fluid or watery, and usually present the characteristic "rice-water" appearance. Rarely they are distinctly col- ored with bile, and in severe cases with blood, and rarely also are they frothy. Suspended in them are numerous small, whitish, mucous flakes ; their reaction is neutral or alkaline, and they contain a small percentage of solid constituents made up largely of albumin and sodium chlorid. The microscope brings to view epithelium, mucus, triple phosphates, and numberless micro-organisms, of which latter the only ones characteristic are the comma-spirilla of Koch. In cholera sicca these serous evacua- tions are absent. Death comes quickly, and post-mortem examinations show the intestine to be filled with "rice-water" material, which is prob- ably retained because of speedy paralysis of the musculature. ' SajoTw^s Annual, 1899, vol. ii., p. 214. CHOLERA. 85 Gastric symptoms appear early. Vomiting soon becomes frefjuent, and at first the vomitns may be bilious; later it is characteristically serous and excessive in amount. Thirst is almost intolerable, anorexia is complete, and the tongue often has a thick coating, which early becomes dry. Gastro-intestinalpam is not severe, but a feeling of" press- ure or burning in the abdomen is experienced, and occasionally there are griping pains with tenesmus. The physical sicjns are few. The belly is usually flat and flaccid, though it may bo sca))hoid and hard, and in some cases palpation detects fluctuation. Painful cramps in the muscles form an early characteristic symptom. They affect the voluntary muscles of the legs, calves, and feet, more rarely the arras and hands also. Their duration is momentary, but they recur at intervals, and are due to the local action of the toxins. Owing to the withdrawal of fluid from the lymphatics and blood- vessels the tissues become dry and shrivelled and the blood much thicker. This condition of the blood obviously increases the labor of the heart, which beats rapidly, and there may be at first a distressing palpitation ; but soon the heart grows more and more feeble and venous stasis ensues. The pulse is at first rapid, soft, and small; it may then be lost at the wrist. The cardiac impulse and heart-sounds may at last disappear. The fades and general appearance also indicate loss of fluid. The cutaneous surfaces of the face and extremities grow cool: there is rapid general emaciation, which may become most pronounced, and the skin is wrinkled. The complexion assumes a livid or blue-gray tint, while the lips become quite dark. The extremities are cyanotic (the finger-tips in particular), the orbits are deeply sunken, the cheeks hollow, the features intensely pincned, the voice husky and feeble, and there is utter prostra- tion. The suiface-temperature drops below the normal, even to 96° or 95° F. (35.5°-35° C), while, per contra., the internal or rectal tempera- ture rises to 102° F. (38.8° C.) or over. The mind may remain clear until the close, but oftener the patient is apathetic, and in grave cases this condi- tion may deepen into stupor or even actual coma. The reflexes are greatly diminished. S. Rogers^ found a variable degreeof leukocytosis, and thelaro-e mononuclear cells were usually increased — an important diagnostic sign. The urine becomes very scanty and is highly concentrated, the stand- ing specimen depositing a heavy sediment. On analysis albumin and casts (chiefly granular) are found. In the serious forms the kidneys fail to eliminate the urea, and there is finally complete anuria. (2) Stage of Algidity or Collapse. — The symptoms which characterize this grave condition are the same as those noted under the latter part of the first stage, only intensified. Asthenia is extreme ; the jjulse is miss- ing and the heart beats faintly ; the voice is lost ; resjnrations are per- ceptibly shallow ; lividity is intense ; the surface ice-cold ; and there is usually stupor or even coma. The excessive serous discharges have given place to mere dribblings from the now relaxed anus. During this stage. which may last a few or many hours, the faint glimmerings of the vital spark are often extinguished. (3) Stage of Reaction. — This sets in promptly, and the case may pursue a favorable course, with return to accustomed health by the end of a week or ten days. The first urine passed is usually albuminous and contains tube-casts. Relapses into the stage of collapse may occur 1 Brit. Med. Jour., July 12, 1902. 86 INFECTIOUS DISEASES. ami be repeated ; in many instances, however, this stage is both pro- tracted and dangerous. It is aptly termed cholera typhoid, since a gen- uine typhoid state develops. The skin may present so-called choleraic eruptions (macular, roseolar erythema). Recovery may now take place, or a great diversity of local secondary inflammation may supervene. Acute neph7-itis may arise in this stage and lead either slowly or directly to uremic poisoning, as shown by the projection upon the scene of grave nervous phenomena — headache, vomiting, delirium or coma, and convulsions. A fatal result may be looked for. Complications. — In this place are to be enumerated the conditions due to secon(hiry inlection, including (commonly) septic and pyemic processes. Diphtheritic inflammations affecting mucous surfaces, but especially the throat, colon, and the external genitals, are among the more common. Bronchitis, pneumonia, and pleurisy may arise, and erysipelas and ])arotitis are not rare. During convalescence digestive disorders may show themselves, and indiscretions in diet may precipi- tate a relapse. Clinical Types. — {a) " Premonitory Diarrhea." — This type has been outlined with suflficient fulness in the foregoing discussion. (/)) " Cholerine," in which the symptoms are mild, resembling those of cholera nostras. Many of the symptoms characteristic of true cholera are also present, particularly the cramps and 2^'^'ostration, cold extremi- ties, and scanty albuminous urine. The stools, however, are not typical of the disease, but are feculent in character, as in ordinary cholera morbus. The duration is from seven to ten days, subject to relapses. (c) The more typical forms — both moderate and severe — have been described under the Clinical History [mipra). (d) The Foudroyant or Asphyxic Form. — This may kill instantly ; more frequently the patient lives for a fcAv hours, with or without vomit- ing and purging. Qholera sicca should be classed with this type. The virulence of the cholera-poison explains the intensity of the symptoms. Differential Diagnosis. — This is difficult in the absence of an epidemic unless bacteriologic and microscopic tests be made, and yet these alone differentiate a sporadic case. The disease most commonly mistaken for cholera (especially cholerine) is cholera morbus, and the fol- lowing points pertaining to the latter disease will eliminate it : 1. No connection with a previous case, but a frequent history of dietetic impru- dence. 2. Absence of "rice-water" stools, which remain turbid with feces or covered with bile or blood. 3. Presence of colicky pains, but absence of painful tonic cramps of legs and feet, 4. Absence of cyanosis and collapse, as a rule, and of urinary suppression. 5. No cholera spirilla in the stools. Arsenic-poisoning and other forms o^ g astro-enteritis must be discrimi- nated by the history, the character of the stools, the absence of violent muscle-cramps and of the effects of great loss of fluid (cyanosis, shrunken body, profound collapse). Chemical tests are not to be neglected. Prognosis. — This is dependent mainly on the type. Thus " chol- erine " is very rarely fatal. It is impossible to state the average mor- tality, since it varies with each epidemic, but it has been found to range from 20 to 80 per cent. Many sufferers perish during the latter part of the first day or during the algid period ; still more during the stage of reaction, the dangers of the latter period being as follows : asthenia, CHOLERA. 87 cholera, nephritis with uremia, and the various complications ((vide supra). The greater the difference between the surface temperature and that of the rectum, the more unfavorable the prognosis. The personal circum- stances which render an attack grave are old age, alcoholism, previous ill-health, and debility. On the other hand, the death-rate may readily be lowered by prompt and judicious treatment. Treatment. — Prophylaxis, — It has been owing in great measure to the efficient quarantine system of the United States that cholera has not gained a foothold on our shores since 1873. Individual Prophylaxis. — In the first place, those nursing the sick can prevent the spread of cholera by prompt and thorough disinfection. The dejecta may be disinfected by pouring upon and mixing with them an equal part of a 5 per cent, solution of carbolic acid or an equal volume of a freshly prepared solution of chlorid of lime. The discharges thus treated must be covered and allowed to stand from fifteen minutes to half an hour, and then emptied into a pit in the earth containing quicklime, with which they should also be covered. It is of the utmost importance to guard against a pollution of the water-supply by these pits. Soiled clothing, linen, and the like should be promptly disinfected, and bedding had better be burned ; none but the attendants should be per- mitted to enter the sick-room. The dishes used should be disinfected immediately after use or before leaving the sick-chamber. After handling the patient or anything that he has soiled the attendants should first dis- infect and then carefully wash their hands. After vomiting and after an evacuation of the bowels the mouth and the parts around the anus should be wiped with a cloth wet with a solution (1 : 2000) of mercuric chlorid. The internal use of sulphuric acid is an important prophylactic. If con- valescence supervene, the patient should be kept isolated for a week and the stools disinfected during that time. For the treatment of carriers an occasional course of calomel, with gallic acid in small doses during the intervals, are measures to be recommended. Persons exposed should use boiled milk and water only. Certain forms of food must be avoided, especially salads and unripe fruits ; also alcoholic stimulants. All uncooked food may be pernicious. Such per- sons should lead regular lives, avoiding fatigue, excesses, etc., and in- testinal disturbance must be met speedily by the use of antiseptics, opiates, and astringents. In India, Haff'kine^ has used a protective virus with encouraging results. Thus, " of 1735 persons not inoculated in a certain section, 174 took the disease and 113 died, whereas of 500 inoc- ulated but 21 were aff'ected and 19 died." He has made, altogether, 70,000 injections in 40,000 patients without a single accident, and claims that the results have been entirely favorable. Klein concludes against Haff'kine's anticholera inoculations, which, however, produce a temporary active immunity. Pfeiff'er and Kolle's method, the injection of dead cholera vibrios, is to be preferred. Immunity as the result of vaccina- tion is to be advised in countries where cholera is endemic and from time to time epidemic — e. g., India. Kraus has obtained a specific toxin and antitoxin, but their practical value remains to be determined. Treatment of the Attack. — (a) Premonitory Diarrhea. — In the instances which are not preceded by premonitory diarrhea opportunity to pre- vent the attacks does not present itself. To dispel the organisms from - Miinch. med. Woch., Jan. 29^ 1895. 88 INFECTIO US DTSEA SES. the intestinal canal, castor oil and especially a course of calomel have been used. In this stage a double indication is presented — " to restrain the development of the bacilli in the intestine and to neutralize the cholera-poison." To meet this Cantani proposes tannic acid by irriga- tion (enteroclysis). He injects into the intestine 4- to 2^- quarts (liters) of water, or infusion of chamomile containing ^iss to ^v (6.0 to 20.0) of tannic acid. gtt. xx to xxx (1.20) of laudanum, and .oV-xij (20,0-50.0) of gum arabic at a temperature of 80° F. Injections should be repeated four times a day, and in grave cases after each evacuation.^ For the same purpose acetate of lead and opium, or large doses of bismuth, Avith or without Dover's powder, have been much employed. (h) Stage of Serous Diarrhea. — The chief indication is to restore to the blood the watery elements Avithdrawn by the diarrhea. Not a moment is to be wasted. Opium, and preferably the salts of morphin, may be administered hypodermically (gr. ] to ^ — 0.0162-0.0216), if the evacua- tions prove too exhausting. Cantani advocates the injection of an artificial serum {hypodermochjsi^) containing 1 dram (4.0) of sodium Fig. 9.— 1, fountain syringe : 2, cock ; 8, attachment for cannula ; -I, needle ; 5, cannula ; fi, soft- rubber rectal tube, with two lateral openings, one a lialf inch from the end (not visible), the other two inches from the end. The latter is to be introduced Ijv a eniiibiiied rual of the Universal Medical Sciences, 1893. YELLOW FEVER. 89 and deep fascia of the flanks, buttocks, or interscapular region. The fluid should be made to flow slowly, allowing fifteen to twenty minutes for the introduction of 1 quart. This is preferred to intravenous injec- tion, in which the licjuid is diffused slowly. The vomitinji is to be relieved by bits of ice, small ar/iounts of brandy and water at brief intervals, cocain, or by lavage. Jn this stage reme- dies by the mouth should be avoided, since they aggravate the gastric disturbance. Thebaud has treated 8 cases of cholera in Indo-China with a 3 : 1000 solution of sodium bicarbonate, to drink freely, up lo 3 quarts a day. Heat should be applied externally with a view to assisting the periphei'al circulation, and thus obviating collapse. Warm baths have been recommended for this purpose. Stimulants must be used to fulfil the same indications. They are of superior value even to the above-mentioned measures, and are to be given hypodermically, and either brandy, ammonia, or strychnin may be employed in large doses. ((,') Stage of Algidity. — If this develop, the case is desperate. The treatment of the preceding stage is to be persevered with, and enteroclysis and hypodermoclysis, hypodermic stimulation, and the external application of heat (e. g.., warm baths, to which from 200 to 300 grams of mustard have been added) are especially indicated. Additionally, intravenous injections of fluids have been strongly urged by informed observers. For this purpose the following standard of saline fluid may be chosen : sodium bicarbonate 1 part, sodium chlorid 6 parts, boiled water 1000 parts. The temperature of the fluid when injected varies from 100|° to 104° F. (38° to 40° C), more frequently the latter (Shakespeare). The quantity demanded may be 1 or 2 quarts (liters), and the injection may need to be repeated in from one to three or four hours. Strychnin, hypodermatically, should also be used. (d) Stage of Reaction. — During this stage the tannic acid may be replaced by a solution of salt in water (10 or 15 per cent.) for enteroclysis (Cantani), and it may be well to continue hypodermoclysis in some instances. Fui'ther than this, the treatment is essentially symptomatic. Food of the blandest sort and in small quantities must be allowed at frequent intervals if we would avoid enteritis and other unfavorable complications. Tonic remedies should be given cautiously, and rest and careful nursing insisted upon. Complications must be met in accordance with general principles. Reference should be made here to the antitoxin and the vaccine that are being used by the Japanese in treating this disease. Schurupow's serum has given good re^sults on therapeutic trial. YELLOW FEVER. (Febris Jiava; Gelfieber, Ger.) Definition. — Yellow fever is an acute, highly infectious (but non- contagious) endemic and epidemic disease. It is characterized by a shai-p period of invasion, followed by a period of remission, and the latter in turn by a relapse and certain symptoms peculiar to the affection (black vomit, jaundice, suppression of urine). Historic Note. — Yellow fever is endemic only within certain geo- graphic limits, where it also prevails epidemically when the conditions are favorable. According to general belief, it first appeared in 1647 in the 90 INFECTIOUS DISEASES. Barbadoes (West Indies). Subsequently, it was conveyed along the chan- nels of commerce until it became ■widely disseminated, and chiefly in sea- port towns. In 1G99 an English vessel carrying slaves transported the disease to Mexico from the Atlantic coast of Africa. Guit6ras classified the areas of infection thus : (1) The focal zone, in which the disease is never absent, including Havana, Vera Cruz, Rio, and other Spanish- American ports. (2) Perifocal zones, or regions of periodic epidemics, including the ports of the tropical Atlantic coast in America and Africa. (3) The zone of accidental epidemics, between the parallels of 45° N. and 35° S. latitude. Yellow fever was brought to the United States (Boston) in 1693, and since then has invaded in epidemic form numerous sea-coast cities, being carried thence to a number of inland towns. For example, in 1853 the disease prevailed tliroughout the Southern States, and since then six epidemic outbreaks (1867, 1873, 1878, 1897, 1898, 1899), though of lesser severity, raged in the same section. The disease has been con- veyed to seaports in Great Britain and France, but has never been carried inland in those countries. The belief that the disease never originates outside of certain territorial limits was advanced for the first time by the College of Physicians of Philadelphia (1797). Pathology. — The shin is jaundiced, and often ecchymotic spots are observed, but the internal viscera show no characteristic lesions in cases of average intensity. In severe forms congestion, hemorrhage, degenera- tion, and necrosis are the changes noted. After death the liver is anemic, as a rule, but in the early stages of the disease it is markedly hyperemic. Its color varies, ranging from pale yellow to an orange hue, and punctiform extravasations cause mottling of the surface. Its size varies little from the normal. Paren- chymatous degeneration of the hepatic tissue is common, though in places it may be entirely normal. The liver cells are swollen, containing fat and orranular matter, with indistinctness or absence of nuclei. The gastro-intestinal mucosa is the seat of acute catarrh (in severe types) and numerous minute hemorrhages, similar spots of extravasation being found on the various serous membranes of the body (meninges, pericardium, pleura, etc.). Hemorrhagic infarctions may be found in the various internal viscera. The black-vomit material is found in the stomach, and less frequently also in the smaller intestines. The spleen is dark and friable, but is not enlarged. The Sidneys show the lesions of diffuse nephritis, the microscope revealing cloudy swelling of the epithelium of the tubules, with fatty degeneration and tube-casts. The heart-muscle looks pale, and may be the seat of granu- lar and fatty degeneration. The brain and its menitiges are hyperemic, and degenerative changes occur in the sympathetic ganglia (Schmidt). Tlie blood is dark, and many of the red corpuscles, having disor- ganized, set free hemoglobin, as in malaria. Fatty degeneration of the walls of the small blood-vessels and the capillaries have been noted, and these, by allowing filtration of blood-serum, produce concentration of the blood. General glandular enlargement is often found. Btiology. — Bacteriology. — At present writing, nothing is known of the micro-organism that causes this disease. H. Seidelin, however, has observed in the red blood-cells certain ring-like and ameboid forms which he believes have an etiologic relation to the disease. The infective char- acter of the complaint is shown by the fact that it can be produced by YELLOW FEVER. 91 the inoculation of a susceptible person with the blood of a patient suffer- ing from the disease. Mode of Transmission. — 'I'he work of the Yell(jw Fever Corn- mission of the U. S. Army (Drs. Keed, Carroll, Lazear, Agranionte) having thoroughly overthrown the claims of Sanarelli, that the baciHus icteroides is the specific cause of yellow fever, his bacillus is now regarded as a secondary invader. In 1881 C. J. Finley ' pointed out that the disease is transmitted through the agency of the mosquito. It, however, remained for the commission mentioned above to furnish incon- testable experimental proof that yellow fever is a mosquito-borne affection. They have shown that the stegomyia fasciata is probably the only carrier of the infecting agent. Twelve days after biting a yellow- fever subject the bite of the mosquito will infect a non-immune person. The insect is capable of infecting man for a period of several weeks. There is some evidence that the mosquito, once infective, is capable of transmitting the parasite for the balance of its life. The mosquitoes, however, are not infected by biting the dead bodies of yellow-fever patients, it being only during the first few .days of the disease that the patient's blood is infective for the mosquito, and only the female mosquito bites. The clothing, vomitus, urine, and feces are non-infectious. The stegomyia fasciata has been found as far north as Charlestown, S. C, and southward to the Rio de la Plata, and is extremely prevalent in Cuba. The larvae only develop in comparatively clean water, and seldom breed far outside a city's limits. Yellow fever is thus a domicil- iary infection. They bite principally late in the afternoon, and are not capable of long flights unless assisted by winds. The stegomyia only travels when it gets into a car, box, or drawer instead of a house ; it " will not voluntarily leave a house, much less cross a street " (White). Amonof predisposing causes, season heads the list. The disease pre- vails chiefly in summer, being completely arrested by one, or at most two, severe frosts. A';^e and race have some degree of influence, children being more liable than adults, males than females, and whites than blacks. The poison is not transferred by fomites. The march of an epidemic may be interrupted or even completely arrested by apparently trivial agencies — e. g., watercourses, rows or clumps of shrubbery. One attack usually bestows permanent immunity/, and natives of an infected district are far less liable to the disease than newcomers. Two attacks, however, have been reported (Boseman, Libby). Clinical History. — Incubation Stage. — This varies, ranging from two to five or more days. During the incubation symptoms may appear, such as languor, headache, anorexia, but are not common. Invasion Stage. — The onset is abrupt, an initial chill usually occurring, but it is very seldom severe or prolonged, a reactionary fever following: promptly and the te?nperafure rising to 103°, 104°, or even 105° F. (40.5° C.). The temperature is apt to be highest at the beginning, and then declines by lysis with slight evening exacerbations and morning remissions. Hyperpyrexia occasionally occurs on the first day of the illness. The chill and fever are accompanied by headache and pains in the loins and legs, often of gi'eat severity, and a little later, restlessness, ^ Annales dela Biol. Academie. vol. xviii.. pp. 147-161. 92 INFECTIOUS DISEASES. saental confusion, and a delirium that is sometimes violent in character may develop. In the majority of instances, however, the mind remains clear. ')^\\q pulse is accelerated, hut not in proportion to tho height of the temperature ; it is full and strong at the start, and is observed to fall Avhile the temperature remains the same or even rises. The face is flushed, "with slight icteroid addition. The early manifestation of jaun- dice is the most characteristic feature of the facies (Guiteras). The eyes are suffused and intolerant of light. The gums may be SAvollen and s))ongy ; later on a red line is seen at their margins and they readily ooze blood. The tongue may or may not be coated, and nausea and vomiting may occur, the latter being one of the most characteristic symptoms of the disease. Associated with these symptoms there arc epigastric oppres- sion and burning sensations, with decided tenderness. The vomitus may be blood-streaked or contain chocolate-colored particles, and occasionally unaltered blood is vomited. Constipation is usually present, the stools showing a deficiency of bile. The urine is diminished in amount, dark- colored, and often contains a slight amount of albumin: this early tran- sient albuminuria is a very characteristic symptom. The initial stage may last from six or eight hours to two or three days, or even longer, and is longer in the milder forms. With the termination of this stage there is a marked remission of the fever and other symptoms, the pulse becoming remarkably slow. Stage of Remission. — From this moment convalescence may begin and proceed to full recovery without interruption, the happy event being often marked by critical discharges. In most instances, however, the patient presents certain symptoms and signs of ill-health during the stage of calm (more or less prostration, epigastric distress with tenderness, mental dulness or even stupor, and a yellowish tint of skin and urine), which lasts from a few to twenty-four hours, when another serious stage supervenes. Stage of Secondary Fever or Collapse. — The patient becomes extremely weak, presenting the signs of profound collapse. The surface of the body is cool (extremities often positively cold), the skin in nearly all instances assuming a yellow or bronzed tinge. It is rarely absent during life, but always present after death. The pulse is rapid and compressible, and soon vomiting becomes distressing. Hemorrhage into the stomach occurs, the blood being acted upon by the gastric secretions, and producing the material which is expelled as the characteristic "-black vomit.'' Occa- sionally unaltered blood may be vomited ; the stools also may be tarry. In the worst cases hemorrhages from other mucous surfxces are common (epistaxis, hematuria, metrorrhagia, etc.), and cutaneous hemorrhages also now occur. In this stage the tongue becomes dry, brown, or even black ; less frei^uently it is smooth, red, and fissured. In most cases the urine is deficient, containing albumin and casts (with careful centrifugation), and in rare instances there is complete anuria. The latter may precede the development of grave nervous symptoms, as convulsions, or even coma, which may be uremic. In some instances the temperature rises during this period (secondary fever), and in favorable cases terminates by lysis, or it may assume the typhoid form and result fatally, and a decided slowing of the pulse may occur, as low as twenty-four beats even. In all cases that pursue a favorable course convalescence is slow and gradual, and it may be inter- rupted by certain complications {e. g., abscesses). The duration of the YELLOW FEVER. 93 entire attack (composed of three stages) is variable, though as a rule it covers about one week. Clinical Varieties. — Many different varieties have been described, each characterized by one or more prominent features, but none seem more justifiable than Finlay's ' classification, in which he distinguishes three forms: (1) the acclimation fever., or non-albuminuric yellow fever ; (2) the plain albuminuric yellow fever ; (3) the 7iielano-aU>uminuric yel- low fever, characterized by the presence of blood or "black vomit" in the stomach or intestines. Relapses occur, but are rare. Diagnosis. — The symptoms that justify a diagnosis in the initial stage, provided an epidemic be prevailing, are the sudden onset, .severe nephralgia, cephalalgia, peculiar facies and pulse (a fall in the pulse-rate while the fever remains high or rising — Faget's sign), nausea, and vomiting of bile. In the early stage intense capillary congestion of the surface of the body is diagnostic and indicative of a severe type. In the third stage the co-existence of jaundice, the black vomit, and suppression of urine, 'vith evidences of collapse, make the diagnosis easy. The mild or rudimentary form offers the greatest difficulty, since the clinical picture comprises only slight fever which, at the end of a day, is followed by speedy convalescence. Serum-diagnosis. — Woodson and P. E. and J. J. Archinard have applied the Widal reaction (agglutination-test) in 100 cases, and claim that the serum-diagnosis of yellow fever is practicable and may be used on the second day. A dilution of 1 : 40 is advised. Differential Diagnosis. — Pernicious malarial fever (estivo-autumnal) has not the early, deep jaundice, the slow pulse, the peculiar temperature- curve, the intense capillary congestion of the surface of the body, the black vomit, the early albuminuria, and the clear mind — all symptoms that mark yellow fever. On the other hand the crescentic or small ring- shaped forms of the plasmodium are pathognomonic of pernicious malarial fever, as is the effect of quinin upon the disease. Kemp has made a microscopic, spectroscopic, and chemical study of the black vomit of yel- low and malarial fevers, and found that the pigment was derived from the blood, which had been acted upon by the gastric juices. The vomitus in malarial fever, however, contains in addition considerable quantities of bile-pigment and bile-salts, which are wanting in that of yellow fever. Further, in the latter, the vomited matter is much more highly acid. The diagnostic features of dengue, which has been confounded with fehris jiava, have been contrasted with those of the latter disease on p. 140. Prognosis. — Different epidemics show widely different death-rates, and the most potent factor is the particular type of the disease in indi- vidual epidemics. Some outbreaks have been characterized by the lighter forms, and in such the death-rate has been low (1 per cent.). In other epidemics the type has been so virulent (with high temperature) as to make the mortality list high — even to 100 per cent. In general, mild epidemics give a mortality of 5 to 10 per cent., and severe ones of 30 to 50 per cent. The death-rate is lower in private than hospital practice. Among the gravest symptoms are intense capillary congestion, coming on during the first stage, suppression of urine, intense jaundice, and uremic toxemia. The black vomit is not as fatal a sign as the symptoms previously mentioned. It has been noted that a larger number of men, proportionately, than ^ Edinburgh Medical Journal, Edinburgh. 94 INFECTIOUS DISEASES. ■women and children succumb to the disease, and that it is less fatal among negroes than among whites. Treatment. — The measures that are employed in yellow fever may be considered under three main heads : (1) Prophylaxis ; (2) general management ; and (3) medicinal measures. (1) Prophylaxis. — Reed claims that the present quarantine laws against yellow fever are needless and the detention system absurd. The effective way to prevent carrying of the fever poison is the destruction of the Stegomyia fasciata — on vessels at sea as well as in infected houses and districts on land. Well persons must be protected against the bites of the Stegomyia by careful screening. It is a twilight mosquito, resting in the middle of the day, hence non-immunes may visit infected localities between 9 a. m. and 3 p. m. with impunity. It is unnecessary to disin- fect articles of clothing, bedding, or merchandise supposedly contaminated by contact with those ill of the disease. W. C. Gorgas ^ has shown that in Havana, since attention has been directed entirely to the mosquito, the minimum annual death-rate from yellow fever has been reached. The patient must be isolated and carefully screened. " When a non-immune is going to be exposed to yellow fever it is better to be inoculated, so that he can be put to bed and treated from the beginning, than to take it accidentally " (Gorgas). To immunize a patient a single mosquito should be employed for each inoculation. (2) General Management. — The sufferer from yellow fever must be put to bed at once, and an abundance of fresh air (without exposure to strong drafts) must be supplied. The medicaments and the nourishment are to be administered through a tube or spout-cup, so as to obviate raising the patient's head. Body- and bed-linen should be kept scrupulously clean, and the patient must not be allowed to leave his bed on any account. The diet should be of the lightest sort and entirely liquid, beginning with peptonized milk, koumiss, or light broths. (3) Medicinal Measures. — At the outset it is w^ell to gently stimu- late the various excretory organs, and mild laxative diaphoretics and diuretics answer this purpose. Hydrotherapy may be employed to maintain the nervous tonicity and reduce the temperature, but when the spontaneous fall of temperature sets in it must be discontinued. The neuralgic pains, which attack principally the head, loins, and nerve-trunk, are to be relieved by morphin given hypodermically ; and for the same symptom Bemiss highly recommends quinin by the rectum (gr. XX — 1.296). Intestinal antiseptics may also be used throughout the attack. During the stage of remission the powers of the system are to be fully maintained by a suitable dietary and by tonics and stimulants if required. In the last stage, supportive measures must not be forgotten. Rectal nutrient enemata should be employed if marked gastric irrita- bility prohibits feeding by the mouth. Stimulants are demanded, and these should also be administered per rectum if not retained by the stomach, or they may in some measure be administered hypodermically. The stomach is, as a rule, tolerant of iced champagne. If irritability of the stomach be present, ice and hydrocyanic acid may be tried. Sodium bicarbonate (gr. x to xx — 0.648 to 1.296) in Vichy, Apollinaris, or Seltzer w^ater is a most useful remedy, and Stern- ^ Phila. Med. Jour., Jan. 4, 1902. CEREBROSPINAL MENINGITIS. 95 berg has used it in combination with naercuric chlorid with success in the following formula : I^. Sodii bicarb., 3iv(16.0); Hydrarg. bichlorid., gr. ss. (0.032); Aquae purae, Oj (480). — M. Sig. For a severe case two teaspoonfuls every hour, day and night ; for a mild case, every hour by day and every two hours by night ; administer always ice-cold. Perhaps the chief indication for the use of sodium bicarbonate is the extreme acidity of the various secretions, especially the gastric and renal. Sternberg contends that by fulfilling this indication we prevent in great measure the occurrence of acute nephritis and suppression of the urine. Hemorrhages and other symptoms must be treated by the usual means. During convalescence tonics are to be administered, and the customary diet can gradually be resumed. Serum-therapeutics. — Prof. Sanarelli records favorable results from the use of his antitoxic serum. Morcour ^ points out that we need to try the serum only in grave cases, since mild cases recover with simpler methods and careful nursing. Wasdin, however, used Sanarelli's serum in 3 cases and noted no advantage over other ti*eatment. Matienzo,^ after a series of experiments on guinea-pigs and human beings with American serum, concludes : Intravenous and subcutaneous injections produce general reaction ; no effect is produced upon the disease. The reaction obtained in convalescence proves that the antitoxin does not produce the cure. CEREBRO-SPINAL MENINGITIS. [Spotted Fever ; Cerebrospinal Fever.) Definition. — An infectious disease, caused by the diplococcus intra- cellularis meningitidis (Weichselbaum). It is characterized anatomically by inflammation of the meninges of the brain and spinal cord, and clinically by an irregular course, a moderate febrile movement with somewhat characteristic and profound nervous symptoms (excruciating headache, pain in the back and upper part of the spine, contraction of the muscles of the nucha, hyperesthesia, delirium, and ofttimes coma). The disease may occur sporadically or in epidemics, or may even assume pandemic proportions. Historic Note. — Cerebro-spinal meningitis was first recognized and described as late as the beginning of the last century (1805) by Viesseux of Geneva. During the next decade numerous limited epi- demics were observed both in Europe and the United States, and subse- quently recurring epidemic and pandemic visitations were noted, though ^ Proceedings Third Pan-American Medical Congress, Feb. 4, 1901. 2 Med. News, Jan. 13, 1900. 96 lyPECTIOUS DISEASES. at longer and variable intervals of time. In nearlv all the larce cities in this country it has become endemic, and in Philadelphia since 18G3. Pathology. — The cases that prove speedily fatal do not present gross characteristic changes, but by the aid of the microscope leukocytes are discovered immediately around the cerebral vessels, and round cells in the cortex of the brain. In some cases the characteristic evidences of encephalitis are already noticeable. On the other hand, the cases in which death occurs after the disease has been full}'^ developed show the lesions of suppurative inilanunation of the meninges of the brain. The arteries, veins, and sinuses are much engorged ; the ventricles are dis- tended with liquid, but the pia mater is principally affected, its vessels being greatly enlarged, and a more or less copious sero-fibrinous or sero- purulent exudate occurring into the meshes of its netAvork. The longer the duration of the case the more purulent is the exudation. The ven- tricles of the brain are filled Avith a similar exudation, and red blood- globules may be present at an advanced stage. The color of the exu- date is at first almost clear (being composed of serum) ; it then changes to a milky turbidity, to a pale yellow, and, lastly, takes on a greenish- yellow color ("leek-green "). The subarachnoid space may be occupied by a uniform layer composed of fibrin and pus. The brain-matter is congested, and sometimes softened in spots, and on section the gray matter may present punctate extravasations. When resolution occurs recovery may be comi)iete, but frequently the pia mater remains thickened. The exudation may follow the auditory and optic nerves along their lymph-sheaths, and pus has been found in the internal ear as well as in the chambers of the eye. The membranes of the spinal cord manifest lesions identical with those of the brain. They are vascular engorgements, followed by sero- fibrinous, and later still by sero-purulent, exudation beneath the arach- noid. The changes are more marked on the posterior than the anterior surface of the cord, and the exudate increases in amount in passing from above downward, in severe cases sometimes assuming the form of a sheath which completely surrounds the cord throughout its entire length. The pia mater is congested, and may be thickened, shaggy, and in places adherent to the cord, of which the gray matter may be the seat of serous infiltration, and rarely of softening. Barker describes certain changes that occur in the nerve-cells and the ventral horns of the nucleus dorsalis (Clarkii) of the spinal cord in epidemic cerebro-spinal menin- The lungs may exhibit the changes peculiar to bronchitis or pneu- monia. In the heart endocarditis may be noted, though rarely, and both the pleura and the pericardium may show inflammatory lesions and con- tain a serous or sero-purulent exudation. Hemorrhages into the serous membranes and into the skin may take place. The spleen may be en- larged, the increase in size and the degree of fever being })roportional, and the liver is hyperemic. The kidneys are congested, and bacterial forms have been found associated in the latter with the lesions of acute nephritis and hemorrhage — conditions of which they were probably the cause. Ktiology. — Bacteriology. — The diplococcus meningitidis is the spe- cific cause of epidemic cerebro-spinal meningitis. The special organism CEREBHO-SPTNAL MENINdlTLS. 97 can be isolated from the spinal fluid, the meninges of tlie l>rain and eoi'd, the blood, the joint-lesions, aiid the nasal mucus. The meningococcus, like the gonococcus, occupies a position witliin the polynuclear leukocytes, but never appears within the nucleus (Park), and like the latter is biscuit-shaped. The bacterium takes the usual stains. It develops upon agar-agar and upon Loeffler's blood-serum, manifesting characteristics of growth that simulate those of the pneu- mococcus. Councilman, Carl Frank el, Boston, and others, by refined methods, have, however, been able to differentiate these organisms. Welch suggests that the meningococcus and the ])neumococcus are possibly varieties of the same bacterium, while Netter regards the meningococcus as a degenerate form of the pneumococcus. Among the associated microbes are the pneumococcus, streptococcus pyogenes, staphylococcus aureus, bacillus coli communis, and the tubercle bacillus, and any one of the latter is capable of causing sporadic cerebro-spinal meningitis. Predisposing Causes. — (1) Age. — Most cases occur in children and young adults, though no age enjoys perfect immunity. Of 94 cases occur- ring in children up to 15 years of age, 56 were under five years (Claytor). (2) Climate. — The disease is unknown in tropical climates, but has occurred in all parts of the temperate zone, and is most prevalent in the more northerly portions of the latter. (3) Season is not an important factor, though the disease prevails largely in winter and spring. (4) Unhygienic Influences. — The disease often appears in ill-ventilated and overcrowded habitations — among the poorer classes, among soldiers crowded together in barracks, and among prisoners. Prolonged march- ing, and excessive physical or mental exertion, may heighten suscepti- bility. In certain epidemics the disease has raged exclusively in villages. Modes of Conveyance. — Precisely how the contagion is transferred from an infected person to a healthy one is not known, but the disease is probably contagious. Hare^ has recorded two cases in which the infec- tion seemed to be transferred directly from the first to the second. The poison may be conveyed hj fomites in cases that furnish intensely viru- lent poison. As to the manner in which the virus gains entrance to the system, our knowledge is imperfect, although Hunt^ states that cerebro- spinal meningitis seems to be an inhalation disease. It is certain that this. germ may enter the meninges (a) by blood metastasis ; (b) by direct extension of an adjacent inflammatory process (e. g., mastoiditis). Elser and Hontoon ^ believe that the disease may be spread by meningococcus carriers. Clinical History. — The period of incubation is brief, though un- known. The prodromal symptoms are variable in diff"erent epidemics. Invasion maybe sudden, a patient in vigorous health often being stricken down as though by a blow. In some rapidly fatal cases there is a short prodromal period, during which the patient complains of lassitude, head- ache, rachialgia, muscle- and joint-pains, and sometimes nausea and vomiting. In ordinary forms the prodromes may last from a few hours to a week or more, and the patient's complaint may be limited to cervical and occipital pains lasting a day or two ; then, without any initial chill, ■ 1 New York Med. Jour., Feb. 10, 1906. 2 Boston Med. and Surg. Jour., Xov. 1, 1906. 3 Journal of Medical Research, 1909, p. 397. 7 98 INFECTIOUS DISEASES. the invasion-period supervenes. In milder and sporadic cases the symp = toms consist chiefly of languor and debility, headache, pain in the back and limbs, vertigo, vomiting, and sometimes diarrhea. Most cases begin ahrKptly, between noon and midnight. The most distinctive and violent features are chill (often severe), /ever of a moder- ate grade, a full and somewhat accelerated pulse, raging headache, and vomiting. In children the ushering-in symptom may be a convuhion. These phenomena are followed by pain in the back and cervical por- tion of the spine — an early and characteristic symptom. Attempts at flexion or rotation of the head increase the pain in the neck and move- ments of the body augment the spinal pains. Later, the muscles in the cervical region contract, at the same time becoming rigid, and produce the condition of opisthotonos. The patient may be unable to swallow. The temperature is but moderately elevated. In a certain percentage of the cases it rapidly rises to 104° or 105° F. (40.5° C), but soon falls to 102° or 103° F. (38.8° or 39.4° C), at which level it is maintained with irregular undulations until defervescence, which takes place by lysis. In fatal cases death is preceded by a sudden great elevation of temperature to 108° and even 1]0° F. (43.3° C). In the very young the thermometric range is lower than in adults. The jniUe is but slightly accelerated, if at all, in the early stages of the disease. Later, in twenty-four to thirty-six hours, it may in severe cases leap to 120 or even 140, its chief characteristic being the variability in its rate. In the early stage it is of good volume and tension ; later, it may be soft and compressible, and in serious cases it becomes small and feeble. Polynuclear leukocytosis, moderate or severe, is constant. The respirations, as a rule, increase in frequency and are sometimes quite irregular ; but marked dyspnea, with slowing of the respirations, may be observed during the advanced stage, being due to pressure ex- erted by the exudation upon the respiratory center. Cheyne-Stokes breathing and sighing respirations may be present. Nervous S3rmptoms. — The headache is racking and often persistent, though it is subject to remissions; it is intensified by light and sounds. There is vertigo in nearly all instances. The pain referred to the spine may be general or limited to either the lumbar or cervical region (rarely the dorsal), and the general myalgic pains are often intense, especially in the extremities and the abdominal region. With the cephalalgia and abdominal pain may be associated vomiting. Hyperesthesia is a promi- nent symptom, the gentlest touch being extremely painful ; and anesthesia may follow. Any voluntary muscular movements, however, excite pain. In some cases delirium appears early, and in others rather late, Avhile in the worst types death often occurs before delirium develops. On the other hand, in a small percentage of cases, this symptom is absent through- out the entire course, and always its character and intensity exhibit a remarkable variety. It may be mild or it may take the form merely of incoherent answers to questions. Active delirium, however, is common and is accompanied by hallucinations, during which the patient shouts loudly, and, unless restrained, gets out of bed. This form of delirium oc- curs in paroxysms that are most apt to appear at night, and in the female it is sometimes hilarious or hysteric. An erotic tendency, with priapism or seminal emissions, has been observed in males. The "maudlin" CEREBBO-SPTNAL MEN/NO ITfS. 99 delirium of the drunkard is sometimes seen, but sooner or later somnolence appears and may deepen quickly into coma, perhaps temporary, though more often it continues until recovery or death. Vomiting is common, usually late in the disease ; it is doubtless of cerebral origin. Symptoms of motor irritation are common, twitching of single muscles or groups often being seen, and occasionally muscular tremors. Muscular contraction is an almost constant feature. After a few days a tonic spasm of the muscles of the extremities sets in, bending the arms upon the chest, the forearm upon the arm, and the thumb upon the palm ; the thigh is also flexed on the abdomen and the leg on the thigh. The opisthotonos may be followed by trismus, which can be considered a mortal symptom. Convulsions do not occur in adults, but are common in children ; occasionally there is paralysis (facial hemiplegia). Organs of Special Sense. — Photophobia is a prominent symptom, and the condition of the pupils is very variable. They may be dilated or contracted (more frequently the former) or remain normal ; and in the majority of cases they are unequal in size and react poorly to light. Strabisfnus is frequent, usually temporary, though it may recur during the attack. Rarely it is permanent. Conjunctivitis of moderate inten- sity and keratitis may occur, the former being common. Burville- Holmes^ invites attention to anesthesia of the cornea and conjunctiva, which occurs in about one-half of the cases. Ptosis is almost always present. Intense purulent irido-ehoroiditis sometimes occurs ; either temporary or permanent blindness and, rarely, nystagmus are noted. Among optical sequelae are cataract and atrophy of the eyeball. Deafness is common, there being an early intolerence of sound and a marked tinnitus aurium. Late suppurative inflammation of the middle ear, followed by rupture of the tympanum and otorrhea, may occur. The internal ear may be similarly involved, with uncertain gait. Cutaneous symptoms appear, some of which possess considerable diag- nostic worth. Pallor and lividity of the skin and visible mucous mem- branes often characterize the period of invasion, and shortly after the onset herpes facialis appears in more than half the cases. This symptom is significant for diagnosis. The separate lesions are extensive, and often coalescence of two or more is witnessed. Herpes facialis belongs in a peculiar sense to cerebrospinal meningitis ; herpes labialis to malaria, and less frequently to pneumonia and meningitis. A petechial eruption is common, in the early epidemics, and more frequently in America than in Europe. To this symptom the disease owes the name, long since given to it, of "spotted fever." It may, however, be absent, and when present it is sometimes limited to a small superficial area, though more fre- quently it is diffuse. At first the eruption may be bright red (erythe- matous), later becoming darker, or it may be distinctly petechial from the start ; purpuric spots of considerable size and sometimes large ecchymoses may appear, but these are most common in the more malignant types. Other forms of eruption are also seen (sudamina, urticaria, ecthyma, erythema, erysipelas, etc.), but are devoid of diagnostic value. Giangrene of the skin is occasionally noticed, and in some cases bed-sores are liable to arise ; but there is no fixed time for the skin-lesions of cerebro-spinal fever to appear, and their duration is exceedingly variable. ^Jour. Amer. Med. Assoc, 1908, ], 280. 100 INFECTIOUS DISEASES. Of gastro-intestinal symptoms vomiting is the most common. It usu- ally lasts only tor a brief period at the onset, though it may recur later at "longer or shorter intervals, and is of nervous origin. The appetite mav be good, but in many cases it is soon lost, the tongue, in a large ])ro- portion of the .instances, being only slightly coated. In cases assuming the adynamic or typhoid type the tongue is apt to become dry and of a brown' color, with the formation of sorties. Under these circumstances the abdomen is tympanitic and the bowels relaxed, and diarrhea may be urgent, resisting "all eflbrts aimed at its relief. Retraction of the belly is common, and constipation instead of diarrhea is the general rule ; the spleen may often be felt a little distance below the costal margin. Renal symptoms are not prominent, though the amount of urine passed is often above the normal despite the febrile movement. It may be below, though rarely, while in still other cases it is about normal ; and retention on the one hand and incontinence on the other have been observed. AJbumiauria is sometimes met with, and rarely glycosuria. Arthritis is not uncommon, particularly in the severer cases. Kernig's Sign. — In 1884 Kernig first pointed out the impossibility of obtaining complete extension of the leg on the thigh when the patient is sittimi and the thiirli is flexed at a right angle to the trunk. The sign is produced by irritation of the meninges of the lower portion of the spinal cord and of the nerve-roots that constitute the cauda equina, Roglet thinks that one cause for this sign is intraventricular pressure.^ Under this irritation, increased by the stretching eifect of the sitting posture, the tonicity of the flexor muscles of the leg is increased, and as a consecjuence complete extension of the leg becomes impossible. The contracture disaj)pears when the patient assumes the dorsal decubitus. If the patient cannot be propped up in bed, the thigh may be flexed upon the abdomen, when, if meningitis be present, complete extension of the leg will be prevented by contraction of the flexor muscles. Head's^ statistics, embracing 156 cases, show that Kernig's sign is present in 84 per cent, of the cases of meningitis. It is not confined to cerebro- spinal meningitis, but is present in all meningeal aff'ections. The time of its appearance is variable ; hence, in order to be certain that the sign is not present, it should be looked for repeatedly. Again, the time of its disappearance varies ; it may disappear during the preagonal period. The value of the sign is real, but its absence does not justify the exclusion of meningitis, while it may be present in other diseases (typhoid, tctanuw). Herrick ^ points out that from its persistence into convalescence it may be utilized to make a retrospective diagnosis. Macewens sign (vide Tuberculous meningitis, p. 253). a hollow note on percussing over the inferior frontal or parietal bone, is an indication of fluid in the ventricle, but is not always present. Brudzinski's Sign. — On attempting to bend the neck flexure move- ments in the ankle, knee, and hip-joints occur (identical reflex). Another, though less constant, sign is produced by passive flexion of one leg, which causes the fellow limb to draw up, and so remain (contralateral reflex). Complications. — Many of these have already been mentioned in the portrayal (d' the symptoms — e. g., destructive inflammations of the eye 1 P. Roglet, Gaz. heb. de Med. el de Chir., July 15, 1900. 'St. Paul Med. Jmir., Sept., 1900. ^ Amer. Jour. Med. Sci., July, 1899. CEREBRO-SPfNAL MENTNGTTTS. 101 and ear and the paralys(!S of the cranial ncrvcjs. The punilont inflam- mations of the serous sacs which were referred to in discussing tlie path- ology (pleurisy and pericarditis) are among associated conditions, and secondary bronchitis is common. Pneimionia (lobar and lobular) is a frequent complication. Endocardial murmurs are common, but pericardial friction is less so. Heniorrltmiv; ne/ihrifis is a rare com plication. Special and Atypical Forms. — (1) Mild or Rudimentary. — Tn this type the characteristic signs are either undeveloped or wanting, and the diagnosis is possible only during the prevalence of epidemics, which furnish typical cases. The most constant and significant symptoms are severe headache, languor, vertigo, nausea, and occasionally vomiting. Fever and contraction of cervical muscles are absent, as a rule. The duration is brief, rai'ely exceeding three or four days. (2) The Abortive Form. — Here the initial symptoms are severe, but after two or three days they rapidly subside, leaving the patient conva- lescent. The disease is cut short by the acquisition of immunity, and not as the result of medical interference. (3) Intermittent Form. — In this variety the symptoms, however in- tense, remit or almost wholly intermit every day or second dav ; these remissions are followed by a decided exacerbation or recurrence of the distressing features of the disease. Intermissions often occur at an ad- vanced stage. There is not observed the strict periodicity that is seen in malaria. Neither is the malarial plasmodium found in the blood. (4) Typhoid Form. — In certain cases the special features are character- istic of the "typhoid state," with protracted course. (5) Fulminant or Apoplectic Form. — The symptoms characterizing this most malignant type of the affection are rather inconstant. There may be severe chill, loss of consciousness, followed by deep coma and death, the whole course occupying the space of a few hours only. I saw two such cases in the same family : the first, a girl of five years, was stricken at 2 p. M. and died at 9 P. M. ; the other, a boy of seven years, was taken ill on the following day about the same hour, and died at 10 p. m. Other instances pursue a somewhat slower course, though manifesting the most striking malignancy. These begin with intense chills, violent head- ache, vomiting, early stupor, great prostration, contraction of muscles of the neck, moderate fever, and a feeble, progressively slowing pulse until it sometimes reaches 50 or even 40 beats per minute. The eruption, when it appears, takes the form of purpura. This form is most apt to be met with early in an epidemic, and with few exceptions proves fatal. (6) Schlesinger ^ states that epidemic cerebrospinal meningitis affects a senile type in elderly subjects, with little tendency to fever, or opisthotonos. Diagnosis. — The most important symptoms for diagnosis are the abrupt onset ; intense pains (cervico-occipital and lumbar) ; prostration ; vomiting ; vertigo ; somnolence, alternating with local or general tonic or clonic convulsions ; delirium (often sportive in type) ; tonic contraction of the muscles of the neck, extending to the back ; marked hyperesthesia ; a slow, followed by a more rapid, though variable, pulse : irregular tem- perature-curve ; and certain eruptions (petechial, herpetic). Lumbar Puncture. — The value of Quincke's lumbar puncture as a means of diagnosis is absolute. It alone • can render the diagnosis certain in many cases, and is a harmless measure, if rigid asepsis be ^Jour. Amer. Med. Assoc, October 16, 1909. 102 INFECTIOUS DISEASES. observed. The patient is placed upon the right side, with the left knee well drawn up ; a fine needle, three inches in lenrrth. and carefully guarded by the index finger of the operator, is introduced between the third and fourth lumbar vertebra '• one-half inch to the right of the median line" (Mallory and Wright), and directed slightly inward and upward. The forefinger of the disengaged hand must be used as a guide, and the site should be anesthetized by the application of a local freezing- mixture. The needle should enter the canal at a depth of two or three centimeters in children and four to six centimeters in the adult. If the fluid does not flow, the dura has probably not been penetrated, and 710 form of suction upon the needle should be attempted ; the fluid should be allowed to fall drop by drop into a sterile test-tube held aslant. From five to ten cubic centimeters of the usually cloudy exudate should be withdrawn and subjected to a chemic, microscopic, and bacteriologic ex- amination. Sugar, which is found normally, is absent from the cerebro- spinal fluid. Lorgo Vinsists that lumbar puncture must be repeated if the result of the procedure is at first negative. The fluid is said to be clear in tuberculous meningitis. If the presence of the diplococcus intra- cellularis in the nasal secretion can be shown, lumbar puncture is unnec- essary. The preci])itin reaction permits one to make a diagnosis, and sometimes with perfectly clear cerebro-spinal fluid (Vincent and Bellot ^). Differential Diagnosis. — (1) Tuberculous Meningitis. — In this aff'ection there is usually a tuberculous history — either personal or family — with prodromes extending over many days (occasional vomiting, unnatural peevishness, constipation), unlike the sudden onset of meningitis. The retraction of the abdomen is greater, while the arching of the neck, the general myalgic pains, and the hyperesthesia are less ; the herpetic and petechial eruptions are rare in tuberculous and common in cerebro-spinal meningitis. Cheyne-Stokes breathing and the well-marked changes of pulse belong peculiarly to the tuberculous form. By the aid of the oph- thalmoscope choroidal tubercles may sometimes be detected. Hand^ urges lumbar puncture, and found polymorphonuclear leuko- cytes in excess wherever tubercle bacilli were absent. (2) Pneumonia. — This affection may be complicated with a meningitis that afl'ects chiefly the cerebral cortex. Hence, while there will be motor spasm (more or less localized) and tremors, there will also be less retrac- tion of the head and less myalgic pain than in cerebro-spinal meningitis. Again, pneumonia precedes the development of the meningeal symptoms. (3) Typhoid Fever. — The carebral type of this affection may simulate closely meningitis. In both may be observed fever, delirium, somno- lence, retraction of the neck, spasm, tremor, and profound prostration. The mode of onset, however, is different, being slower in typhoid and unaccompanied by vomiting, muscular spasm, or hyperesthesia. In typhoid there is also the characteristic mental dulness ; the fever ig higher, with a typical fever-curve ; the roseate eruption and sero-reaction are characteristic, and there is greater enlargement of the spleen. Sequelae. — The leading sequelae are permanent blindness (due to optic neuritis with atrophy) and deafness, which sometimes terminates in 1 Pnh/rlinico, March, 1901 ; Saundei-s' Year-Book, 1902. "^ Biillftin Academie de Medecine, vol. Ixi, p. 326. 3 Pliila. Med. Jour., Aug. 30, 1902. CEREBROSPINAL MENINOITIS. 103 deaf-mutism; and in many cases headache ouUasts the disease for months. Chronic hydrocephalus and mental enfeeblement are not rare sequels (Ziemssen). Various local paralyses are observed, probably due to cer- tain peripheral lesions (neuritis and perineuritis). Immunity. — Permanent immunity is rarely conferred by the occur- rence of cerebro-spinal meningitis, relapses being common, and second (recurrent) attacks having been occasionally observed. Duration and Prognosis. — In very mild forms the duration is from one to four or five days. The most malignant type runs an even shorter course, when, as is the rule, it terminates fatally. If recovery ensues, it is after a long, serious, and protean illness. The abortive form is neces- sarily of brief duration. In the ordinary type convalescence usually sets in at the end of one or two weeks, but a slow convalescence, hindered by numerous complications and sequelae, is the rule. Apart from the fulminant form, which nearly always proves fatal, the severity of the infection may be appreciated by noting the degree of fever and the intensity of the nervous symptoms, especially the vomiting, coma, headache, opisthotonos, character of the respirations, etc. Complications may likewise affect the prognosis, pneumonia, and suppurative inflamma- tions of the pleura or pericardium, rendering it particularly grave. In children under two years the disease is very fatal, this period giving the highest mortality-rate ; between two and five and after thirty years it is a more serious disease than during young adult life. The death- rate of cerebro-spinal fever varies greatly in different epidemics, ranging form 25 per cent, in the mildest to 80 per cent, in the severest. Prophylaxis. — Disinfection of the nasopharynx, the expectoration, conjunctival secretions, and the urine is recommended with a view to destroying the specific poison. Meningococcus carriers must be discov- ered and treated. Isolation is to be carried out. Persons in any manner exposed and suffering from diseased conditions of the respiratory appa- ratus or pharynx should^ receive prompt and active treatment. Sophian and Black claim that the injection of dead meningococci confers consid- erable immunity. General Management. — The sick-room must be quiet and somewhat dark. All excitement is to be avoided ; the patient must not be allowed to leave his bed until convalescence is firmly established. The diet should be composed of nutritious liquids, such as milk and animal broths, etc., and as soon as convalescence begins the dietary should be increased by the addition of semisolid substances (rice, eggs, milk- toast, etc.), and, finally, the more easily digestible solids. The period of convalescence may be much abridged by systematic feeding. Medicinal Treatment, — Individual cases are to be treated accord- ing to the special indications presented. I regard it as extremely improbable that any case of this affection has been benefited by vene- section. Among medicinal agents narcotics are the most useful. Morphin hypodermically affords relief from intense headache, myalgic pains, mus- cular contraction, and other nervous symptoms in some cases. If the respirations be irregular, atropin may be combined with the opiate : and if the heart threatens to fail, strychnin may be administered. Should morphin fail, the bromids and chloral (the latter in small doses) are to be employed. In young children we must rely upon the bromids rather than the opiates. 104 lyPECTIOUS DISEASES. Flexner and Joblinix' present a report on 393 patients treated with Flexner's curative i^erlnn. Of these. -\)b, or 75 per cent., recovered and 98, or 25 jier cent., died. The serum is injected directly into the sub- arachnoid space after the withdrawal of an equal amount of cerebro-spinal fluid by means of lumbar puncture. The injections should be repeated daily for three or four days. When the Macewen percussion-note, however slight, is obtained, Koplik proceeds to puncture. Cantas ^ advocates the injectinii: of the serum into the lateral ventricle. Wasserman ^ reports 1<>2 cases treated with antimeninirococcus seruu) ; it had a curative effect when injected early (dose, 5 to 10 c.c. ie])eated two or three times a day). McKenzie and Martin have introduced an autogenous serum ; they with- draw blood-serum of a patient suffering from meningitis and inject it into the spinal canal of the same or another meningitis patient. Such a serum is an actively bactericidal fluid. For the tonic contraction of the muscles and violent cerebral symp- toms, cannabis indica should be tried. Convulsions call for hot baths (105° F.) or ether inhalations. Mercury has been, and still is, advocated (mercuric chlorid, gr. -^^ — 0.002, every four hours to an adult; calomel, gr. yVt^g — 0.005-0.004, every four hours to children). Belladonna and ergot have been employed in the early stages to diminish the congestion of the cerebro-spinal capillaries. Stimulants are required if signs of heart-exhaustion apjiear. They may be freely exhibited in accoi'dance with the customary rules. After effusion of the exudate has taken place, the narcotics are to be replaced by agents that promote absorption, as potassium iodid. The local means are also important. When tub-baths are not avail- able, cold should be used locally, since it is both of value and very grate- ful to the patient. An ice-bag is to be put on the head, and, if possible, long ice-bags placed along the spine. In rare cases of sthenic type we may employ small blisters at the nape of the neck or over the mastoids ; they are u.-eful during the stage of effusion. In the usual form of the disease it is better to apply the thermocautery lightly over the mastoid region. A small amount of blood may be withdrawn by means of leeches or by a few wet cups placed behind the ears. Quincke's lumbar puncture and laminectomy with free drainage have been practised, and lumbar puncture should, if necessary, be repeated, but only in case benefit follows first puncture. The principal effect is the relief of the pressure upon the central nervous system. In cases in which lumbar puncture only brought 2 to 20 c.c. of fluid, Cantas* obtained 40 to 120 c.c. from the lateral ventricle. Convalescence is prolonged, and requires to be diligently and judi- ciously treated. We must rely upon the generally accepted tonics — iron, cod-liver oil, arsenic, and strychnin ; the potassium iodid and the mer- cury also being continued for their influence in promoting the absorption of the exudate. Special attention is, however, to be paid to the hygienic management of this period. An abundance of fresh air, sunshine, and easily assimilable food must be furnished at all hazards, and electricity and massage, judiciously employed, will hasten recovery. » Jour. Amer. Med. Assoc, July 25, 190S. - Bulletin de I'Acadernie de Medeaine, Paris, January .30, Ixxvi., No. 5. 3 Deutsche medizinische Wochenschrift, .Sept. 26, 11)07. * Loc. cit. LOBAR PNEUMONIA. 105 LOBAR PNEUMONIA. [Croupous or Fibrinous Fneumoaia ; I'neumoidiis ; Lung Fever.) Definition. — An acute infectious disease caused by the Micrococcus lanceolatus, which produces a specific inflammation of the parenchyma of the lung and marked constitutional disturbances — chill, extreme prostra- tion, and fever which terminates by crisis. There are different forms of lobar pneumonia, as primary lobar pneumonia, secondary lobar pneumonia, and pneumonia with the formation of new connective tissue. Pathology. — Usually the lesions are confined to the whole of one lobe ; less frequently to the whole of one lung, and rarely to parts of both lungs. From JUrgensen's analysis of 6666 cases the following statement, showing the different situations of the lesions and their relative frequency, was taken : Right lung, about 54 per cent. ; left lung, about 38 per cent. ; and both lungs, about 8 per cent. In the right lung the lower lobe was involved in 22 per cent., the upper in 12 per cent., the middle in nearly 2 per cent., and the whole lung in about 9 per cent. In the left lung the lower lobe was involved in about 23 per cent., the upper in about 7 per cent., and the whole lung in about 8 per cent. The dis- ease involves whole segments of the lungs, and these may embrace more than one lobe. The lesions of pneumonia are divisible into three stages : (a) Stage of congestion or engorgement ; {b) Red hepatization (consolidation) ; and (c) Gray hepatization. (a) Stage of Engorgement. — The part or parts implicated are of a dark- red color, and firmer to the feel, but less resilient and crepitant, than normal. The cut section drips a blood-stained serum, and dark blood exudes from the distended capillaries. The air-cells do not collapse, though they are not solid, since excised pieces float ; but the weight of the lung-tissue is much increased. Collapsed portions may be observed which may readily be insuiBated from the bronchus, and areas of extravasation may occasionally be noted near the pulmonary pleura. On microscopic examination the alveolar epithelium is seen to be swollen, the capillaries greatly distended, and the air-cells containing alveolar epithelial cells, red corpuscles^ and a few leukocytes. Similar elements occupy the small bronchi. {b) Red Hepatization. — The affected tissue is solid, airless, and firm, resembling, as the term indicates, liver-tissue. It is reddish brown (ma- hogany) in color, presenting a dry, mottled appearance, and when, as is usual, an entire lobe is involved, it is more voluminous than normal and its surface is often furrowed by the impress of the ribs. Being airless, the affected portion does not crepitate, and its weight and specific gravity are increased. It cannot be inflated ; is extremely friable, and its lace- rated surface presents a finely granular aspect, this latter appearance being due to the minute plugs of inflammatory matter (fibrin) Avhich fill the air-spaces. The air-passages and small bronchi are distended with similar material, and granular masses can be removed from the air-cells of a cut or lacerated surface by carefully scraping the latter. If death 106 INFECTIOUS DISEASES. takes place during this stage, the ante-mortem, dry, inflammatory exudate soon softens, and may flow from the cut section as a grumous, viscid fluid ; the consolidated tissue sinks i*apidly in water. The pulmonary pleura is covered with a fine sheet of fibrin, and in cases complicated by marked pleurisy the fibrinous, inflammatory exudate forms a thick coating upon the pleural membrane, and the sac may contain liquid effusion. Microscopic examination shows the air-spaces filled with clotted fibrin, in whose meshes are held red blood-corpuscles, pus-cells, and changed alveolar epithelium. The interlobular connective tissue may be infiltrated with leukocytes and fibrillated fibrin, but the blood-vessels in the walls of the alveoli remain pervious. The pneumococci (micrococci lanceolati), less frequently also streptococci and staphylococci, are detectable. (6*) Gray Hepatization. — In this stage the fibrinous exudation becomes decolorized, the surface at first resembling granite in color, and later appearing uniformly gray. Associated with this change, and following it, there is fatty and granular degeneration of the inflammatory exudate, in consequence of which the latter becomes moist and soft. The exudate loses its granular character, while at the same time the friability of the lung-tissue is further increased, and from the surface of the cut section there flows usually a grayish-white or yellowish-white purulent liquid. Not less than one-half of the fatal cases die in the early part of this stage. The pleura is usually covered with a fine fibrinous exudation. Microscopic examination shows the air-cells stuffed with leukocytes, while the other histologic elements (fibrin, red blood-cells) have disap- peared ; and with the full development of gray hepatization resolution usually commences. The exudate is now softened into a liquid material with disintegration of cellular elements, and is absorbed by the lymphatics. Resolution usually corresponds in time with the occurrence of the crisis, though it may begin later. Pratt ^ found larger phagocytic cells in all stages of the disease ; it is likely that they play an important part in resolution. Among unfavorable terminations are — (1) Purulent Infiltration. — Here the lung-tissue becomes very soft, friable, and is bathed in purulent material ; and microscopic observa- tion shows the pus-cells densely infiltrating the interalveolar tissue and filling the air-spaces as well. Necrosis of the lung-texture may occur, producing abscess. (2) Abscess. — This is due to subsequent infection by streptococci, hence is a complicating lesion. The abscesses vary in size within wide limits, most frequently being situated near the base of the lung. In most instances the abscess-cavity has a fistulous connection with a bron- chus, but occasionally the abscesses become encapsulated in fibrous tissue, their contents undergoing first caseous, and then calcareous degeneration. When multiple, they sometimes coalesce, forming large abscesses. (3) Gangrene may rarely follow, but is due to a specific cause. (4) Induration. — A. Frankel states that in a few instances (about 1 per cent.) pneumonia ends in induration, and is found upon section to lie smooth and its tissue resistant (xncle Chronic Interstitial Pneumonia). (5) Pneumonia, particularly of the apex, may terminate in phthisis. Tubercular infection commonly occurs in unresolved pneumonias. Changes in other Viscera. — The heart often appears pale and is flabby, 1 W. H. Welsch's Fetsebrift, p. 265. LOBAR PNEUMONrA. 107 but upon. microscopic examination tlie muscular cell-fibors of the or^an are not found to be degenerated, except in rare, protracted cases. The cardiac chambers, particularly the right, are distended with firm, tough clots, which are usually removable en masse from the great vessels in the form of arboreal casts. The blood tends to coagulate, owing to the fact that its fibrinous elements are vastly increased, although Dochez found the coagulation time to be generally prolonged. Flexner found that coagulation was favored by auto-agglutination of the red cells. Pericarditis occurs in about 5 pei' cent, of the cases, and is relatively more frequent in right-sided or double pneumonia. Endocarditis is more common, especially the ulcerative form — in 11 out of 100 autopsies (Osier). With malignant endocarditis the lesions of meningitis are often combined, but as a separate complication the latter is rare. The spleen is congested, moderately enlarged, and softened, and the litter is likewise hyperemic and somewhat swollen. In the kidneys are found the lesions of parenchymatous inflammation, and with remarkable frequency also those of chronic interstitial inflammation. A catarrhal state of the gastro-intestinal mucosa (often with jaundice) is common ; and a frequent complicating change is croupous inflammation of the colon. When the infection is caused by the Friedlander's bacillus the dis- eased portions of the lung are increased in volume, and multiple foci may be formed throughout one lobe (Kokawa). The cut section is char- acterized by a slippery sensation to touch owing to the presence of a large amount of mucus, especially in the early stages. Swelling, pro- liferation, desquamation, and necrosis of the epithelium is observed. The fibrino-hemorrhagic exudate is not great, the large, emigrated leu- kocytes, and the epithelial cells forming the principal constituents of the exudate in the later stages. The bacilli are taken up by the epithelial cells and leukocytes, which swell up and develop vacuoles. Other infec- tions may be caused by the pneumobacillus — pleuritis, endocarditis, peri- carditis, abscesses, otitis media, and osteomyelitis. etiology. — Bacteriology. — The generally accepted specific cause of pneumonia is the Micrococcus lanceolatus of Frankel. It is a lance- shaped (slightly elliptic) coccus, united in pairs, when typical has the shape of two cartridges placed end to end, is surrounded by a pale capsule, and is present occasionally in the nose, Eustachian tubes, and larynx of healthy individuals. Netter found it in 20 per cent, of the specimens of buccal secretion taken from well persons, and " it is the migration of these ever-present germs into the pulmonary alveoli which causes pneumonia " (Wells). It is present in about 90 per cent, of all instances of pneumonia, and in persons who have had the disease it is detectable for many months or even years. It is generally present in pure culture, but may be associated with pyogenic organisms. It is probable that Friedlander's bacillus (discovered in 1888) and other micro- organisms (Eberth's bacillus, streptococcus of erysipelas, bacillus pestis) may also have the power to cause the disease ; and Wassermann ^ sug- gests that specific forms of pneumonia may coexist in the same indi- vidual, as, for example, lobar pneumonia and influenzal pneumonia. The organism grows upon all the culture-media except potato, between the temperatures of 24° and 42° C. (McFavland). The diplococcus pneumonicB (Fig. 10) can be readily demonstrated in the sputum by ^ Deutsch. med. Woch., Leipzig, Nov. 23, 1893. 108 INFECTIOUS DISEASES. treating a fixed cover-slip preparation 'svith glacial acetic acid which is allowed to drain off and is rei)lacetl (without washing in water) by anilin oil-gentian violet solution ; this is to be poured off and renewed two or three times. The Pnc-umAicoccus in Other Diseases. — It has been found in pure culture in pleuritis (including empyema), pericarditis, meningitis, peri- tonitis, endocarditis, synovitis, bronchopneumonia (principally in adults), acute abscess and other conditions. The mode of infection is by inhalation, although there may be other portals of entry. The first eiiects of the germ are local — in the lung, though it may reach more distant organs. To the w^idespread distribu- tion of the pneumococcus is due, in part, the septicemic process sometimes observed. The toxins of the mierococcus lanceolatus also become diffused throughout the system, pro ^ - o S-^" »*wS;;mS'?i"NjKKSS^;KS&-EKt' j > ~J -J 30 OO vo vo cn Oi ui - - - . - ; ' — — sj 1 > r ": ui ui 0-. -/, i ^ — _ _ ID lO? VO C -^ COS ^ - M u P. M. TEMP, 108 107 106 105 104 •> 2 '■ - J T - - ,_ « ~-~^ — --•,. " -' -■ ^ "; "" ~--» -':y' I""!" ': i^i-E:':' " - :;^"::::::::^s:^:::::::::::::: - m :::;:i::::::::::::!!^:: :::::~ - _._;! :>, * ,-^ -- A ::::::::::::::::::::::::::::::( "::::::::::::::•:::!:::: :::::: *■ c :^:::~':::::::::::nr! :"" - --*'v »■--•■""" = id U--.- - --^^ ^ ► < •V """"■--. ,^- _-^ _^ _. S ,>__,■ ^ ' 1» -,£' '"' . " r - " s . .^_ ' s •^ < s^". f=':'- - - » .!___ [ 5 ' ,. - ^^-■' a :::::::::::::::::::::::::::::]- '-' ^ ^f'"' z. ''.' «■"' ' - V """"--. _$, =:. ^ 5 _i--^ »- " " \_ _ ' --' ' S ,_« * <; r=cr "■"--- c= "^ J~ ~ - K ' ; ~ — ^_^ "" """--^ * "^ pi "''.7 ~~-3| = _ = ■■- ■ri . <:: _ _ _ __ <^ 5 : : ::: " ":3 > ' "■ > : J" -*' - _*'' s -5:--:::::!. -sfe-''- '-' •<• X -__ ^ .. — "- ^L = "^r -- S V ^ '' '-'' ' ~ i : ri"^^'^": " C" ' : :: c= ..'_,-: :> ;: < / -- » >< 'S. i ^=' ,^ S - -r -4^^'- - ^'- !=■ c -■ ' --•=' 3 114 INFECTIOUS DISEASES. about 100 to 108 per minute, and wben it exceeds 120 there is just cause for alarm. The rate may be increased either suddenly or gradually, but in any event augmented frequently implies danger. Cardiac failure is generally (lue to the eftect of the pneumotoxin upon tlie heart, although less commonly also either to previous organic disease of the heart or to some complicating condition (pericarditis, collateral edema), and the period of greatest liability is in the advanced stage of the disease. A^aso- motor paresis affecting the splanchnic area is also a factor in causing heart-exhaustion. At first the pulse is small, especially in extensive consolidation ; a little later, full and bounding. Dicrotism may be noticeable, and an irregularity in the volume and rhythm of the pulse may be observed; it is an unpropitious sign. In the aged and the weakly a feeble, frequent pulse may be present. The blood-pressure generally begins to fall after three or four days, and -when it progresses and exceeds 25 mm. Hg. it is significant and calls for increased stimulation. A prompt fall indicates approaching dis- solution, as a rule. Brem^ states that the first sign of exhaustion is ahvays a fall of the peripheral tension. MacKenzie points out that when the line of blood-pressure, measured in mm. of Hg., falls below that of the pulse-rate, there is danger, and vasomotor stimulants are required. The heart-sounds are clear, and owing to increased tension in the. pulmonary vessels the pulmonary second sound is accentuated. This is the state of things throughout in favorable cases. With failure of the right ventricle (a not rare event) there arise the signs of dilatation of this chamber (extension of cardiac dulness to the right, epigastric impulse, a low systolic murmur, shortening of the diastole, or fetal heart-sounds, cyanosis, and indistinctness of the second pulmonary sound). A soft, low-pitched murmur may be audible in the mitral and pulmonary zones. The blood-appearances are somewhat characteristic. There is a leukocytosis varying from 10,000 to 40,000 or more. The reseaches of Lacbe^ show that leukocytosis is of some value in determining between the crisis and pseudo-crisis, continuing in spite of the fall of temperature, etc., in pseudo-crisis, while it disappears with the true crisis. Stienon^ finds that in the febrile stage tlie polynuclear forms predom- inate, but as soon as these diminish the eosinophiles begin to increase. A small percentage of myelocytes may be found. Slight leukocytosis may indicate a mild infection, but, as a rule, it is a bad prognostic sign. Leukopenia occurs in the malignant cases ; on the other hand, leukocy- tosis of high deiiree, while indicating a severe infection, " it, at the same time, shows a good reaction."^ Leukocytosis, however, may be pre- vented by previous infections (e. g.^ typhoid) and the use of internal antipyretics. Ludwig Jehle^ reports 6 cases of the agglutination of the pneumococcus by the serum of pneumonia patients. The red corpuscles and hemoglobin remain little changed during the fastigium, but show a marked decrease almost immediately after the actual crisis.^ The blood-plates are also increased in number (Hayem). Da Costa has collected 9 cases of phlegmasia alba dolens in pneumonia. 1 Johm Hopkins Hasp. Bull., 1905, xvi., 321. 2 Berliner klin. Woch., 189.3, Nos. 36 and 37. ^ la PrcKse med., 13, 1895. * E. Becker, Dmtsch. med. Work., Aug. 30, 1900. ^ |j^^,„_ j.ii^_ Woch., 1903, No. 32. ® Sadler, Fortsckritle der Medicin, 1892 ; Leichtenstein, Ueber der Hiimoglobin-gehalt des Blutes, etc., Leipzig, 1892. LOBAR PNEUMONIA. 115 Cerebral Symptoms. — Headache sets in early and may be a prominent and persistent feature. In many cases, and particularly in children, the disease is ushered in by convulsions, this symptom occurrinif more often in the apical than in the basilar form of pneumonia. JJelirium may come on during the acme of the disease (rarely, it may start as an acute mania), and may assume a maniacal form, but oftener in my experience conscious- ness has been retained. In the drunkard delirium tremens usually devel- ops, and may anticipate the symptoms referable to the lungs ; and I fully agree with Osier in stating that it should be an invariable rule, if fever be present, to examine the lungs in delirium tremens. These cases may often be appropriately termed ^^ walking pneumonia," since they go about until excitement gives way to a coma that deepens into death. In adynamic forms a low, muttering delirium and coma are frequent. In the so-called cerebral pneumonia the nervous phenomena are quite pronounced, and simulate closely cases of cortical meningitis. It is often associated with excessively high fever, except in the aged, when the cerebral symptoms are also well marked, but the fever is mod- erate. Apical pneumonias are apt to assume the cerebral type, but in my experience this dictum is correct as relating to children only. Double pneumonias are commonly characterized by severe cerebral symptoms. The Cutaneous Symptoms. — As stated before, herpes is common and its diagnostic importance is considerable. Naso-labial herpes is but little less frequent in this disease than in malaria, being present in about one- third of the cases. It usually comes out from the second to the fifth day of the disease, and rarely may appear upon the cheek, lobe of the ear, the genitals, forearm, or upon the mucosa of the tongue. Sweats are not common except at the time of the crisis, when they may be copious. The deep-red circumscribed spot upon one cheek [mahogany flush), usually on the side of the aifected lung, has already been men- tioned. Urticaria has been observed, though rarely. Digestive System. — The mouth is dry, the tongue has a coating of a yellowish-white color, becoming dry and brown in cases representing a low form, and anorexia and thirst are present. Vomiting is not uncom- mon at the outset, and may be repeated, while constipation is the general rule and diarrhea the frequent exception. Sears and Larrabee^ in an elaborate analysis of 949 cases found that pain below the costal margin was frequently present, and in several cases appendicitis, especially when the pain was associated with muscle spasm. Splenic enlargement of slight degree can usually be detected on palpation. Urinary Symptoms. — The urine is febrile, diminished in amount, and high-colored, the urea and uric acid being greatly in excess. On the other hand, the chlorids are, according to the older authors, either diminished in amount or absent during the febrile stage, presumably for the reason that they pass into the inflamed lung-tissue. They are not, however, constantly absent, and sometimes they are not even lessened, in pneumonia ; moreover, their disappearance is not peculiar to this dis- ease. The above-mentioned facts justify two important inferences : (1) The absence of chlorids is a symptom of little diagnostic value : and 1 The Mfd. and Surg. Reports of Boston City Hospital, Twelfth Series, Dec. 1, 1901. 116 jyFECTIOUS DISEASES. (2) their reappearance in the urine tmvard the close of pneumonia is of small prognostic worth. Slight (febrile) albuminuria is common. Physical Signs. — Stage of Congestion. — The density of the lung is increased, but the involved tissue is not consolidated and the pleura is not yet covered with fibrin. Inspection. — The movements of the affected side (especially if the base be involved) are defective, the degree of expansion being much diminished. In double pneumonia the costal type of breathing, com- bined with a vigorous play of the abdominal muscles, is observed. Palpation. — There is a slight increase in the tactile fremitus over the congested area, and defective expansion is noted. Percussion. — The note may be normal, though more often it is briefer, higher-pitched, or even distinctly tympanitic. Auscultation. — The breath-sounds are weak, and sometimes become broncho-vesicular upon deep inspiration, while over the unaffected lung- tissue they are exaggerated. If, as often happens, inflammatory prod- ucts due to associated bronchitis occupy the small bronchi, subcrepitant rales may be audible. The crepitant rale, however, is rarely heard until the close of the first stage. Stage of Consolidation. — Insjyection. — There is little or no expansive motion of the chest over the affected area, while upon the unaffected side it is increased. The volume of the thorax on the diseased side is increased, as shown by mensuration, but the intercostal depressions are not effaced. Palpation renders clearly perceptible the defect or absence of expan- sion. Vocal fremitus is usually much increased, though in exceptional instances it is diminished or absent — a circumstance which can, as a rule, though not invariably, be attributed to an associated pleurisy with more or less effusion. Frequently a friction-rub is felt before complete consolidation is established. Percussion. — A^arying degrees of dulness are obtained in this stage, and before the lung-tissue becomes thoroughly solidified the note may have a tympanitic quality. After complete consolidation there is usu- ally marked or absolute dulness posteriorly, unchanged by full inspira- tion, while the note may be more or less tympanitic anteriorly, where the vibrations are more apt to reach the air in the larger bronchi. A sense of resistance is offered to the pleximeter-finger, but not to the same degree as in the case of a pleurisy with effusion. When the latter condition is associated and in massive pneumonia the percussion-note will be flat. Deadness is less marked in old people in whose ribs senile changes have taken place, which render them more resonant, or in cases in Avhich the consolidated areas occupy the central portions of the lung. Above the solidified part Skodaic resonance is usually obtainable. Auscultation. — Bronchial or tubular breathing is heard, as a rule, over the solidified lung, but it may be absent in consequence of the plugging of the large bronchi with exudate (so-called massive pneu- monia). Bronchophony is usually obtainable over the portion of the lung affected, though this may also be absent, and for the same reason as in the case of the bronchial breathing: it sometimes takes the form of egophony. Subcrepitant rales, due to associated bronchitis, are sometimes heard with unusual distinctness (ownng to the consolidation), and the crepitant rale at the end of inspiration is best heard at the beginning of consolidation, when the pleura receives its coat of fibrin LOBAR FNEUMONTA. 117 and while the lung is yet capable of sufficient movemeijt to produce fine pleural friction. A distinct friction-rub may also be hoard occasionally. Stage of G-ray Hepatization. — With beginning resolution the solid con- tents of the air-cells liquefy and are removed, so that air now re-enters the air-cells and permits a consequent increase in the movement of the lung. Inspection. — The normal expansile movement gradually returns. Palpation. — Tactile fremitus progressively diminishes. Percussion. — The dull or tympanitic quality of the note is gradually lost, though the fact must be emphasized that the abnormalities in the note vanish more slowly than the other abnormal physical signs. .Some degree of deadness often remains long after apparent recovery. Auscultation. — With increased movement of the lung there may be a reappearance of the crepitant rale, due to interplay of the pleural sur- faces, and the softened exudate in the air-cells gives rise to subcrepitant rales, heard both on inspiration and expiration {rdle redux), with coarser rales over the bronchi. Bronchial breathing gradually gives place to broncho-vesicular, and the latter in turn to normal, breathing. The Pneumococcus Septicemia. — The pneumococcus infection may cause severe toxic features and even speedy death without any, or with but little, involvement of the lung-texture. The general inva- sion symptoms, such as the chill, high fever, and nervous symptoms which always predominate, however, are present and persist until death ends all. Death is preceded by signs of cardiac failure, by vaso- motor paresis, or, more rarely, by coma. In some of these cases localiza- tion of the morbid process may occur in organs other than the lungs, as the cerebral meninges, the endocardium, pericardium, and the pleura. An assured diagnosis in these atypical forms of the pneumococcus infec- tion can be arrived at by a bacteriologic examination of the exudate obtained by aspiration. The pneumococcus can also be demonstrated in blood-cultures, provided that they are made Avith large quantities of blood. Complications. — Many of these are due to the primary infection. Pleurisy is, of necessity, associated in all instances in which the con- solidation reaches the pleura. In most cases the presence of the diplo- cocci has been demonstrated. Cases are met with in which the truly pneumonic symptoms are overshadowed by the intensity of the pleuritis and to these the term pleuropneumonia has been applied. There is often a copious effusion which is exceedingly rich in fibrin — a circumstance which distinguishes it from other forms of acute pleurisy. There may be the ordinary grade of pleurisy on the side of the pneumonia, and a severe grade on the opposite side which is apt to be purulent. Indeed, empyema has of late been shown to be a frequent complication of pneumonia, and it also occurs as a sequel. A condition that affects its incidence is involvement of the lower right lobe. Lambert and Daly^ report 5 cases of empyema developing as a complication in lobar pneu- monia, which showed a sudden rise of leukocytosis to nearly or more than double the count of the previous day. Its development is accompanied by replacement of ordinary dulness by flatness with great resistance, and by the disappearance of rales and breath-sounds, normal and abnormal. Other characteristic features of empyema are present, but if doubt sur- round the diagnosis, the needle should be introduced. ^St. Paul Med. Jour., Dec, 1902. 118 INFECTIOUS DISEASES. There is a prompt rise of fever, the temperature leaping to 103° or 104° F. (39° or 40° C.) quickly, after which it is decidedly remittent in type, but there are no hectic chills. Fistulous connection Avith a bronchus, however, and the establishment of empyema necessitatis are common events, and may ,be preceded by diurnal chills, sweats, etc. The occurrence o^ septic phenomena is a certain indication of second- arv infection by streptococci. The pus is rarely absorbed and frequently becomes encysted. I saw one instance in which the effusion measured 8 liters, while ordinarily the amount ranges from 2 to 5 liters. Removal of the effusion by aspiration is promptly followed by the disappearance of the fever, but reaccumulation generally occurs. Finally, if defervescence in pneumonia takes place by lysis or if an irregular fever persists, a residual purulent or sero-fibrinous effusion may be considered as the likely cause. This latter complication is attended by a paroxysmal cough which is excited by movement, and is not usually accompanied by expectoration. Acute general broncliitis may pre-exist or arise as a complication, and often proves formidable, intensifying the fever and increasing the dysp- nea, the tendency to heart-failure, and the cyanosis. The expectoration is freer than in uncomplicated pneumonia, and over the bronchi moist rales intermingled with sibilant and sonorous rales are audible. Pericarditis. — This is an important and serious complicating affection. According to Chathard, it is oftener synchronous with involvement of the right than of the left lung, hence arises as often by a metastatic process as by direct extension. It was present in 4.66 per cent, of 665 cases and occurred most frequently in young adults. Although gener- ally of the plastic variety, it is not infrequently sero-fibrinous, and rarely the effusion is purulent. The diagnosis can be made here as under other conditions (pericardial friction rub, etc.), but the complication is often insidious. The occurrence of increased dyspnea, with or without pre- cordial pain, should serve as a signal and lead to a physical examination. Endocarditis. — This is somewhat more frequent than pericarditis. Preble ^ has well said that endocarditis should always be suspected in a case of pneumonia, which is followed by an irregular temperature not suffi- ciently accounted for by some other complication, such as empy- ema. Out of 209 cases of malignant endocarditis collected by Osier, 54 cases occurred in pneumonia. Endocarditis complicates pneumonia in 1 per cent, of all cases and in 5 per cent, of the fatal cases (Preble). It is generally of the malignant type and may attack any valve (the aortic leaflets, however, being most commonly affected). There are no reliable symptomatic indications of this condition. The physical signs must be faithfully and systematically noted. Fre- quently murmurs are absent ; and, on the other hand, the presence of a murmur alone is by no means diagnostic of the complication. Brady- cardia is not uncommon, but oftener the pulse is rapid and feeble. The development of septic manifestations, especially irregular fever, chills, and sweats, renders the case highly suspicious, and when in addition there arises distinct evidence of embolic processes the diagnosis becomes highly probable. If, now, the symptoms of meningitis supervene, little doubt remains as to the character of the complications, since meningitis and endocarditis are often combined in pneumonia. ^ Amer. Jour. Med. Sci., Nov., 1904. LOBAR PNEUMONIA. 119 Netter, Weichselbaum, and Bigniirni have shown that acute endocar- ditis may be caused directly by the diplococcus of pneumonia.' Chronic Endocarditis, — J'neumonia arising in the course of chronic en- docarditis is apt to be attended by cardiac failure, with ensuing venous stasis. The murmurs of chronic valvulitis often dis;ip[)ear with the de- velopment of pneumonia. Cardiac clots (ante-mortem) may form, but are rare. They result from weakness of the ventricular wall, especially in the right heart; and are most apt to arise, therefore, in cases in which the preagonal period is much prolonged. Venous thrombosis is rarely seen, and embolism of the larger arteries is a rare complication, the lesions and determining factors being similar to those in typhoid fever. The cerebral embolism, causing aphasia and even hemiplegia, has been observed, but seldom. Pneumococcus meningitis may be a complication ; it differs only in the bacteriologic findings from meningococcus meningitis. Pneumococcus meningitis may also occur independently of lung involvement. The symptoms are not clearly defined ; particularly is this true when it develops during the invasion-period and the basilar meninges are not involved. The presence of intense and persistent headache, rigidity of the nucha, wild delirium, followed by stupor, deepening into profound coma, affords a basis for a probable diagnosis. Its frequent association in the purulent form with ulcerative endocarditis has been pointed out above. The cerebrospinal fluid contains no sugar in this condition. Peripheral neuritis is among the rare complications of this disease. Parotitis is also sometimes, seen, and may cause a fatal termination of the case. I have seen two instances, however, in which this was a com- plication, and both ended in recovery. It is thought to be associated usually with endocarditis, but not so in my cases. Arthritis. — A pneumococcic arthritis occurs, but it is rare. The joint is occasionally primarily involved, showing the importance of toxemia (Herrick). It is most prone to develop after the crisis, and is associated with meningitis and endocarditis. The exudate is generally a thick creamy pus, less commonly sero-fibrinous. The changes may be either slight in the acute forms, or extensive and destructive of cartilage and bone, particularly in the more chronic cases. A recognition of the con- dition demands exploratory aspiration and bacteriologic examination. The mortality-rate is 65 per cent. Rheumatism and otitis media may be rarely met also, particularly in children. Gastro-intestinal Complications. — Croupous gastritis may rarely inter- vene. Fussell ^ calls attention to complicating acute dilatation of the stomach ; it causes vomiting, sudden epigastric distention becoming gen- eral, and collapse, Avhich is an urgent symptom. Croivpous colitis is a frequent concomitant, sometimes grave, giving rise to tympanites and diarrhea. Peritonitis occurs, but with great rarity. Jaundice may be observed ; it is more frequent in serious than in mild forms of the disease. It is rarely intense, and is most probably an obstructive (hepatogenous) jaundice. N. V. P^trov has reported 13 cases complicated with icterus, and in all observed local lesions (mainly catar- ^ Practitioner, London, Aug., 1894. "^Amer. Jour, of the Med. Sci, Dec, 1911. 120 INFECTIOUS DISEASES. rhal) of the duodenum and the biliarv canals. A catarrhal or suppura- tive cholecystitis may rarely complicate lobar pneumonia.^ Acute nephritis is a complication, and its recognition is dependent upon the discovery of albumin and casts in the urine. In 20,107 cases of lobar pneumonia, acute nephritis occurred in 208, or 1.3 per cent. (Norris). Clinical Varieties and Anomalous Types. — (1) Typhoid Pneu- monia. — This relates to an adyn;imic, serious type of the disease with typhoid Kjinipfoms, and not to typhoid fever. It is often secondary to low fevers, to septicemia, diabetes, and chronic nephritis, and is also the vari- ety met with in drunkards and in persons previously enfeebled. The onset is somewhat gradual. The physical signs may be ill defined, but the general features are always striking and characteristic. Prostration is extreme ; there are delirium and often stupor ; the temperature may or may not be high ; while the respirations and pulse are almost always fre- quent. The skin is dry, and may show a dusky tint or slight jaundice. The tongue is dry, often brown, and vomiting is common ; the sputa may be rusty or decidedly hemorrhagic. Splenic enlargement is often clearly perceptible. When recovery ensues convalescence is tedious. Some of the cases belong in the category of atypical pneumonias. (2) Epidemic Pneumonia. — This is often of malignant type. Tlie symptoms exhibit noticeable variations, according to the special etiology and to different epidemics. The pneumonias of epideniw influenza are complicated with or preceded by general bronchitis. The heart-power often becomes exhausted early, and then follow congestion and edema of the lungs. The physical signs are often slight. The so-called serous pneumonia often complicates influenza; it is ascribed to streptococcus infection (streptococcus pneumonia). Septic phenomena often arise, such as irregular fever and sweats. The physical signs, for a time indefinite, when fully developed resemble those of bron- chopneumonia. There may be a tendency to migration from one to the other lung. There may be a late-appearing rusty expectoration, and in some cases the sputa are mucopurulent throughout. The course is often protracted, and the fever may terminate by lysis. In two of my cases the pneumococcus was detected in the sputum in increased numbers. It is said that in mixed infection the micrococcus lanceolatus is abundantly present. In so-called ''larval p>neum(>nia'' the general symptoms are mild and the local signs ill defined. The epidemic outbreaks that occur in institutions, tenement-houses, jails, etc., belong to this variety. (3) Latent Pneumonia. — To this class belong central pneumonias. The sputum is to be stained and examined microscopically, when the pneumococcus will be found. The sputum is gummous and rusty, as a rule. When pneumonia arises in the course of emphysema the dilated air-cells are not filled with the exudate ; hence dulness is less marked, and true tubular breathing may be absent. Before the crisis occurs consolidation usually advances to the periphery. • (4) Migratory Pneumonia. — By this is meant an extension of the spe- cific inflammation to other parts of the lungs. Such extension may pre- vent the occurrence of the usual crisis, and often occasions an exacerbation of the general pneumonic features. 1 '' Cholecystitis as a Complication of Lobar Pneumonia, with a Report of Three Cases, and Remarks on Icterus in Pneumonia," by tiie writer. LOIIAII PNEUMONIA. 121 (5) Bilious Pneumonia (" Malarial Pneumonia "). — In pneumonia oc- curring in malarial subjects the initial chill is prolonged and tlie fever paroxysmal or remittent. Jnundice and vomiting are common. (6) In children, the first symptom is often a convulsion. Cerebral symptoms (delirium, stupor, coma) may appear early. The upper lobes of the lungs are frequently involved. Unless the objective indications be examined for, the disease is frequently overlooked. The characteristic sputum is rarely seen in juvenile pneumonia. Crozer Griffith reports 8 cases in which the pain suggested appendicitis. (7) In old persons the initial chill is often absent or- replaced by moments of chilliness. There may be nausea and vomiting. Prostra- tion is profound ; there is fever, but it does not range high and is irreg- ular. Nervous phenomena, sometimes prominent, are not uncommon, but the local symptoms (cough, expectoration, and pain) are mild or wholly absent. The physical signs are defective owing to impairment of the respiratory movements; dulness on percussion (with a tympanitic quality), tubular breathing, and a few subcrepitant rales may, however, be noted. This affection is a most deceptive one in old people, the cases gener- ally ending fatally after an illness of an apparently mild degree of intensity. (8) Abortive pneumonias last no longer than twenty-four or forty- eight hours. The general features are rigor, high fever, and deferves- cence by crisis with profuse sweating. The sputum is rarely characteristic, and the physical signs variable ; typical tubular breathing is rare, while rales and pleural involvement are common. Bechtold^ has frequently observed this form affect all the members of a family. (9) Terminal Pneumonia. — Many instances of pneumonia are dis- covered in the post-mortem room. These arise in advanced cases of chronic pulmonary tuberculosis, organic heart diseases, chronic Bright's disease, diabetes, and the like, and manifest no clinical symptoms other than slight elevation of temperature, an increase in the respirations, and lung consolidation. A fatal termination is the rule in terminal pneumonia. (10) Ether-pneumonia. — Opinions are divided as to the frequency of occurrence of pneumonia after ether-narcosis. The aggregate number of cases from all sources (57,842) gives a percentage of 0.07. My own statistics, embracing 12,842 cases, give a percentage of 0.23.^ The principal causes are — {a) Season. According to my investiga- tions, over 80 per cent, of the cases occur during the winter and spring months. The patient is sometimes carried from a heated operating-theatre through a cold corridor to a room or ward with a lower temperature. (6) " Catching cold," or exposure as may obtain during protracted opera- tions, (e) Bronchitis, coryza, and the like present at the time of anes- thesia, {d) Dried secretions or incrustations of foreign matter that are loosened by the ether and drawn into the lungs, (e) Abdominal opera- tions give the highest percentage of cases, due, as my studies show, to the more protracted etherization. Mikulicz has shown that ether-pneumonia following these operations is caused by embolism. (/) Graves ^ believes that most cases are caused by the lighting up, or aggravating of, pre- existing foci in the lungs. The clinical features are aptly compared with those of secondary pneu- monia (vide p. 130). The diagnosis rests principally upon the typical » Munch, med. Woch., No. 44, 1905. 2 " Ether-pneumonia," Univ. Med. Mag., Aug., 1898. ' Boston Med. and Surg. Jour., Sept. 29, 1910. 122 INFECTIO US D ISEA SES. physical signs. Owing to the extreme latency of the condition, and the danger that the symptoms may he regarded as being septic in nature, I would emphasize the importance of a physical examination of the thorax upon the sudden accession o^feve)\ particularly if associated with thoracic pain, however slight, following an operation. Relapses. — These are rare, and are usually rudimentary. Recur- renres. liowever. are ordinary (vide Predisposing Causes, p. 110). Course and Duration. — In most instances, the crisis occurs on the seventh or ninth day, anright's disease, diabetes, and organic aff"ections of the heart) fever is developed, physical exploration of the thorax is imperatively demanded. Fie. 13. __ ^:zj •Acute pneumonic phthisis, posterior view : 1 , cavity ; 2 and 3, consolidation ; 4, infiltra- tion ; the white spots indicate r^les. Differential Diagnosis. — This relates to {a) acute pneumonic phthisis, (h) pneumo-typhoid, {c) meningitis, {d) broncho-pneumonia, {e) acute pleurisy with eifusion. (a) Primary Lobar Pneumonia. There may have been prior attacks. Sudden, with severe rigor and rapid rise of tempeiuture. Fever of continued type, terminating by crisis. No drenching sweats, except at time of crisis. Hei'pes common. Not much emaciation. Pulse-respiration ratio much disturbed. Sputum rusty-colored, viscid, and sticky; contains pneumococcus. Leukocytosis present. Duration of febrile stage shorter. Acute Pneumonic Phthisis. Inherited predisposition or previous tu- berculous disease. Genei-ally more gradual — repeated fits of chilliness (rarely severe rigor), often following exposure oi' " cold." Fever of remittent type, often becoming intermittent, without crisis. Drenching sweats present and oft re- peated. Absent. Eapid emaciation. Less so. Sputum may be blood-tinged ; is more purulent and copious, and contains nu- merous bacilli and yellow elastic tissue. Relative lymphocytosis. Duration lonsrer. 124 INFECTIOUS DISEASES. [a) Primary Lobar Pneumonia. Acute Pneumonic Phthisis. Physical signs, as a rule, first referable First referable to apex. to base of lung. Usually limited to one lobe or the lower Usually extension from apex to base. segment of one lung. Signs of consolidation, followed by reso- Signs of consolidation, followed by cavity- lution. formation, with large gurgling r^les at apex. Apex of opposite lung not involved. Apex of opposite side generally in- vaded. Prognosis not hopeless. Hopeless. Tuberculous disease of other organs does Often does, not follow as a rule. [h] Typhoid pneumonia must be diagnosed from p)neumo-typ1ioid., and the blood in the two conditions may be of service in the discrimination. Leukocytosis usually exists in pneumonia, and there is hypoleukocytosis in typhoid ; but this fact is only of value when there is marked increase or decrease of the leukocytes, since figures about normal may occur in either condition. In pneumo-typhoid, after the end of the first week, hoAvever, undoubted symptoms of typhoid fever arise, and often before this period the Widal test will clear the diagnosis. On the other hand, typhoid pneumonia is characterized especially by great physical prostra- tion, feeble heart-action, and other symptoms of the typhoid state. {e) 3Ieningitis is sometimes mistaken for pneumonia, and particularly when the latter occurs in children. The initial symptom of pneumonia in the very young is often a convulsion ; whereas, though in meningitis this symptom is not uncommon, it is more apt to manifest itself later. When headache occurs in pneumonia it is frontal. It is almost invari- ably complained of in meningitis, but is occipital, and is associated with rigidity of the cervical muscles. Before the occurrence of pressure- symptoms in the latter disease the patient is very restless and m-^rose; his reflexes are exaggerated and there is marked hyperesthesia. The temperature-range is lower, more irregular, and there is no crisis, while the pulse is more variable and often irregular in meningitis. In pneu- monia with latent local symptoms the pulse-respiration ratio is greatly altered and the type of respiration peculiar (vide ante). The important rule, to examine for the physical signs in doubtful cases, must not be neglected, and if the subject be young the apex region in particular. The differential diagnosis between pneumonia and broncho-pneumonia and pleurisy with effusion will be found on pages 558 and 592. Prognosis. — The mortality from pneumonia in hospitals averages about 25 per cent. It is less in private practice — about 15 per cent. The death-rate, however, is greatly modified by the type of the indi- vidual epidemic ; hence a precise statement as to the percentage of fatal cases cannot be ventured. Wells collected 22o,730 cases, which gave a mortality of 18.1 per cent. The elements that enter into a correct prognosis are in the main identical with those in other acute infectious diseases, and concern (1) the severity of the type of infection, (2) the presence or absence of complications, and (3) circumstances peculiar to the individual. (1) Severity of the Type of Infection. — In sthenic cases this is shown by (a) the temperature-range, (b) the degree of heart-power, (c) the in- tensity of the nervous symptoms, and to some extent by {d) the size of LOBAR PNEUMONIA. 125 the area of lung-induration. It is a matter of common observation that the absence of leukocytosis is indicative of a grave type. In case the diplococcus be found in the blood, the prognosis is by most writers con- sidered grave, and it is to be recollected that with the improved tech- nique of the present day this organism is readily isolated, (a) The Temperature-ranf/e. — A continued high temperature, as, for example, 105° F. (40.5° C.), on two or three consecutive di»ys without material remissions, is ominous, (b) The Degree of Beari-fowcr. — A steadily rising pulse-rate after the fifth day indicates real danger, since it points indisputably to gradual cardiac failure. The same thing is shown by a diminution in the intensity of the second pulmonary sound ; it indicates the giving out of the right ventricle, {c) The Intensify of the Nervous Symptoms. — Active delirium is not favorable at any stage, and is partic- ularly unfavorable if it develop early. When it assumes the form of delirium tremens the case has usually passed beyond the hope of re- covery, {d) The Size of the Area of Lung-induration. — I have observed that extension of the consolidation at an advanced stage belongs to serious types. The same may be said of double basic pneumonias. Typhoid pneumonia., being of low type, gives an unfavorable prog- nosis, notwithstanding an absence of high temperature and of extensive inflammation of the lung-texture. (2) Presence or Absence of Complications. — Cases in which there is involvement of a single lobe or two lobes, if it occur on the right side and without complications, generally terminate in recovery. In nearly one-half of the instances complications occur, and these greatly increase the death-rate. Among the most common is pleurisy., which, unless accompanied by considerable effusion, does not add fresh danger ; when pleurisy attacks the non-affected side, however, it does. Empyema, following pneumonia, generally terminates in recovery unless septic phenomena are superadded. Extensive bronchitis is a most perilous com- plication in my judgment. Pericarditis decreases the chances for re- covery, but by no means to the same extent as ulcerative endocarditis. Cardiac clots may form, but usually the patient is already moribund. Abscess of the lung and gangrene form highly unfavorable complications. Congestio7i and edeina of the uninvaded portions of the lungs render the outlook bad, and these, together with cyanosis, are apt to be dependent upon failure of the right heart. Acute meningitis is exceedingly grave. Fenwick, as the result of an analysis of 10,000 cases, found that the quantity of albumin in the urine is of considerable prognostic value. G-astro-intestinal complications occurring at the outset are unpropitious. (3) Circumstances Connected with the Individual. — Of these age heads the list, and after the twentieth year the mortality increases progres- sively until the seventh decade, when it rises more abruptly. It has been claimed that nine-tenths of the deaths after the seventy-fifth year are from lobar pneumonia. Under the twentieth year, according to the analysis of 708 cases at St. Thomas's Hospital by Hadden, H. W. G. Mackenzie, and W. W. Ord, the mortality is 3.7 per cent. Sex has little influence. Napier's figures indicate that pneumonia is a more deadly disease in men than in women. The alcoholic rarely escapes death, and adiposity is an unfavorable condition. 126 INFECTIOUS DISEASES. Modes of Death. — Death is due to : (1) overwork or overdistention of the right ventricle ; (2) from niechanical interference with respiration (rare) ; (o) pneumococcus infection of other organs, as the meninges, pleura, pericardium, endocardium ; (4) pneumococcus toxemia and sep- ticemia as shown by the typhoid state, progressive lieart weakness, tym- panites, and diarrhea ; (o) vasomotor paresis is often the cause of death. Treatment. — General Management. — The patient should be isolated in a well-aired apartment. Fresh air constantly breathed improves the appetite, lessens cough, diminishes the temperature, pulse-rate, and respiration-rate ; in short, a less marked toxemia is observed than in patients treated by the more usual method.^ Spolverini ^ points out that the pneumococcus in the sputum may remain virulent from fifty-five to one hundred and forty days, hence it is important to sterilize pneumonic sputum. An antiseptic mouth-wa«h should be advised. In severe forms the constant presence of a physician is required. The patient must be kept at perfect rest, and not allowed to leave his bed for at least one week after the occurrence of the crisis. The beneficial effects of rest, in the fullest sense of the term, are not appreciated to the extent they deserve. Perhaps the principal object is to support the powers of life until the crisis is passed. The diet should be light, chiefly liquid, but of the most nutritious sort. 3filk should constitute the chief article of diet ; meat-broths or meat-juices, egg-white, and light farinaceous substances may also be al- lowed. The food, particularly the milk, is to be administered at stated brief intervals and in definite quantities. When resolution is delayed stronger forms of nourishment (scraped meat, etc.) may be given. After the crisis a gradual return may be made to the usual forms of solid foods. Page^ and others advocate abstinence from practically all nour- ishment except ivater. Alcohol has considerable food-value ; it lessens waste and improves the appetite and digestion. To accomplish this ob- ject, it should be given in small amounts, two or three ounces daily. The medicinal treatinent is that of a toxemia, although the patient himself is the main factor. The use of calomel in fractional doses or one of the saline laxatives in the early stage is an important procedure. Subsequently the liver and bowels must be kept acting freely, so as to eliminate waste products and toxins, and to obviate "absorption of fermentative products from the alimentary canal " (Thornton). The action of the kidneys is best maintained by the regular use of Avater and that of the skin by sponge- baths. Stockton advises stimulation of the eliminative organs — skin, liver, kidneys — in senile pneumonia. Cardiac stimulants are often indicated. It is well to begin their use as soon as the slightest tendency to cardiac failure is shown. AVhen the pulse becomes more accelerated and feeble, the first sound of the heart less distinct, and the second pulmonic sound loses its accentuated char- acter, or marked nervous symptoms or adynamia appear, then alcoholics must be used. At first they are to be employed in moderate doses {^ ounce — IG.O — of whisky or brandy every three hours), to be increased ^ Medical Record, 1906,. No. i, p. i, bv the writer. 2 Centralb. f. alhj. Path. v. pathol. Anal., July 18, 1900. 3 Mediccd kecord, Dec. 23, 1905. LOBAR PNEUMONIA. 127 if the effect be favorable proportionate to the urgency of the indication. In the pneumonia of drunkards its early use is to be recommended. If the alcoholic stimulants fail, other cardiants must bo administered simultaneously. Of these, strychnin has been the most serviceable in my own hands, its mode of administration foHowing the same rules as have been mentioned for alcohol — at first in inoderate-sized doses, to be in- creased as occasion demands. Should urgent need of stimulation arise, strychnin should be exhibited hypodermically. It is my custom in desperate cases to use subcutaneously as much as gr. ^ (0.004'3) every two or three hours. As soon as the condition of the heart denotes resto- ration of cardiac power the size of the dose is to be reduced. In no other disease do strychnin and alcohol possess greater potency for good than in pneumonia ; they lessen the depressing effect of the poison. For sudden heart-failure ether, administered hypodermically, is also very efficacious. In severe forms of pneumonia digitalis is invaluable during the advanced stages; it may be given in doses ranging from 5 to 15 minims (0.333—0.666) of the tincture every third hour. In cases in which extreme cardiac weakness with depression of respiratory forces supervenes the drug is to be administered hypodermically in the same dosage. Strychnin may be combined with the digitalis. The effect upon the pulse and heart-sounds should be the criterion of sufficiency. Lowenstein states that both camphor and caffein are far superior to digi- talis. S. West^ sees most benefit from caffein citrate with nux vomica. Recent experience enables me to speak strongly in favor of atropin ad- ministered subcutaneously in the threatened collapse that sometimes at- tends the crisis. Nitroglycerin is especially indicated when the renal secretion is scanty and the urine contains more than the usual trace of albumin. Ammonium, adrenalin chlorid, and camphor (gr. 1 to 2 — 0.027—0.054) in sterile oil, hypodermatically, are also excellent stimu- lants to the feeble heart of pneumonia. Peripheral stimulants, such as cold or heat, either locally or gen- erally, may be useful after the blood-pressure falls. It is claimed by some that central stimulation to an over-acting heart may hasten exhaus- tion rather than prevent the same. Saline injections are valuable in overcoming a falling blood-pressure with increasing toxemia, for the purpose of filling the vessels. The hypo- dermic method of administration is preferable. From 1 to 2 pints (strength 0.7) may be injected, and allowed to flow under the skin from a rubber bag ; and this may be repeated at intervals of eight hours if necessary. For an acute exacerbation of a chronic nephritis in the course of pneumonia, venesection with saline infusion is worthy of trial. Respiratory Stimulants. — Beginning cyanosis is the signal for the use of respiratory stimulants, of which the best are strychnin and atropin, and they should be given hypodermically. Oxygen, if given freely, often serves to tide over periods of marked cyanosis. The gas should be inhaled directly from the cylinder until relief is afforded, when it may be allowed to escape near the patient's nose, so as to become mixed with air. Stoker - advises the continuous use of oxygen from the moment the disease declares itself. 1 British Medical Journal, March 11, 1908. ' Medical Press and Circular, 1908, Ixxxvi., 90. 128 INFECTIOUS DISEASES. Hydrotherapy. — In meeting high temperature, marked nervous symp- toms, dyspnea, cardiac Avoakness, etc., hydrotherapy offers many superior advantages. When the temperature is high, ice-hags over the chest and abdomen are useful. Tub-baths have been for the most part omitted from consideration in the treatment of lobar pneumonia, rest being of the great- est importance. Cool sponging, combined with tlie ice-cap or the wet pack, serve as a substitute for the full baths [vide Local Measures infra). Abortive Method of Treatment— Petresco found hirge doses of digitalis (oj-ij — 8.0 of the digitalis leaves in an infusion daily) administered at the onset to jugulate the s- ing erysipelas, and erysipelas neonatorum — should be mentioned. The first exhibits an inflammation of the subcutaneous tissue, which tends to suppurate. Relapsing erysipelas constitutes the chronic form of the dis- ease, recurring at intervals, and usually in the same locality. It is com- monly due to some deep-seated focus of suppuration. Erysipelas neona- torum is the result of infection of the stump of the umbilical cord. From the navel the inflammation spreads to the thighs and genitals. As a rule, there is fever, followed in a few days by fatal collapse. Sequelae. — The hair often falls, but it is usually replaced by a fresh crop. Otitis media and chronic nephritis may date from an attack of erysipelas. Per contra^ erysipelas is reputed to be curative of certain afi"ections (eczema, lupus, carcinoma, sarcoma). Out of 476 cases collected by me relapses occurred in 54 (11.3 per cent.), and in 1 of these instances 5 relapses occurred; in 2 others, 4.* The diagnosis is made with ease after the eruption has fully devel- oped, and its appearance, seat, and behavior, particularly the manner of extension of the brawny, ridge-like edge (best marked on the fore- head), are the features that distinguish it from every other disease. A bacteriologic diagnosis is often possible, the streptococcus being found in the pus and secretions from the naso-pharynx. Differential Diagnosis. — Erythema produces superficial redness, but is not attended with heat, swelling, or fever. Urticaria assumes the form of pale-red circular wheals, which cause marked itching and appear in successive crops, often disappearing in the course of a few hours. Acute eczema of the face, when intense, may resemble erysipe- las ; but it lacks the peculiar border and mode of progression so charac- teristic of the latter disease. Again, eczema produces troublesome itch- ing, and the swelling is less than in erysipelas. Chronic erythematous eczema is met with later in life, is without fever, without any considerable swelling or pain, and excites intense itching. Eczema nodosum is char- acterized by its nodosities near the joints. Course and Duration. — In my own experience, based upon 1880 cases, ^ the average duration (including the prodromal stage and period of convalescence) in persons under forty years of age is fourteen days. The course of the disease is much lengthened by complications, the pre- existence of chronic affections, and by age (after the fiftieth year). The prognosis is favorable, and it is rare for erysipelas to assume a malignant type. Perhaps the chief dangers lie in certain complications, especially extensive suppuration, pneumonia, acute nephritis, delirium tremens, etc. Acute articular rheumatism is comparatively harmless ; but previous debility, especially if dependent upon chronic diseases, as syphilis, chronic rheuuiatisra, gout, tuberculosis, organic disease of the heart, and the like, increases the percentage of deaths considerably. Again, age has a positive influence upon the mortality, which it augments moderately after the forty-fifth year, and most decidedly after the sixtieth ^ Journal of the Ameri/-an Medical Association, .July 2-, 189.3, by the writer. 2 " Points in the Etiology and Clinical History of Erysipelas," by the writer: Journal of the Am. Med. Assoc, July 22, 1893. ERYSIPELAS. 149 year. Of 2663 deaths duo to erysipcdas (United States Census Jleport), the death-rate per 1()0,0()0 inhabitants was as follows: under 5 years, 31.34 ; 5 to 15 years, 0.81 ; 15 to 45 years, 2.80 ; 45 to 65 years, 8.88; 65 and over, 38.55 (Wm. L. llodrnan). Death is due to exhaustion. The mortality-rate is low, as shown by the results of my own collective investigations into the subject. I found the general average death-rate to be 5.6 per cent., while in cases from private practice it was 4 per cent. In persons over seventy years it was 46 per cent. The traumatic cases gave a mortality of 14.5 per cent. Treatment. — The treatment of erysipelas falls naturally into four subdivisions: {1) Dietetic; {'I) Constitutional ; (S) Local; {^)Proj)hylactic. (1) Dietetic, — Proper attention to the diet is of the first importance. It must be generous and composed of highly nutritious articles, and if the temperature be high, only liquid forms of nourishment should be admin- istered in definite quantities and at stated, brief intervals. Rectal alimentation should be resorted to if the stomach rejects a suitable diet- ary. Lack of attention to the patient's diet during the primary attack tends to increase the frequency of relapse. In persons over fifty years of age, and in those in whom the vital processes have been lowered on account of previous chronic diseases, correct alimenation is of paramount importance, often abridging the course of the afi"ection. (2) Constitutional Treatment. — When, despite an appropriate diet, the pulse becomes very rapid and feeble, the heart's first sound indistinct, and the tongue dry, indications for the use of stimulants exist. Alcohol may be given with a comparatively free hand, 12 to 16 ounces (360.0-480.0) of whisky daily in divided portions. Strychnin gives prompt results, and digitalis may be used in severe cases. In marked gastric irritability champagne is to be preferred. The eliminative organs, especially the kidneys, are to be stimulated, so as to rid the economy of the bacillary toxins. The tincture of the chlorid of iron was first extensively used in this disease by English authorities, and was formerly regarded by most clin- icians as a truly specific remedy. In 74 cases of erysipelas which were treated by this remedy alone, the average quantity being 1 dram (4.0) daily in divided doses, in the Pennsylvania Hospital by Drs. Lewis, DaCosta, Longstreth, Meigs, and others, the death-rate was 4 per cent.^ Other preparations of iron, however, are equally efficacious. Quinin is a valu- able remedy in erysipelas, and during the past twelve years I have em- ployed it in not less than 30 cases, confining its use to instances in which the temperature touched 103° F. (39.4° C), and, with a single exception, in uncomplicated cases (22 in number) the nocturnal remissions were de- cidedly greater. In every instance iron in ^ome form was administered simultaneously. Numerous antiseptic remedies have been recommended. Antistreptococcus Serum. — Andrd, Robinson, Cox, Anderson, and others have reported instances of its successful use. The serum is injected subcutaneously ; its influence endures over several days, but it is important that the injections are repeated at forty-eight-hour intervals. Marmorek's serum (care being taken that it is not too old) is to be pre- ferred. G. H. Sherman reports uniformly good results from the use of stock vaccines (streptococcic), especially when used early in the course of the disease. The dose is 20,000,000 for the adult, and where local im- ^ " The Treatment of Erysipelas," by the writer, Therapeutic Gazette, July 16, 1S94. 150 INFECTIOUS DISEASES. provement with the rctluctioii of teiiipevaturc does not occur, this should be repeated at the end of twenty-four liours. Certain si/)npto)n8 demand internal medication. When the fever is high, its reduction is best accomplished by means of cold spongings com- bined -with the ice-cap, or cold or gradually cofded baths. Guaiacol applied externally has recently been employed for the same purpose. For nvirked nervous phenomena, such as pain, sleeplessness, and active delirium, hyosein hydrobromate (gr. ^H — ().0()06) has been tried hypo- dermically at the Medieo-Chirurgical, Pennsylvania, and Philadelphia hospitals, and has given promise of being a valuable remedy. It should not be employed when the heart-power is deficient. For the same indi- cation we may utilize the following : Sodium bromid, gr. v (0.324) every two houi-s, or gr. xx-xxx (1.296-1.944) at night; morphin, gr. ^ (0.008). and chloral, gr. x (0.648), in combination every half-hour for three doses; potassium bromid, gr. x (0.646), and tincture of cannabis indica, TTtx (0.666), in combination, and morphin, gr. -^ (0.0108), hypodermically. The treatment of the various complications must be conducted in accordance with general principles applicable to each. 3. Local measures have always held a prominent place in the treatment of erysipelas. In my paper previously cited those most frequently used were elm (37 cases) ; lead-water and laudanum (20 cases) ; carbolic acid (1 : 40), injected subcutaneously (18 cases) : zinc oxid (14 cases) ; mer- curic chlorid solution (14 cases) ; ichthyol ointment with lanolin (8 cases), etc. P. Ph. Smolitcheff,^ !^. Tr. iodi, 25.0 grams ; 01. camphor, Ichthyoli, da 12.5 grams. — M. Sig. For external use. Shake before applying. Many of these preparations were prescribed for their eifect in excluding the air — a leading indication. This I am in the habit of meeting by the use of carbolized vaselin or cool carbolized oil. IchthyolcoUodion (strength 10 to 50 per cent.), painted over the erysipelatous area and also over the surrounding healthy skin for 2 or 3 cm, has been advocated. Tucker^ recommends the application of a saturated solution of mag- nesium sulphate in water. This is applied in facial cases on a mask con- sisting of from fifteen to twenty thicknesses of ordinary gauze, of suffi- cient size to extend beyond the area involved, with a small opening to permit breathing, but none for the eyes. After thorough saturation with the solution, the mask is applied and covered with oiled silk or wax paper ; it is wetted often enough to assure a moist dressing — usually every second hour. The dressing should not be removed oftener than once in twelve hours to permit an inspection of the parts. A knowledge of the microbic nature of erysipelas has led to the local application of numerous antiseptic remedies. Mention has been made of the method of injecting carbolic acid. Here the aim is to check the spread of the inflammatory process by inserting the needle at numerous points just beyond the inflamed border. The method (introduced by Heuter) has been much practised by Henry at the Philadelphia Hospital, and is especially applicable in erysipelas migrans. In the statistics before given a solution of mercuric chlorid (1 : 4000) was used locally in 14 1 Medical News, Nov. 14, 1903. ' Therapeutic Gazette, June 15, 1908. DrPIITHERIA. 151 instances, to which I can add the results of 12 others at the Medico- Chirurgical Hospital and in private practice. In a few cases it was injected beneath the skin, as in the case of the carbolic acid. More recently it has been recommended to scarify the affected part and follow with the application of a solution of mercuric chlorid. In view of the fact that the streptococcus is found chiefly in the more superficial chan- nels of the corium, it follows that it may be attacked directly by the mercuric chlorid solution when the latter is used after scarification ; and this method of treatment is at once most promising and rational. G. L. Curtis ^ advises sodium sulphate, which acts by depriving the germs of oxygen, as a local application. MacLennan advocates a saturated solution of picric acid as a local remedy. (4) Prophylaxis embraces isolation and care of the skin of the whole body. Bathing with a boric-acid wash (3 per cent.), at intervals of several hours, so as to disinfect the desquamating epidermis, removes a source of danger. It is probable that relapses are sometimes due to autoinfection. Frequent change of the body-linen is to be advised and removal to another room during convalescence may prevent a relapse. Admission of erysipelatous patients to hospitals should be refused, except such institutions be provided with an isolation building. DIPHTHERIA. {Diphtheritis ; Angina Maligna ; Croup.) Definition. — xln acute, contagious disease caused by the Klebs- Loffler bacillus, and characterized, anatomically, by a croupous-diph- theritic faucitis, less commonly rhinitis and laryngitis. Clinically, it is characterized by irregular fever, prostration, and albuminuria ; also by the secondary development of toxemia, and often cardiac failure. It is commonly followed by peculiar paralyses. In large municipalities it behaves endemically, and from time to time epidemically. The disease, however, is less prevalent than formerly. Pseudo-diphtheria. — There are forms of inflammation occurring most frequently in the pharynx and adjacent air-passages (and also in many other parts of the body) that are attended with the formation of a pseudo-membrane, and are not caused by the Klebs-Loffler bacillus. These cases have been studied exhaustively by Prudden and others, who have usually found the streptococcus. The latter, however, has been found in the inflamed mucous surfaces met with in erysipelas, scarlatina, and measles. Vincent's angina is a form of pseudodiphtheria. Pathology. — The true diphtheritic inflammation has for its chief pathologic peculiarity the production of a fibrinous exudate. When the inflammation is superficial and of a mild grade, a croupous membrane is produced which can be easily removed from the mucosa, which it covers. In the severer types of the aff"ection, however, the fibrinous membrane infiltrates all the layers of the mucosa, which undergoes necrosis more or less nearly complete. In the severest forms the submucous layer may also become necrotic. It is to be borne in mind that the production of the fibrinous exudate in diphtheria is always preceded by coagulation- 1 Med. Record, April 20. 1901. 152 INFECTIOUS DISEASES. necrosis of the epitholhim. The membrane-formation is accompanied by changes in the underlying tissue which represent a combination of degen- eration and exudation (Councilman. Mallory, and Pearce). The mucous membrane surrounding the exudate is hy))eremic, more or less edematous, and the seat of muco-purulent secretions. The Pseudo-membrane. — Its composition comprises fibrin, pus, disin- tegrated leukocytes, flakes of necrosed epithelium, bacilli, and sometimes red blood-corpuscles. The fibrin has two main sources : (a) '* The fibrinogen of the inflaunnatory matter." which transudes through the capillary walls; and {b) Disintegrated, migratory leukocytes, which form branching fibrillae. Weigert holds that the inflammatory exudation is coagulated by a ferment derived from the disintegrated leukocytes. The Klebs-Loffler bacilli are found in the meshes of the fibrilhe, in the granular fibrin, and on the adjacent mucous membrane; they are never found ffrowinsr in living tissue, but always in necrotic tissue. Fre- quently other micro-organisms are associated (streptococci, staphylococci, etc.). The membrane presents a grayish-white color ; it is thick, firm, and adherent, so that its removal entire cannot be effected without great diflSculty, and without, as a rule, injury to the surface, as shown by bleed- ing, etc. The character of the pseudo-membrane is affected by the nature of the underlying structure ; thus in the pharynx it is firmer and less easily separable than in the larynx and trachea, where a distinct basement-membrane is found (Flexner). As the membrane becomes older its color is apt to grow darker, becoming yellow or even dark brown. It sometimes becomes gangrenous, and softens or disintegrates, with the production of a very offensive brownish, semiliquid excretion. The advancing edge of the false membrane is usually thin. On the other hand, when the process has become arrested the edge is apt to look raised or wrinkled, and later it may be distinctly curled up. The membrane may extend downward into the ramifications of the bronchi. In such cases there is apt to be a lobular pneumonia, but the lung may be invaded by the bacillus without any clinical indications. Lung-infection, due to the streptococci and (less commonly) the pneumo- cocci, is common. A generalized bronchitis extending to the smaller bronchi is common from the irritation of aspirated substances. In rare cases the membrane has spread into the esophagus and even into the stomach. After separation of a croupous membrane repair consists merely in a restoration of the epithelial layer — a process which is initiated by the fragments of epithelium that remain along the edges of the diseased area, and proceeds centrally. On the other hand, in true diphtheria, with necrosis (more or less complete) of the mucosa, sloughing occurs, and the missing structures are replaced by cicatricial tissues. The Heart. — The muscular structure and the nervous mechanism suffer most. The histologic changes may be of the parenchymatous va- riety, but only in mild instances ; whereas in severer cases fatty degen- eration is conspicuous. In still other cases the chief pathologic charac- teristic is an interstitial myocarditis, and rarely the lesions of peri- carditis and endocarditis have been noted. The heart is by no means always involved. The spleen is commonly enlarged, though not to an excessive degree. The blood is dark, its coagulability is greatly diminished, and Canon and Frosch have in a few cases found the bacilli in the blood of those dying DIPIITIJERTA. 163 of diphtheria. The red corpuscles are somewhat decreased in number during the course of the disease, whikj the white corpuscles are increased. Bouchut and Dulinsay consider the grade of leukocytosis of prognostic value, and claim that it varies directly with the severity. Grawitz has determined in numerous cases a higher specific gravity of the blood during diphtheria. The lymphatic glands of the neck become swollen, as a rule, and are often greatly enlarged, but they show little tendency to suppurate. In pronouncedly septic cases in which a mixed infection is found by culture a good deal of tumefaction of tbe neck occurs, this sometimes even obliterating the normal contour from jaw to clavicle. The Kidneys. — The kidneys show degenerative changes, the usual kidney-lesion being a hyperemic swelling with edema of the interstitial tissues, and often hemorrhagic spots in the cortex. Sometimes there is a marked glomerulo-nephritis, and rarely a diffuse granular degeneration of the epithelium. Minute areas of necrosis have been observed in the internal organs, in which fibrin has been found deposited (Oertel). Welch and Flexner have produced, by artificial inoculation upon guinea-pigs, kittens, and rabbits, foci of cell-death in the lymph-glands throughout the body, in the spleen, liver, lungs, heart, and intestinal mucosa. When the dose is small and the animal lives several weeks, paralysis may develop. The nerves, in cases of paralysis, have shown parenchymatous and interstitial inflammatory lesions. In paralysis of throat-muscles (i. g., those near the locality of the pseudo-membranous inflammation) the latter show also round-cell infiltration and fatty degeneration of the fibers. The nerve-fibers of the central nervous system may also show fatty degener- ative changes. In fatal cases lesions have been found to engage either the meninges, the cerebro-spinal substance, or the nerves. l^tiology. — True diphtheria is caused by the Klebs-Loffler bacillus, and all cases of supposed diphtheria in which the bacillus is absent are to be regarded as non-diphtheritic. The etiologic is, therefore, quite dif- ferent from the pathologic significance of this term. Recent researches have removed all doubt as to the specific nature of the Klebs-Loffler bacillus. Bacteriology. — The bacillus diphtherias nearly equals in length that of the bacillus tuberculosis, and is twice the diameter of the latter. It has rounded extremities, which are also frequently bulbous, giving it the appearance of a dumb-bell. At times one end only is clubbed, or, more rarely, one or both ends appear pointed. The bacilli are immobile, do not form spores, and stain readily, the best agent being alkaline methyl-blue. Their manner of taking the stain is important. The bacilli show alternating segments of darker and lighter stained areas. and often minute dots showing a most intense and deep staining. They grow on most culture-media, but for clinical purposes Loffler's blood- serum is important (3 parts blood-serum and 1 part neutral or slightly alkaline nutritive bouillon, containing 1 per cent, of glucose). Inocu- lated on this, they outgrow all other organisms that may be present, and within eight hours or less show numerous spots, one-half to one millimeter in diameter, which have a dull surface and a dense white or somewhat yellowish color. There are usually present also smaller points which have different appearances and which are colonies of other organisms. The former are the colonies of the bacillus diphtherise, and from these microscopic preparations and (by further cultivation) pure cultures can be obtained. The bacilli are semi-anaerobic, and thrive at the temper- 154 INFECTIOUS DISEASES. ature of the human body ; a temperature of 122°-136.5° F. (50°- 58° C.) causes their destruction in ten minutes. Pseudo-diphtheria Bacillus or Bacillus Xerosis. — From many cases, often showinj]; no lesions, an organism may be obtained that is identical in appearance, manner of culture, growth, etc. with the bacillus diphtheritie, but inoculation with it causes no lesions. The works of Abbott, Roux, Yersin, and others seem to show that this is an attenuated form of the true bacillus, and varying grades of pathogenicity may be found between the two. The distinction from the pathogenic bacillus can only be made by determining the lack of infection after inoculation. Site of Infection. — In the human family the seat of election of the bacillus diphtheriiB is usually the faucial mucosa, and less frequently other mucous surfaces and abraded skin. The bacilli do not penetrate the mucosa, and hence do not find their way into the lymphatic or cir- culatory system, but remain at or very near the site of the local changes. The Toxins. — Toxins are absorbed from the diseased spots by the lymphatics and blood-vessels, and produce the general phenomena in un- complicated cases. They have been isolated from artificial cultivations of the microbe, and when inoculated the chief ptomain of the Klebs- LoflBer bacillus so modifies the solids and liquids of the body as to render the subject immune (Behring). Another, however, if employed in like manner, produces dangerous and even fatal symptoms (convulsions, paralysis, etc.). It is certain that the bacillus can maintain an existence for months outside of the body, though its usual habitat is unknown unless it be the organic constituents of the superficial soil. The virulence of its products is modified by many individual conditions, and chief among these is a healthy and intact condition of the mucous membranes, which greatly reduces the susceptibility to the disease. Associated Microbes. — With the Klebs-Ldffler bacillus are frequently found other microbes, especially streptococci and staphylococci. These pass beyond the site of local infection, reaching the internal viscera and other structures, and, as will be seen hereafter, give rise to the serious septic element of the disease. VY. Bloch and P. Sommerfield,^ in studies on the pathogenicity of the Lbffler bacillus, have verified the accepted statement with reference to the germ, their article being a good exposi- tion of the present status of the bacteriology of diphtheria. From a study of 436 cases, the authors state that the Loftier bacillus was never found in culture, but always associated with other bacteria, among which streptococci played the greatest part. The two doctrines concerning the relation of streptococci to septic diphtheria are given, the one being that the streptococci increase the virulence of the diphtheria bacillus and cause sepsis by gaining access to the circulation ; the other is that the diphtheria toxin, l)y its eff"ect on the organism, prepares the way for an invasion by streptococci. The pneumococcus ma\' be found. Modes of Infection. — When the bacillus leaves tlie body of the sick it is contained in particles or shreds of the diphtheritic membrane or in the expired air. Infection may then occur (a) By direct contact with the shreds of membrane thrown oft" — e. g., when the latter are ejected by coughing and lodge upon the conjunctivae or faucial mucosa of bystand- ers. The deadly poison is sometimes transferred to the physician and • Arch. J. Kinder., Bd. li., Ileft 2. DIPITTTTERTA. 155 attendants, with resulting infection, from the sucking of tracheotomy tubes, (h) By inhaling the. air surrounding tlie patient (contagion). In- fection by contagion, however, does not extend beyond a radius of a few feet from the patient, (c) A very leading matter of conveyance of the bacillus from the sick to the healthy is by fofnifes. The contagion ad- heres tenaciously to a great variety of objects (toys, clothing, library books, letters, slates and drinking-cnps in the public schools, etc.), iind in this way the germs of diphtlieria have been transferred over great dis- tances and have given rise to the disease long after. The latter fact ren- ders it difficult to trace certain cases to previous ones, to which they in- variably owe their origin, (d) Sewer gas^ per se, is to he regarded as non-pathogenic, or at least so far as this affection is concerned (Laws). It may, however, become a carrier of diphtheritic poison, (e) ]Joni.ei>tic animals may be occasional carriers, especially cats. (/) Tlie disease is kept alive in a community largely by virulent organisms in immune per- sons (" healthy carriers" — 13.3 percent. — Sobernheim). Rarely, "latent carriers," who conceal the bacillus for a time before they show the clini- cal evidences of diphtheria, may convey the disease. Our knowledge as to how the infection occurs is incomplete. \Ve know definitely the usual point of local infection in man, and also that a catarrhal mucosa or an open lesion of a mucous surface invites infection. It is not certain, however, that even a slight lesion of the mucous surface is essential to infection. Some writers claim still that the Klebs-Loffler bacillus may enter the blood through the respiratory system and give rise to primary constitutional symptoms, the local manifestations in the throat being secondary. Predisposing Factors. — (1) Age. — This is the most important factor, diphtheria being, in the main, a disease of childhood. Most cases occur between the second and seventh years, while the receptivity diminishes rapidly after the tenth year. Instances have, however, been observed up to the fiftieth or even the sixtieth year. During the first year of life also it is rare. (2) Sex. — This is without appreciable influence. (3) Season. — Cases are more numerous in winter and spring than at other seasons. (4) Climate. — Diphtheria is met with less frequently in tropical than in temperate and cold climates. Humidity favors the propagation of the diphtheria germ, and hence damp cellars also promote the spread of the disease. (5) Unhygienic Conditions. — Unfavorable sanitary sur- roundings tend to lower vital.ity, thus increasing the susceptibility to the specific virus. Most epidemic outbreaks have held more or less intimate relationship with decomposing organic matter, defective drainage and sewage, cesspools, etc., though it is to be especially remembered that the disease often prevails in sparsely-settled rural districts. Immunity. — A single attack does not confer perfect immunity. Second and third attacks not infrequently occur in the same individual. Symptoms. — Incubation. — The duration of this period is from two to seven or ten days, and in a small percentage of the cases it may be longer. In virulent epidemics and when the disease is produced experi- mentally the incubation-stage is short — from twelve hours to two or three days. The prodromal indications of diphtheria are not strikingly characteristic. They may either be acute in character or very mild ; but usually the child will complain of feeling weary and indisposed to 156 lyFECTious DrsEASf:s. plav. of sensations of chilliness, and of ))ain in the head, back, and limbs. In youn>: children the onset of diphtheria may be marked bv connihions. There is nothinij in this early stage of the disease to distinguish it from simple ])haryngitis or tonsillitis. There may be some fever, not very high — an elevation of one or two degrees at most. The urine contains a small amount of albumin. R. Koch found diphtheria bacilli in the urine of 2 out of 26 diphtheria patients. The child often complains of discom- fort in swallowing, and on examination the fauces will be found to be red- dened, and in a short time the exudate will be found on the tonsils or soft ]ialatc. This is tlic usual type of simple tonsillar diphtheria. Pharyngeal Diphtheria. — The symptoms are nsuallj slower of develop- ment than in tonsillitis. The child is sluggish, looks heavy-e3^ed. languid, and pale for several days. The fever may not rise above 101° or 102° F. (38.8° C.).. On examining the throat, however, it is found to be swollen and red, and if Uvidity is more pronounced than the swelling, it suggests the true nature of the disease. The membrane begins on the tonsils in the form of small patches of yellow exudate, resembling the thick, cheesy plugs of inspissated dead epithelium and secretion which issue from the mouths of the follicles of the tonsils during the course of acute or chronic tonsillitis. Quite early this exudate is easily removable. The membrane spreads from the tonsils to the soft palate and half arches within a few days, and it may also appear on the pharyngeal wall. During this stage the throat may become much swollen and the tonsils greatly enlarged, frequently meeting in the median line. The glands immedi- ately beneath the angle of the lower jaw on one or usually both sides become hard, painful, and slightly enlarged; the swelling of these glands is not great in mild forms, although their presence, in association Avith the foregoing symptoms, is an almost infallible indication of the disease. The child, as a rule, shows grave constitutional symptoms for a few days and albuminuria is present. Acetonuria is common in the severer forms of the disease. The temperature is not characteristic, as a rule not being high, and the pulse is rapid and weak, being out of proportion to the general indications of the disease. The blood-pressure is below normal in about one-third of the cases (Rolleston), and the degrees of depression bear a direct relation to the severity of the infection. In mild cases the symptoms abate by the end of the first week, and the pseudo-membrane separates, leaving a red, inflamed surface behind. The child is pros- trated for a number of weeks, and in abo.ut 20 per cent, of the cases neuritis, with its accompanying paralysis, occurs. Simple leukocytosis is present in diphtheria, although this symptom may be absent in mild cases. Variations in 3Ianifestation. — Diphtheria may exhibit variations as regards the s6at of attack and the severity of the poisoning. In some epidemics the Klebs-Loffler bacillus seems to be more active, or more virulent, than in others. The severity of the attack does not seem to depend on the amount of the pseudo-membrane, but rather, according to Rotch, upon three factors : (1) the virulence of the bacteria ; (2) the local resistance ; and (.3) the general resistance. The mucous membrane of any part of the body (lips, tongue, conjunct! vib, vulva, or glans penis) may be the seat of the membranous growth. Malignant Diphtheria. — The symptoms are severe from the com- mencement. There are one or at most two days of slight illness, and DIPHTHERIA. 157 then alarming symptoms manifest tlicmselves, cardiac failure possibly setting in without a specially severe local lesion. Vomitinf^ and hujh fever, resembling tbe onset of scarlet fever, may initiate the attack ; and within a few hours we may find extensive swelling at the angles of the jaws, of stony hardness, an offensive bloody discharge coming from the nostrils, accompanied with difficulty in opening the mouth. If the throat is examined, there will be found extensive swelling of the tonsils, even to meeting, the uvula and soft palate being edematous and covei'ed with much sloughy-looking membrane. The temperature in severe cases soon reaches a point between 103° and 104° F. (40° C), while the heart- beats become exceedingly feeble. In a day or two the cellulitis extends, the face becomes edematous, the skin pits all over the face, neck, sternum, and chest-walls. The patient becomes drowsy, cyanotic, and an erythem- atous rash may appear about the face, neck, and chest, while a purpuric rash is not infrequent. Death occurs in such cases within one week from toxemia. Cases of diphtheria septicemia have been recorded in the liter- ature by Mahler^ and others. Nasal Diphtheria. — In all severe cases of pharyngeal diphtheria the inflammatory process is likely to extend to the nasal mucous membrane. In some cases the nasal mucous membrane is found to be the first in- volved ; the exudate may spread to the tonsils, involving the back of the soft palate and pharynx as well. In many cases of nasal diphtheria no membrane may be found during life ; there may be only a purulent dis- charge with blood, the presence of which in the nasal passage obstructs breathing, giving rise to a bubbling sound, and rendering sleep trouble- some and noisy. Cases have also been reported of formation of pseudo- membrane in the nose with mild general symptoms, and from which or- ganisms identical with diphtheria bacilli were obtained by culture. Some- times the cases have recurring mild attacks of pseudo-membranous in- flammation of the nose, while the bacilli may be constantly present. It is probable that these cases may give rise to infections of like nature, and even of true diphtheria. In nasal diphtheria the symptoms are quite as severe as in faucial diphtheria, and in cases in which the soft palate and tonsils are also involved the general symptoms, the depression, and also the albuminuria are apt to be well marked. In all cases of corvza with fever we should be guarded as to opinion, especially if an epidemic of diphtheria is prevalent at the time. The diphtheritic inflammation may spread from the nose to the conjunctivae, with the formation of a false membrane, and much purulent discharge may escape .from the eyes, the lids of which may be greatly swollen. In this place it is well to remem- ber that in measles we sometimes have a form of membranous exudation occurring on the nasal mucous membrane, and as a primary disease — "rhinitis fibrinosis " — which is not always diphtheria. This disorder runs a favorable course, the membrane being less adherent than in diph- theria. Ravenel has collected 77 cases, and in 33 out of 41 cases exam- ined bacteriologically the Klebs-Lofiler bacillus was found. Constitutional symptoms were either slight or wanting. Wound-diphtheria. — The bacillus wnll not live on normal skin, but when the skin is cut or bruised, as after blistering or an eczematous condition, and when a moist, raw surface is present, this germ freely ^Berliner klinische Wochenschrift, 1907 , xliv., 1499. 158 INFECTIOUS DISEASES. flourishes. Granulations also form a favorable soil. The diphtheritic germs may be introduced into the system durint;; an operation, sucii as an excision of the tonsils, or even a vaginal examination ; and in newborn infants the granulating surface left after sloughing of the cord may be- come the seat of diphtheritic inflammation. Laryngeal Diphtheria or Membranous Croup. — The exudate may appear first on the mucous membrane of the larynx, and in these cases the mucous membrane of the nose and pharynx may never give evidence of a false membrane. A close inspection of the posterior aspect of the palate and tonsils, however, may reveal a slight primary membranous formation in these situations. In laryngeal cases the first symptom is a cough of a harsh, metallic, ringing character, and never to be forgotten when once heard. The temperature may be slightly above normal, or even, in many cases, normal. The toxic absorption is slight, on account of the locality affected, and the constitutional symptoms are usually mild. The local 8i/mptoms, however, are very alarming, and result from laryngeal obstruc- tion, there being marked dyspnea with retraction of the intercostal and supraclavicular spaces, and later of the epigastrium and lower chest, with an increasing cyanosis. The child is soon restless, is forced to sit up to breathe, and for the same reason bends forward with its head thrown back. In these extreme cases unless relief is soon gained the child dies of suffocation. In many instances a slower form of suffocation may result from the extension of the membrane downward to the bronchi. Complications. — Local complications may be mentioned — e. g., hemorrhage from the nose and throat in the more severe ulcerative cases. Skin-rashes are not unusual, especially diffuse erythema. Broncho-pneumonia is the most serious pulmonary complication of diphtheria. It is is not produced by the Klebs-Loffler bacillus as a rule, but by the streptococcus or pneumococcus. Broncho-pneumonia usually terminates laryngeal cases that have been operated upon. Albuminuria is a constant symptom (not a complication) of the dis- ease (vide supra), and is almost as certain in establishing a diagnosis of true diphtheria as a bacteriologic examination. It is met with in both mild and severe cases, and the greater the amount of albumin the more severe the case. Acute nephritis not infrequently complicates diph- theria ; it is usually not accompanied by edema or anasarca. It may set in with suppression of urine. Dysphagia may, by its constant existence throughout the disease, pro- duce a profound impression on the general nutrition. Involvement of the conjunctivce is a rare but grave complication. Otitis media occurs frequently, and may be a troublesome complica- tion as well as a sequel. Snow^ reports a case of diphtheria complicated with Escherich's pseudo-tetanus. The most frequent sequelae are anemia, chronic naso-pharyngeal ca- tarrh, and peripheral neuritis and its associated paralysis. Anemia may so prolong convalescence as to expose the child to some intercurrent disorder. The chronic naso-pharyngeal catarrh may be marked and offer a favorable ground for new diphtheritic invasion. Paralyses — e. g., palatal and cardiac — may appear in the first and sec- ond weeks of the disease. Other forms of paralysis occur later. Par- * Amer, Jour. Med. Sciences, Dec, 1902. DIPHTHERIA. ] 59 alysis usually is first seen when the child attempts to swallow, and the food, especially if liquid, is regurgitated tli rough the nose. This is due to a paralysis of the muscles of the soft palate, which also produces a peculiar alteration of the voice. The paralysis may take a general form, such as is seen in multiple neuritis, the lower extremities heing affected and the knee-jerk absent. It may extend to the external ocular muscles and cause squint, to the ciliary muscles and cause dimness of vision from unequal accommodation, or to the muscles of the trunk in general, producing widespread paralysis. The child, unable to hold any- thing, may stagger about as if intoxicated, so much so as to suggest the existence of a cerebral tumor. The disturbance of vision and the absence of the patellar tendon reflex has in adults led to a mistaken diagnosis of locomotor ataxia. Loss of taste, deafness, and a disturbance of sensa- tion are not infrequent. Thus, paralysis is to diphtheria what dropsy is to scarlet fever — a proof positive of the disease. T^o make one step more, in many sudden deaths occurring in early diphtheria, we must recognize paralysis of the heart outside of all toxic influence. In these cases there occurs sudden disturbance of the vagus, which may be the seat of degenerative changes in some instances at least. The prognosis in post- diphtheritic paralysis after the third week is favorable, while the cardiac, pharyngeal, and diaphragmatic palsies beginning before the third week are serious. Myocardial weakness tends to supervene as a sequel. It is evidenced by the sudden accession of pallor, nausea, sometimes by vomit- ing, and also by weak heart-sounds and a feeble, broken, irregular pulse, etc., and usually leads to a fatal termination. Diagpaosis. — The diagnoses of a pharyngeal diphtheria is not difiicult if an epidemic be prevailing. The false membrane on the fauces and the presence of albumin in the urine give us a practically certain diagnosis. The only unequivocal evidence of the disease, however, is the finding of the Klebs-Loffler bacillus in the membrane. An immediate recognition of the disease is often possible from a smear-preparation of the exudate from the throat (see Fig. 14), the Klebs-LofBer bacilli being present in sufl5cient numbers to be readily distinguished by the microscopist. Park, who has had a rare experience with this affection, makes the following statement : " In cases in which the disease is confined to the larynx or bronchi, surprisingly accurate results can be obtained from cultures, and although, in a certain proportion of cases, no diphtheria bacilli will be found in the first, yet they will be abundantly present in later cultures. We believe, therefore, that abso- lute reliance for a diagnosis cannot be placed upon a single culture from the pharynx in purely laryngeal cases." When a bacteriologic examina- tion cannot be made the practitioner must regard as suspicious all forms of throat affections in children, and carry out measures of isolation and disinfection. In this way alone can serious errors be avoided. Mistakes usually occur in the lighter types, many of which are in reality due to the Klebs-Loffler bacillus (Osier). Differential Diagnosis. — From follicular tonsillitis we differentiate diphtheria by the seat of the membrane, that of the former being in the tonsils, while diphtheritic membrane is over the tonsils and over the soft palate. Moreover, in follicular tonsillitis the fever is high, the onset is sudden, and it is usually associated with gastric disturbance. Albu- 160 INFECTIOUS DISEASES. minuria is gentM'ally present in diphtheria, while it is present in folHc- uhvr tonsillitis in exceptional cases only. Moreover, mild cases may not present albuminuria, or fail to sliow the presence of albumin until later in the disease. The histories of the two cases are quite different. (For differential diagnosis between diphtheria and follicular tonsillitis, see also Table, p. 756.) In many instances of so-called diphtheroid lesions the membrane is formed only by streptococcus pyogenes {iiietn- hranuus (inyina), and these cases are sometimes of an intense grade. Croupous or 7}umbra)nnis aiu/itia (a st7-eptococcus infection) may offer some dithculty ; yet in this disease there is no tendency to sj»read to tiie nasal mucous membrane or to the larynx ; there is a diminished glandular enlargement : there is no albumin, and the onset is more sudden. In Vincent, s angina there is an absence of the formation on the surface of the mucosa of a thick false membrane; it is an ulceromembranous process. There is a deep and often widespread necrosis of the mucosa of the palate and tonsil. Bacteriologic examination shows the presence of a large number of atypic bacilli, Avhich are often associated with a spiril- lum. According to H. W. Bruce ^ there is an absence of the diphtheria bacillus. Fig. 14.— 1, A tube of blood-serum ; 2, a sterilized cotton swab in test-tube. Rub the swab gently but freely against the visible exudate, and without laying it down, after withdrawing the cotton plug from the culture-tube, insert it into the latter, and rub that portion which has touched the exudate gently but thoroughly over the surface of the blood-serum with- out breaking its surface. Now replace the swab in its own tube, plug both tubes, and place thcui in the box provided by the health officials. This is to be sent to the bacteriologic expert. In laryngeal diphtheria the swab is to be passed far back and rubbed freely against the mucous membrane of the pharynx and tonsils. Diphtheria frequently is associated with a rash, rendering it difficult to distinguish the condition from scarlet fever ; but in diphtheria the rash is more truly an erythema, while in scarlet fever it consists of slightly raised points between which there may be an erythematous condition. The rapid pulse of scarlatina is of assistance in the discrimination. The glandular swelling and sloughy condition of the throat, however, closely resemble diphtheria, and a positive diagnosis without a bacteriologic ex- amination is often impossible. Prognosis. — Formerly diphtheria was at the same time the most prevalent and most fatal of the acute infections, the mortality being 30 to 40 per cent., although variable in different epidemics. The case- mortality from diphtheria has been very materially reduced since the introduction and wide use of antitoxin — certainly over 50 per cent. The remarkable diminution in the death-rate from laryngeal diphtheria has coincided precisely with the use of antitoxin. Of especially unfavorable prof^nosis are those cases that show large quantities of albumin in the urine, cervical glandular enlargement, excessive na.sal discharge, rapid ^Lancet, 3 n\j 16, 1904. DIPHTHFJRIA. 161 extension of the exudate, a necrotic membrane, vomiting, and partial or complete suppression of the urine. A sudden Ml of temperature to a subnormal level and an irregular pulse, or bradycardia, are a bad augury. Recovery from a severe attack in which there are extreme depression and much albumin is unusual in a child under six years of age, though re- covery may take place in apparently hopeless cases. The results of Morse's extensive observations are opposed to those of Bouchot and Dulinsay, who claim that the degree of leukocytosis is of prognostic value. The cases of neuritis invariably recover. The child is liable to suffer from the effects of the disease for years after apparent recovery. The causes of death, in their order, are as follows : membranous croup or laryngeal stenosis ; septic infection, which may be a slow death ; sud- den heart-failure — paralysis of the heart ; bronchopneumonia, following tracheotomy or occurring during an advanced stage. Treatment. — Prophylaxis. — The best preventive measures against diphtheria are a clean nose and mouth. The slightest appearance of a coryza must be overcome at once by the use of a mild antiseptic wash ; all accumulations of crusts, dust, dried blood, etc., should be removed from the nose twice daily, especially in children attending school or during the prevalence of an epidemic. The child should be early taught to employ a small antiseptic gargle as a daily routine, using a weak solution of hydrogen dioxid or listerine. The teeth should be carefully cleaned daily, and all decaying teeth should be filled or removed. Since domes- tic animals, especially cats and dogs, may communicate the disease, they should be excluded from the sick room. All cases of sore throat should be examined for the Klebs-Lojffler bacil- lus, and, if it is found, the individual should be isolated ; and all cases of diphtheria should be kept isolated until cultures taken from the throat or nose fail to indicate the presence of the specific germ. This is espe- cially true in schools and asylums. Moreover, all persons exposed to this disease, and those caring for diphtheritic patients, should receive im- munizing doses of antitoxin. Dzerjgowsky recommends the subcutaneous use of minute doses of toxin with a view to establishing active immunity. Bacteriologic examination of the throats of school-children is of the great- est aid in controlling epidemics. The fact that the Klebs-Lofiler bacilli when found in healthy throats may not be active is no argument against isolation and antitoxin injections, because if the same germs were to find a broken or catarrhal membrane they Avould rapidly develop. An unrecognized feature in the prophylactic treatment of the disease is seen in the uncertain period of convalescence. It frequently happens that long after all membrane has disappeared active bacilli may still cling to the throat. The persistence of the bacilli may be accounted for at times by assuming that the accessory sinuses of the nose may be involved. This condition may also continue for from two to six months, and even longer in deeply fissured tonsils ; and the disease may be communicated by such throats in the act of kissing young children or adults with sensi- tive throats or with a broken buccal mucous membrane. For this reason the indiscriminate kissing of young children on the lips should be inter- dicted by the physician. Hewlett and Nankwell advise the use of endo- toxin as an aid to the antitoxin treatment with a view to reducing the number of these diphtheria carriers. 11 1G2 INFECTIOUS DISEASES. Insufficient attention to isolation and disinfection of the milder caaes explains the occurrence of many house-epidemics. The physician must, durin^y his visits, wear a surgeon's apron or linen duster which has been steeped in a mercuric chlorid solution and allowed to dry. His hands and face should be washed in a similar solution on leaving the room. Treatment of the Attack. — The treatment falls naturally under several departments : [a) the hygienic measures to limit the diffusion of the dis- ease ; (/') the local management of the throat to destroy early the toxic germs; (f) medication to antagonize the effect of the toxins, and event- ually to overcome the complications and sequela'. (a) Hygienic Treatment. — The patient should be in a room well ex- posed to sunliiiht and fresh air, and superfluous furniture and hangings should be promptly removed. No stationary washstand should be allowed in the room, and Goodhart well says that many cases seem to have their origin in the proximity to foul-smelling drains. Even in mild cases the patient should be kept in bed throughout the attack. White and Smith, from a study of the heart complications in 946 cases of diph- theria, believe that the presence of murmurs and a slight degree of irregularity are no contraindications to getting out of bed at the end of two weeks, if the first sound is strong and the heart is not dilated. Patients who have been severely ill, or ill several days without treatment, should not be allowed out of bed before five weeks. The general comfort of the patient is enhanced by two daily sponge-baths of tepid salt-water or of alcohol and water. Feeding. — Nursing infants may be fed on breast-milk obtained by a breast-pump, but should not be placed at the mother's breast (Holt). The feedings should be regular, yet lighter in quality and quantity than in health, remembering the fact that gastric disturbance is closely asso- ciated with diphtheria. The rule must be to pay every possible attention to the feeding. Milk in some form being our main dependence, it should usually be diluted, and for young children partially if not wholly peptonized. The greatest difficulty comes in the latter part of the disease, when the child is septic and most likely has a strong objection to being disturbed. At this time vomiting is most easily provoked and swallowing is rendered very difficult on account of the swelling and pain. We must not neglect the feeding even if it does cause discomfort, and here forced feeding by means of gavage is most valuable. Gavage is likely to be more success- ful with children under three years than rectal alimentation. In older children who object to the tube through the mouth, it may be passed through the nose with little difficulty, and gavage by this route, even in intubated cases, will be extremely satisfactory. Concentrated broths, meat-juice, and even milk-punch or raAV eggs, may be given in this way. (b) Medicinal. — Alcohol no longer holds a debatable ground in the treatment of dij)htheria ; it is the most powerful drug in our possession to offset the ravages of the disease on the nervous centers and for the control of the circulation. Stimulation should be commenced as soon as there is a reasonable certainty as to the correctness of the diagnosis, and by commencing early Avith whiskey or brandy we may prevent the depress- ing effects of the poison of diphtheria as seen in the pulse and general condition of the child. The indications for the free use of alcohol are marked prostration, feeble pulse, and a weak first sound of the heart. The DIPHTHERIA. 163 quantity must be adjusted to the age and gastric condition of the child, and usually one ounce (32.0) of good whiskey or brandy, well diluted, in twenty-four hours is sufficient for a child four years old. In very bad cases five or six times this quantity may be given, the only limit being the tolerance of the stomach. The stimulants should be mingled witli the food, as the child may rebel against taking both food and stimu- lants. Strychnin stands next to alcohol in importance in the treatment of diphtheria, and usually it is given in too small doses. For a child four years old gr. -^^ (0.0021) may be given every six to eight hours, and may be administered in little tablets by the mouth or hypodermically. Digitalis does not hold an important place in the heart-weakness of diphtheria, and yet it is strongly indicated on theoretic grounds. Clinic- ally, it has been found to have an unfavorable action on the stomach before its good influence can be had on the heart itself. The same may be said of camphor and ammonium carbonate. The aromatic spirits of ammonia is valuable for rapid eff"ects in syncopal attacks. In cases of threatened heart-paralysis occurring late in the disease Holt has found nothing so valuable as morphin employed hypodermically, the drug being given in full doses and repeated every two hours, keeping the child under its influence for some days. In cases of diphtheria in which a murmur and slight arrhythmia develop, efforts at treatment should be concen- trated on the general condition. Internal medication should be minimized. Symptoms, as vomiting or diarrhea, are to be met with sufficient therapy only for their control. {c) Local Treatment. — For the direct attack upon the membrane in the throat nearly all the remedies of the Pharmacopeia have been used. Gargling, swabbing, painting, spraying, and washing the throat, all have their advocates. Since the acceptance of the antitoxin treatment medi- cal opinion has suffered a decided change as to the importance of local measures. The very best local application for pharyngeal or nasal diph- theria consists of hydrogen dioxid, diluted one-sixth, and used both as a gargle and spray as most convenient ; this is usually sufficient in the early stage. Norikove ^ advises for infants who cannot use a gargle the administration of peroxid internally by the following formula : hydrogen dioxid, 5 to 7 c.c. ; distilled water, 85 c.c. ; syrupus simplex, 15 c.c. I have found a solution of mercuric chlorid, 1 : 1000, with an equal part of hydrogen dioxid, used as a spray, an excellent disinfectant and deter- gent. The tincture of iron and glycerin (one part of the former to two parts of the latter) is a valuable local remedy ; it should be applied by means of a swab. The object of local treatment is a more thorough cleanliness. To avoid new lesions in making applications, the spray alone should be used, and for the nose boric-acid solutions or hydrogen dioxid, 1 : 10, will be most serviceable. Fackenheim's experience with a local spray of pyocyaneus convinced him that it is a valuable adjuvant to the serum treatment ; it hastens the disappearance of the throat lesions and improves the general health. In this work the utmost tact and kindness must be maintained, for it is truly pitiable to force a struggling child. Warm, weak solutions, most thoroughly applied by means of the fountain- syringe, often have a better effect than the more frequent use of the hand-syringe or spray in cases of nasal diphtheria. Rendu advises in- 1 La Medicine, Oct. 8, 1902. 164 INFECTIO US nrSEA SES. halation of hot air as a siipi)lementarv measure by exposing patients to a teuipcrature of 176° F. for five minutes at a time. In laryngeal diphtheria the child should inhale an atmosphere laden with the vapor of slaking lime, or, Aviienever practicable, an atmosphere saturated with, Lij tiler "s solution (menthol 10 grams, dissolved in sufficient toluol to make 36 c.c, liq. ferri sesquichlorid, 4 c.c, absolute alcohol, 60 CO.). J. Cordin warmly recommends mercurial fumigation for the relief of lai-yngeal stenosis. The development of the signs of actual stenosis, as shown by stridulous breathing, cyanosis, etc., furnishes an indication for either intubation or tracheotomy. According to my observations, the results of intubation have been quite favorable, and I would strongly recommend a trial of this procedure before resorting DAr OF DISEASE 1 3 4 5 6 7 E 9 10 - 12 13 14 15 ,a 17 18 19 20 1 M E M E M E M E M E M 6 M E M E M E M E E M E M E M E M E E E M E M E M t 106° 106° 104° 103° 102° 101° 100° 99° 98° 97° -" — - — - -. - _ _ _ _ L_ _ _ _ _ _ _ L — — — — — — — — fo^ — — — — — — — — - - — — — [— lit cr — - . m K ^ / Jl 1 / = <- — R E — E \\ / - - - - A ■\ - A / / — 4- \-^ / ; 1 , — J — - y - -/ V 1 \ 1 - \. v/ y / A — — -1^ >7 i — - / 1 / / 1 1 / 1 1 \ / V ■>, f 1 / \ h A V J' \l - — \ — / I / \ A A J 1/ V ' V \ / 1 1 - V L \/ _ 1 FiG. 15. — Temperature-chart of a case of diphtheria. to tracheotomy (see temperature-cliai-t, Fig. 15). To obviate the neces- sity for reintubation, vapor inhalations have been successful in my hands. ((i) External Applications. — External applications to the throat have no effect on the course of the disease. They are useful, however, in relieving the pain and the swelling in the lymph-glands. Careful massage of the neck with campiiorated oil, as hot as the skin will tolerate, is very sooth- ing ; and soap liniment may be used in the same way, or, if much pain exists, chloroform liniment may be substituted. Poulticing for the relief of pain is not desirable, as it seems to favor suppuration. In older chil- dren the ice-collar has been used with good effect, and it soon brings grateful relief from the tension and subdues inflammation. Levinson recommends early lancing of su))purating glands to prevent a general septicemia. All manipulations about the child, however, should be car- ried on as L'^ently as possible. Serum-therapy ; the Antitoxin Treatment. — This has now passed be- yond the stage of experimentation. The general average mortality of diphtheria has been reduced by means of the antitoxin treatment to DIPHTHERIA. 165 about 10 per cent., and the greatest decrease has been shown to have occurred in children under six years of age. No physician shouhl be guilty of failure to employ the serum in any case of diphtheria. The studies of Bchring, Koux, Kitasato, and others, published in 1890, have demonstrated that the use of the blood-serum of the lower animals, arti- ficially rendered imnmne against diphtheria, has a powerful healing influ- ence upon diphtheria that has been contagiously or spontaneously acquired by man. The principle was first shown to be true of tetanus, and, late in 1892, Behring further showed that the blood of an immunized animal had the power both of protecting and of curing susceptible animals which had been inoculated either with the toxins or the bacilli of diphtheria. In preparing the blood-serum it is desirable to have a uniform strength or standard. One-tenth of one cubic centimeter of what Behring calls his normal serum will countei'act ten times the minimum of diphtheria poison, fatal for a guinea-pig weighing three hundred grams. One cubic centimeter of this normal serum he calls an antitoxin unit. The serum prepared by his method is labelled in three strengths : No. I. is sixty times the strength of the normal serum ; No. II. is one hundred times as strong ; No. III. is one hundred and forty times as strong. Dosage. — To a child of two years or over not less than 2000 to 4000 units should be administered at the first dose; hence solution No. I. is rarely employed at the present day. Should a favorable result not be attained, then, on the following day, a similar dose should be repeated, and a third dose if necessary. Massive doses should be em- ployed at the outset in severe cases, in laryngeal diphtheria, and in advanced cases. The sites to be selected for injection are various. In very young children either the buttock or thigh is to be preferred, while in older children the flanks or subscapular spaces may be chosen as well. The injections should be made deeply into the subcutaneous cellular tissue, and the swelling which results should not be rubbed. It is to be emphasized that the best results are obtained from early injections. In laryngeal cases intubation should be combined with the serum treatment in suitable cases. The early use of antitoxin in this disease has greatly diminished the proportion of cases in which the usual complications, par- ticularly paralysis, occurred previously. In fortunate cases the influence of the serum soon becomes apparent. Within twenty-four hours the faucial SAvelling diminishes, the membrane exfoliates, the temperature falls, the pulse becomes slower and stronger, and the general condition of the patient quickly improves. In cases of moderate severity and when injections are employed early the improve- ment in the throat and the constitutional symptoms is very decided ; and the earlier the case comes under treatment the better are the results. There are, however, some cases of great severity in which the antitoxin has been used early, yet has not shown any benefit. Kronig ^ has found that incising the hard, swollen process enhances the efiiciency of the diphtheria antitoxin. A danger in serum-therapy may be the development of local abscesses, which, if full antiseptic precautions be taken, must be rare indeed. I have escaped them altogether. Certain skin eruptions have been observed after injections, mostly urticarial, though sometimes scarlatiniform. The latter form has given rise to apprehensions of scarlatina. Widerhofer had one case which was isolated as measlee, but never developed any ^ Jour, of the Amer. Med. Assoc, August 8, 1908. 166 INFECTIOUS DISEASES. symptoms other than the suggestive eruption. Rarely, joint-pains and swellings, with general prostration, supervene. Abnormal sensitiveness to horse-serum is found in certain persons, <'•rated through the diaphragm to tlie peritoneum. Bronchitis is sometimt-s present, but is rarely a part of the rheumatic morbid ])rocess ; it is secondary, and is ofieu occasioned by the co-operation of the factors that are at work in every disease in which enforced recumbency and great prostration coexist. Bfonclio-j>neu7n are exposed to the virus at the time of birth, will not take the disease if immediately and successfully vaccinated. Sex is without influence. Season. — In temperate climates, most cases occur during the winter months. On the other hand, in tropical countries it is said that the worst cases occur during the hottest months. Ra,ce. — Among uncivilized peoples variola spreads with frightful ra- pidity, the negro and other very dark races being affected in lai-ger num- bers and more severely than whites, since they are not so generally vac- cinated. A dread of the infection predisposes to its occurrence. The Contagion ; where Found ; Modes of Conveyance and of Infection. — One case of variola is prima facie evidence of the existence of another, the poison having been transferred. The specific poison exists in the blood and in the secretions and excretions (most probably), but mainly in the pustules and dry scabs and in exhalations from the lungs and skin. The contagion is conveyed principally from the sick to the healthy by the dust-like particles of the dried scabs. Modes of Infection. — (a) Inoculation with either the blood or the contents of the eruption or the dissolved dry scabs is followed by variola. (6) Contact with, or proximity to, a patient suffering from small-pox is very apt to convey the poison, with resulting variola in the person thus exposed. To what distance the contagion can be conveyed through the air is not known, but it is probably considerable ; and all authors are agreed that it is one of the most infective diseases with which we are acquainted. It is contagious from the earliest active stage to the end of convalescence, and possibly even during the stage of incubation. (c) Transmission hj fo7nites is common, the poison adhering to clothes, body- or bed-linen, etc., and evidence is not wanting to show that the poison is highly tenacious of pathogenic power. Its vitality is retained after death, and the room occupied by a patient, the bedding, and the articles of furniture all serve to convey the disease unless thorough dis- infection be enforced. The infection atrium for the poison into the sys- tem is probably the respiratory tract. Clinical History. — Incubation. — This stage varies with the mode of communication of the poison. If following inoculation, the symp- toms appear in six or seven days ; when originating from infection, usually in twelve days, though this stage may be either lengthened by a day or two or shortened to an equal extent. During a portion of this period complaint may be made of certain ill-defined symptoms, but these are usually absent. Invasion is sudden and accompanied by characteristic signs. These are — a severe rigor, liigli fever., headache., and intensf linn- bar pai7is. Instead of the usual severe rigor, repeated chills. extendinleurisy, pericarditis, laryngitis, and hernia in severe, prolonged coughing. Convulsions and broncho-pneumonia are alarming, and in young children a profound stupor may replace the convulsions. Eshner^ states that peripheral neuritis is a rare complication of this disease. Interlobular emphysema has resulted from whooping-cough (Finch). Sequelae. — Acute nep>hritis frequently occurs, and is as severe as that found in scarlet fever. In a series of over 200 cases I have found the kidneys affected in 20 per cent. Knight found albuminuria in 66 out of 86 cases examined. Emaciation is a very important se- quence of pertussis. All the viscera are liable to fatty degeneration, and nutritional changes open the door to cheesy, glandular altera- ' American Medicine, June 21, 1902. WJ-IOOPINO-COUOH. 227 tions, and eventually to a secondary tuberculosis. Atelectasis, by curtailing lung space, frequently brings about a general collapse, and this condition frequently explains the flattened chest found in young adults. Conversely, emphysema may be initiated by peitussis early in life. Emaciation may also be due to mucous disease, a chronic gastro- intestinal catarrh of lonij standing:. Prognosis. — Associated with its complications, pertussis is a very fatal disease, especially in children under two years of age. Dolan re- gards it as third in rank among the fatal diseases of England, where the death-rate per million is five thousand annually. The deaths occur chiefly among children of the poor and in bottle-fed infants. Goodhart regards whooping-cough as the most fatal of all the dis- eases in children under one year of age. He places the mortality at 12 per cent., and thinks that this is not too high; his statement, however, is hardly warranted, as he includes the deaths from the many sequelae which we cannot estimate. Ashby and Wright place the mortality at 7.6 per cent. Differential Diagnosis. — Young infants usually do not " whoop," but cough spasmodically. Children with pleurisy/ or pneumonia do not whoop, yet we diagnose whooping-cough by the preceding catarrhal fever. From influenza in its early stages it is most difficult to differen- tiate the affection. The pink under eyelid has to me been the most cer- tain sign. When the whoop appears and during the existence of an epidemic, however, the diagnosis may be rendered certain. The diagnostic points prior to the whooping stage, enunciated by Eustace Smith are as follows : " If a child be made to bend back the head, so that his face becomes almost horizontal, and the eyes look straight upward at the ceiling above, a venous hum, varying in intensity according to the size and position of the diseased glands, is heard with the stethoscope placed upon the upper bone of the sternum. As the chin is now slowly depressed the hum becomes less loudly audible, and ceases shortly before the head reaches its ordinary position." It is true that we do not recognize the hum caused by the enlarged bronchial gland, but it occurs long after other symptoms are manifest. I have for several years been able to place considerable value on the peculiar puflfiness of the mucous membrane of the eyes and the swollen or edematous condition of the Avhole face and almost dusky color. This condition may exist for days before the catarrhal symptoms have extended throughout the respiratory mucous membrane. The cough at this stage may not be at all suggestive, but purely bronchial. This symptom of fulness about the eyes suggests measles, and must be differentiated from it. As we are able to diagnosticate measles by its appearance first on the hard palate, so we may diagnosticate whooping- cough in its earliest stage by the characteristic swollen condition of the eyes and face. The diagnosis may be confirmed by leukocytosis and the presence of a sublingual ulcer. Treatment. — The gravity of pertussis is scarcely appreciated either by the general physician or the public, and there is more criminal neglect in connection with whooping-cough than with any other disease. Hygiene. — Throughout the whole course of the disease out-door life, as far as possible, should be encoui-aged, and if convenient a sojourn at the sea-shore will shorten the progress of the trouble and limit to a 228 INFECTIOUS DISEASES. great extent tlio number of se([ne\x. Only the severe and complicated cases need to be kept in bed. It has been shown that the number of attacks is directly dependent upon the amount of CO.^ present in the atmosphere (Forcheiuier). In cities the sufferer must be protected against the dust; this may be accomplished by the ■wearing of a veil in suitable cases. Medicinal treatment is exceedingly unsatisfactory, althouizh the thera- peutic measures which have been advocated are boundless. The remedies most in use are the antispasmodics and the germicides. Whooping-cough has a striking parallel in diphtheria, in that it has in its early stages a strong tendency to fasten itself upon the throat. How long this period exists we do not know to a certainty ; yet there is undoubtedly a period in whooping-cough, as there is in diphtheria, long or short, in which the virus — if it could be recognized — could be destroyed and the disease terminated. To abort cases thus within two weeks is not unusual, and this explains the number of reported cures made by germici- dal remedies. I have notes of 2 recent cases in which the characteristic whoop com- menced at once with the general catarrhal symptoms, and was cut short by a hydrogen-peroxid gargle. These 2 cases illustrate very clearly the fact that the germs of the disease will locate on the mucous membrane of the respiratory passages and bring about a nerve-discharge which ends in the characteristic whoop. In mj treatment of this disease I find the greatest necessity for recognizing the aff"ection early in the catarrhal stage. We must remember that the two stages are not sliarply defined, and that either the one or the other may be lacking. The drugs I have found most efficient in the catarrhal stage have been hydrogen peroxid for sterilizing the naso-pharynx, and belladonna and asafetida for the paroxysms. To be more explicit, I will detail the methods of procedure in a fam- ily in which I have instituted my plan of thorough treatment : A child of four years attending kindergarten was brought to me with a suspicious cough. The history was given of an exposure of over two weeks prior. The child had coughed for a few days, more at night than in tlie day- time ; Avas feverish during the evenings ; showed slightly swollen eyelids, thus suggesting the nature of the impending trouble. I ordered hydro- gen peroxid and pure glycerin in equal parts, which were well diluted and thoroughly sprayed through the naso-pharynx every four hours. The diet was light and digestible ; out-door life was encouraged, except on windy days. At night the child was placed in a large, well-ventilated room, and over its cot was erected a mosquito netting, so as to prevent any unusual draught — a procedure Avhich I have found highly beneficial. When the cough was fully established and was accompanied by eructa- tions of stringy mucus, I commenced the exhibition of the mixture of asafetida h dram (2.0) every two hours. The record of the paroxysmal stage Avas as follows : The first week averaged six coughing spells per day; the second Aveek averaged ten per day; the third week, four par- oxysms ; and the fourth and fifth weeks averaged about tAvo paroxysms during the tAventy-four hours. When the younger brother, but eight weeks old, commenced to shoAv evidences of the disease, I first used hydrogen peroxid as in the older brother, and immediately followed it with asafetida. The case ended favorably. PAROTITIS. 229 My second choice is tlie tincture of belladonna, exhibited in doses of one drop for every year of the child's life, the doses being rapidly in- creased until toxic effects are reached. ^Flien I gradually increase tlie amount as tolerance of the drug seems to be established. In very young children I have obtained good results from the use of a freshly prepared belladonna plaster placed between the scapulae, and the physiologic action of the drug seems thus to be more constantly maintained. I have gained a decided advantage by an application of a 2 per cent, cocain solution directly to the naso-pharynx in a few bad cases. This treatment, liow- ever, does not preclude the use of hydrogen peroxid, which should be continued throughout the catarrhal stage. Irrigation of the nostrils thrice daily with a 1 : 40 carbolic acid solution has proved curative in its effects. Bradt declares tiiat local treatment of the naso-pharynx tends to arrest the syndrome. Bromoform was ' resorted to in fully 20 per cent, of my cases, and was a keen disappointment. The coal-tar products, pushed to the toxic limit, modified the disease but slightly. A drug that has almost reached the rank of a specific in my hands is the following : Atropin sulph., gr. j ; aqua distil., 5J. Each drop contains -^^ gr. atropin and this dose may be increased drop by drop until the full physiologic effect of the drug has been obtained. If this effect is maintained with the onset of the paroxysmal stage, much time is saved. This outline of the drug- treatment in whooping-cough has reference solely to the catarrhal and paroxysmal stages of the disease. Kilmer has advocated a tightly placed thoracic and abdominal belt, which has yielded great satisfaction. Goodson commends the use at the earliest moment of the continuous in- halation of creasote ; he also advocates clearing the lungs of bronchitis as much as possible before using any special internal antispasmodic remedies. Graham advises a trial of the vaccine treatment. Oomplicatioyis and Sequelce. — Complications may be avoided by main- taining constantly the alkalinity of the body fluids. Sodium bicarbonate and the various alkaline waters are strongly indicated, and milk should be given in seltzer water. Passalarqua^ has employed diphtheria antitoxin successfully in 7 cases ; it is especially indicated when bronchial or pulmonary complica- tions exist. Diet of the simplest character and a uniformly quiet life must be maintained. PAROTITIS. {Mumps ; Parotiditis ; Epidemic Parotitis?} Definition. — An acute contagious disease, characterized by an in- flammation and swelling of the parotid gland, and occasionally by an involvement of the salivary glands, the testicles, and in the female the mammae. Pathology. — Opportunities for post-mortem examinations are rare, leaving in some doubt the pathologic course of the disease; but it probably begins as a catarrhal inflammation of the ducts, involving the ' Rev. Francaise de Med. et de Chirurg., 1905, No. 11. 230 INFECTIOUS DISEASES. periglandular connective tissue. The inflammation is seldom severe enough or of such a nature as to produce suppuration. Etiology. — Mumps is undoubtedly a constitutional or blood-disease ■with local manifestations. ''It is a question." Goodhart says, "with mumps ^\•hother this disease shall be placed with the specific diseases or •with those affecting the parts or organs with which the symptoms more particularly concern themselves." The disease is no doubt of wicrohic origin, but the specific organism has not yet been isolated, and, while there has been some reason to be- lieve that it is a bacillus, this has not been proved and is still doubtful. It is highly contagious, and at times, usually during the spring and autumn, becomes epidemic. It is communicated principally by the breath and crhalations, the greatest source of contagion being the salivary secretions. It may, however, be carried by a third person or by fomites, and is most liable to be communicated during the begin- ning of the attack, although the contagiousness continues until after the subsidence of the febrile symptoms. It occurs mostly among cliildrot and young adults, infants and old persons being rarely affected, while males are more liable than females. One attack usually gives immwiity from a second attack in the same gland. Clinical History. — The average period of incuhatinn is fourteen days, but it may develop as early as ten or as late as twenty days after exposure. The invasion is marked by languor and a temperature from 101° to 103° F. (38.3°-39.4° C), with possible headache and vomit- ing; the patient complains of pain at the angle of the jaw, and this is greatly increased if an acid (such as vinegar) is swallowed. With these symptoms is noticed a pgriforin swelling of the parotid glands, the one on the left side usually appearing first, and the other one soon following. Occasionally cases are seen in which but one gland is involved, or the swelling may begin in both at the same time. This increases gradually until some time between the third and sixth days, involving the other salivary glands and causing marked disfigurement; the swelling fills the depression beneath the ear and extends to the cheek and neck, the most prominent part l)eing just below, and ]n-essing outward, the lobe of the ear. The salivary secretions are generally much increased, though there may be the opposite condition of marked dryness of the mouth. When the swelling has reached its height, pres- sure on the adjacent tissues causes a disagreeable sensation of tension, and chewing, swalloAving, and even speaking, are at times painful and difficult. The skin over the affected part may be of a pale or of a dull- red color. Rinffino- in the ears and a dullini2: of the hearing is common. The nervous system may be affected, causing headache and delirium, or a low typhoid state may be present. The duration is about one week (six to ten days), after which time the swelling subsides, and by the tenth or twelfth day entirely disappears. Diagnosis. — The diagnosis is easy, tlie nature and position of the swelling and the course of the disease being characteristic, while the fact that the tonsils are seldom involved prevents a diagnosis of acute tonsillitis. Occasionally, however, in the course of septic infection or after operations, or owing to tlie extension of inflammation along the duct TUBERCULOSIS. 231 from the mouth, tlie parotid frhind becomes the seat of an acute infhirn- mation at first hardly distinguishable from mumps. The existence of a possible source of infection, and the fact that the gland under these circumstances usually undergoes suppuration, should lead to the recog- nition of the true nature of the case. Complications and Sequelae. — Mumps, as a rule, runs a mild course without any serious symptoms, but occasionally complications arise. The most common of these are orchitis in the male, which may be followed by atrophy of the testicle; and mastitis, ovaritis, or vulvo-vag- initis in the female, especially after puberty. These complications appear after the subsidence of the swelling of the glands of the neck, only occa- sionally developing while the glands are still affected, though cases have been reported in which the disease first manifested itself by involvement of the sexual organs. This complication lengthens the course of the attack and increases the constitutional symptoms, but the rule is complete re- covery. Otitis media sometimes occurs, and a lesion in the auditory nerve, with more or less deafness (which, unfortunately, may be perma- nent), has been observed. Meningitis, with active brain-symptoms, facial paralysis, convulsions, albuminuria, and arthritis, have all been noted in certain cases. Jacob and others report cases of mumps compli- cated with acute pancreatitis. Treatment. — The patient should be kept in a well-ventilated room of even temperature, and in bed if the fever is at all severe, and should be isolated from those Avho have not had the disease. Either hot or cold applications to the swelling will often give relief, and support to the swollen gland by means of cotton and a bandage is very comforting. Saline laxatives may be given, and aconite or some simple fever-mixture at the beginning of the attack is usually indicated. These simple measures are all that are required in an ordinary case, while complica- tions or unusual conditions must be treated as they arise. TUBERCULOSIS. Definition. — A chronic (less frequently acute) infectious disease, caused by the bacillus tuberculosis. This organism produces specific lesions, taking the form either of separate nodular masses or diffuse growths, infiltrating the tissues, while aggregations of these element- ary tubercles give rise to large tubercular masses. Tubercles undergo caseation and sclerosis, followed in turn by ulceration (in consequence of secondary pyogenic infection), or, more rarely, calcification. Historic Note. — Prior to the discovery, in the early part of the nineteenth century, by Bayle and Laennec, of the tuberculous new growth as a distinctive body, this disease had been studied chiefly from a clinical point of view. At this early period the disease was believed to consist chiefly of a suppurative process, and in its observation the physician was unaided by auscultation. Later, the tubercle was recog- nized as a small rounded nodule without any special histologic cha- 232 INFECTIOUS DISEASES. racteristics. Villemin in 18G5 performed bis epoch-making experi- ments, and the tubercle was no longer distinguished by its anatomic characters alone. Though the theory of the infectious nature of tuberculosis had been previously advanced by Buehl and others, it was first clearly demonstrated by Villemin's beautiful inoculation- experiments ujion rabbits and guinea-jjigs ^vith particles of tubercular and cheesy substances, producing the characteristic lesions of tubercu- losis. It then remained for Koch to discover (in 1881) the sj)ecific cause of the most important of all human ills — the tubercle bacillus. So soon as the specificity of the disease was definitely established it became clear that the associated inflammatory processes, that were for- merly believed to be primary lesions, were secondary. Geographic Distribution. — Tuberculosis prevails in almost every quarter of the globe, but is more prevalent in certain latitudes than in others. Thus, in general terms, it may be said to prevail more exten- sively in Avarm than in cold countries. Local conditions, however, exer- cise a more decisive influence in engendering predisposition than mere geographic position. It is of quite frequent occurrence in all densely populated municipalities, and more especially in the overcrowded sections of the latter; this fact explains why the iniiabitants of cities of the North are but little less spared than those of the cities of the South. On the other hand, residents of mountainous countries, owing to the purity of the atmosphere and the elevation, are rarely victims. General Pathology of Tubercular I/esions. — Distribution of the Lesions in the Body. — Tuberculous new growths elect, most fre- quently, the lung, and when the disease occurs in the adult this organ is almost invariably implicated. Next in frequency follow the larynx, intestines, peritoneum, urogenital organs, and the brain. The other chief viscera of the body (spleen, liver, heart, etc., particularly the lat- ter) are less commonly the seat of tuberculosis. In children the lesions exhibit a diff"erent distribution, the favorite seats being the lymph-glands, intestines, bones, and joints. In them the distribution corresponds pretty closely, if we except the bronchial and mesenteric glands, to that of surgical tuberculosis. The Elementary (Nodular) Tubercle. — This may be developed in any tissue to which the tubercle bacillus has found its way, and the presence of the bacillus is its sole distinguishing feature, since apparently iden- tical bodies are produced by other micro-organisms — f. ^., certain of the worms (eggs of the distoma), actinomyces, aspergillus glaucus, aspergil- lus funigatus, and even as a result of irritation by certain foreign bodies (podophyllum). Various forms of pseudo-tuberculosis have been de- scribed, but all are due to micro-organisms that differ from the bacillus tuberculosis. Mallassez and A^ignal described a form produced by a micrococcus occurring in a zooglea ; this was confirmed by Nocard, Eberth, and others. Charrin and Rogers have described still another form, in which they found bacilli about 1 /i long, actively motile, and growing freely upon ordinary media, but not growing upon glycerin and agar, ami not liquefying gelatin. The various stages in the development of a tubercle are — (a) Proliferation of the fixed-tissue elements (connective tissue, endo- thelium of the capillaries, etc.) of the part infected, due to the local. TUBERCULOSIS. 233 specific irritant action of the bacilli. These anatomic elements are transformed into epithelioid and giant cells. The epithelioid cells assume various shapes, chiefly rounded and polygonal ; they liave vesic- ular nuclei, and soon show tubercle-bacilli in their interiors. A certain proportion of the epithelioid cells, as the result of increase in their size and a repeated division of their nuclei, or by union of contiguous cells, become giant cells. The latter occupy the center of the tubercle, and also contain bacilli, the number of giant cells and of the bacilli being largely reciprocal. Thus, the giant cells are numerous in tubercular lymph-glands, joints, etc., in which the bacilli are relatively few ; on the other hand, they are scanty in miliary tubercles, in which the bacilli are numerous — two facts supporting the view that giant cells display phagocytic action. Hektoen asserts that the giant cell is a living defensive agent. [h) About the site of infection a diapedesis of leukocytes occurs in the nature of a defensive inflammatory process. At first the leukocytes are of the polynuclear variety and are quickly destroyed ; but later mononuclear leukocytes (lymphocytes) appear. These latter resist the action of the bacilli, and I think their true function is a phagocytic one. The various forms of cells described are connected and sur- rounded by a reticular stroma "formed by the fibrillation and rarefac- tion of the connective-tissue matrix " (Baumgarten). The fully-developed tubercles are small, nodular bodies whose diam- eters range from |- to 2 or 3 mm. At first they are almost transparent, but soon lose this quality in consequence of the further changes de- scribed below. They are avascular bodies, and invariably undergo de- generative changes : {a) caseation and (h) sclerosis. (a) Caseation. — This implies "coagulation-necrosis" — a destructive process proceeding from the center toward the periphery of the tubercle, and the result of the local action of the bacilli or their toxins. The cells are thus transformed into a uniformly yellowish-gray structureless matter. When the foci are numerous and closely set, fusion may occur, with the production of larger or smaller homogeneous masses (cheesy pneumonia). The latter may soften, resulting in the formation of cavities : this is due, usually, to secondary pyogenic infection, causing ulceration. Less frequently the cheesy masses undergo calcification or become encapsulated, and are then practically harmless. (6) Sclerosis. — Preceding and during the time that cell-destruction is going on in the center of the tubercles the protective forces of nature are asserting themselves, though too often without avail. In the first place, hyaline transformation, with conversion of the cellular elements into fibrous tissue occurs. Frequently, now, the center of the tubercle is caseous and contains bacilli, while the peripheral parts are quite hard. Here the bacilli are incarcerated {latent tuberculosis). The fibroid change may pervade the entire tubercle. Again, the fibroid ele- ment in the tissues immediately surrounding the tubercle may be greatly increased and form new connective tissue, and this process be followed by secondary contraction, converting the tubercle into a firm fibrous nodule. The fibroid change in its completest development is observed in tuberculosis of serous membranes. In every case of tuberculosis there is a battle for supremacy between 234 INFECTIOUS DISEASES. the destructive forces on the one hand and the resisting, conservative forces on the other hand. As mentioned above, limitation of the tuber- culous process takes place by fibrous encapsulation. In the majority of instances, however, the bacilli fall upon a receptive, favorable soil, when nature's benign curative means fail and extension occurs by the appearance of secondary tubercles in adjacent tissues. The dissemina- tion and transportation of the bacilli are effected principally through the lymph-channels and blood-vessels, although to some extent also by the phagocytic leukocytes. Again, infection may occur by actual contact of the affected organ with neighboring parts, the disease spreading by continuity. Lastly, lesions may be propagated by the movement of orjrans ; thus localized peritoneal tuberculosis mav rarelv become gren- eralized in consequence of the peristaltic movements. Again, fusion of minute centers of infection or of miliary tubercles results in the formation of larger nodules or areas, which lead by a process of local extension to diffuse tuberculous infiltration (gray infil- tration of Laennec). An entire lobe may become similarly involved (tuberculous pneumonia^ and '' there may also be a diffuse infiltration and caseation without any special foci, a widespread tuberculous pneu- monia induced by the bacilli " (Osier). The term '• gray infiltration "' is misleading, since the morbid changes differ in no essential manner from those described as occurring in the miliary or nodular tubercle. Moreover, the latter also presents a grayish appearance. The apparent difference between a miliary tubercle and diffuse tubercular infiltration lies in the fact that the latter displays a clearer tendency to spread b.v direct extension. Associated Inflammatory Processes. — The tubercle bacilli excite asso- ciated inflammatory processes in the organs affected, and if the tubercu- lous lesions run a slow course a limiting wall of true fibroid induration circumscribes the area involved. By means of this induration the nat- ural protective forces, either temporarily or permanently, check the progress of the local lesions, and the change is strictly analogous to the sclerosis that takes place in the peripheral parts of the elementary tubercle or immediately surrounding the latter, as in tuberculosis of serous membranes. On the other hand, when the tuberculous infiltra- tion is less tardily developed the collateral reactive inflammation may show changes similar to those of catarrhal or croupous pneumonia (vide supra). Examination of the sputum, to determine the nature of a mixed infection, is of little value, since the sputum may show various organisms that have not caused any real infection, and that have entered the sputum from the throat or buccal cavity. Etiology. — The Specific Cause and its Physical Characteristics. — In 1881, Koch discovered the tubercle bacillus. Avliich is the sole cause of the disease. The bacillus is rod-shaped, straight or somewhat bent, and slender, its length equalling about one-third or one-half of the diameter of a red blood-corpuscle (Fig. 19). Its ends are slightly rounded, it is non-motile, and on the interior of the Ijacilli small colorless spots can be observed on microscopic examination : these clear spaces represent plasuiolysis. Spores do not occur, except in mixed infection (e. g., old cavities) due to symbiotic growth. TUBERCULOSIS. 235 When stained the Ijacilli have a somewhat beaddl appearance. The tubercle bacillus is one of tlie lew varieties of bacteria that I'etain the aniliu dye after washings with acids. Biology. — The bacilli can be erown on culture-media, .'J A^ ^^r. :■¥■ ' ;;^/'',ii^ IK M5^ ,.%^-'''i ^//. '''%" CP-A'V '^^* ^^ ^'^ ', ,y- ■'/ "^ Fig. 19.— Tubercle bacillus in sputum (Frankel aud PfeittcD. but not without difficulty, since they demand an even temper- ature between 98° and 100° F. (37.7° C), or that of the hu- man body. The best soil is blood-serum previously coag- ulated by heating and glycerin- agar. Over the surface of the medium gently rub tubercu- lous tissue, which is then al- lowed to remain on the surflice. The growth of the bacilli re- quires about two weeks, when colonies appear as dry, gray- ish-white or grayish-brown, thin scales or masses on the surface of the culture-medium. From such cultures others may be grown on glycerin-agar or on the potato. The grass or butter bacillus has staining properties much like those of the tubercle bacillus, and since this organism is commonly found on hay and straw it should be carefully excluded in the study of milk, butter, etc. Both the lepra bacillus and the smes:ma bacillus resemble the tubercle bacillus in their manner of taking stains, but neither organism is capable of cultivation. Inoculations into the guinea-pig and other animals are succeeded in three to six weeks by the appearance of elementary tubercles — first, .locally, and then in other organs of the body. Chemical Products. — The growth of the bacilli is possibly attended by the formation of secretory products. Thus an albuminoid substance has been separated, and this when injected into the bod}-^ of an animal pro- duces slight fever. The albuminoid separated from cultures of tubercle bacilli is a nuclear proteid, and not a specific toxin. The constitutional features of the disease may be ascribed, in part, to the circulation of these poisons in the blood, but principally to the pus-producing organism. Bovine Tuberculosis. — The disease is common among cattle (TO to 20 per cent.), and Koch first pointed out certain differences between the bovine bacillus and the bacilli of human and animal tuberculosis. Smith's^ studies show that the bovine bacillus possesses the greater virulence. It is known that the human bacillus infects cattle with diffi- culty, while " the bovine bacillus infects animals, and probably also man, with great readiness " (MacFarland).^ Koch.^ in an address before the English Congress on Tuberculosis, said that man is rarelv infected ^ Trans, of the Assoc, of Amer. Pliys., 1896, xi., p. ^ Text-Book Upon the Pathogenic Bacteria, p. 331. ^ Jour. Compar. Path, and Tlierap., Sept., 1901. 1^8, and 1898, xiii., p. 417 236 INFECTIOUS DISEASES. with bovine tuberculosis. At the seventh International Congress on Tuberculosis (1908), Koch stated that he knew of no authenticated case of pulmonary tuberculosis in -which bovine bacilli had been found repeatedly in the sputum. The results of the investigations made by the German Imperial Board of Health sliow that the dangers from the use of milk and other dairy products derived from cows with tuberculous udders is extremely slight.^ The British Hoyal Commission found that one-third of the cases of tuberculosis in children under five years of age were due to the bovine bacillus, hence attention must be paid to this factor in connection with methods of prophylaxis (Woodhead). M. P. Ravenel concludes : (1) That the tubercle bacillus from bovine sources has in culture fairly constant and persistent characteristics of growth and morphology, by which it may tentatively be distinguished from that ordinarily found in man ; (2) that cultures from the two sources differ markedly in pathogenic poAver, affording further means of differentiation, the bovine bacillus being very much more active than the human for all species of experimental animals tested, with the possible exception of swine, which are highly susceptible to both ; (3) the tuberculous mate- rial from cattle and from man corresponds closely in comparative patho- genic power to pure cultures of the tubercle bacillus from the two sources for all animals tested ; (4) that it is a fair assumption from the evidence at hand and in the absence of evidence to the contrary, that the bovine tubercle bacillus lias a high degree of pathogenic poAver for man also. Sources of the Bacilli. — The chief sources are the sputum of tubercu- lous patients and the dejecta of persons with tuberculous enteritis and infected meats and milk. The desiccated, germ-laden sputum is wafted into the atmosphere in the form of dust-like particles. Distribution of the Bacilli. — The tubercle bacilli are found in a viable condition, both {(() inside and (6) outside of the body. (a) Inside of the Body. — As before stated, the number of bacilli found in tuberculous growths varies within wide extremes. In general terms, it may be said that the more rapidly the process advances the. greater the number of bacilli present. It must not be forgotten, how- ever, that the activity of the tuberculous processes is intimatelv con- nected with the degree of resistance offered bv the tissues. A clironic tuberculous focus may establish a fistulous connection with a vein or a lymph-vessel, and thus scatter the bacilli to the remotest parts of the body ; and in such instances (as the direct effect of the original number of bacilli present) a chronic is quickly converted into an acute form of tuberculosis. Strauss ^ demonstrated virulent bacilli within the nasal cavities of healthy persons whose positions necessitated their association with, and frequent presence in rooms occupied by, tuberculous patients. {h) The Bacilli Outside of the Body. — Tubercle bacilli can maintain their existence almost indefinitely outside the body. On the other hand, they probably do not develop or multiply under the usual external influ- ences, but their vitality is extraordinary. Their destruction cannot be effected by freezing nor by desiccation, and they survive for months in water. Their power to resist chemical agents (nitric acid, etc.) is also very great, but they may be destroyed by boiling for four or five min- utes or by exposure to the direct solar rays from four to eight hours ' A. AVeber in Ileft 10 of Research Work in Tubercvlom. ^ Milnch. med. Wochen, TUBERCULONTS. 2'i7 (Jousset). In milk they may be destroyed by beating in a closed pasteurizer for a period of twenty minutes at 140° F. (60° C). Tubercle bacilli are undoubtedly present in all inhabited places, and they may be conveyed for long distances by means of water, food, and fomites. Willson and Rosenberger have shown that tlie presence of living tubercle bacilli in the urine and the feces is of importance in relation to the infectiveness of sewage and of drinking water. The sputum dries and flies into the atmosphere in the form of dust, which not only floats in this medium, but also settles upon articles of furniture, the floor, the walls of living-rooms, hospital wards, draperies, clothing, bed-linen, etc. ; and from these resting-places it may be con- veyed back into the atmosphere. It has been shown, experimentally, that the dust obtained from the walls or from the air of rooms and hospital wards occupied by tuberculous patients is frequently, though not invariably, infected. It is the in-door atmosphere, laden with bacilli, that is especially liable to be dangerous. In places only rarely frequented by consumptives the dust is usually free from virulent bacilli. Modes of Infection. — (1) Inhalation of the Bacilli. — Inhalation tuber- culosis is, doubtless, less common than formerly supposed. There is some question as to the power of dust containing tubercle bacilli to infect persons and animals when inhaled. It has been demonstrated conclu- sively that when such dust-like material is mixed with the food, infection follows. In view of this evidence it is probable that the particles of sputum floating in the atmosphere are deposited in the mucosa of the nasopharyngeal ring and tonsils, gaining the lymphatics through these structures and passing to the cervical glands, thence to the apices of the lungs. Klebs and Flligge claim that infection may result from moist particles (salivary droplets) thrown ofi" in coughing, and Boston ^ has demonstrated that in 75 per cent, of consumptives, with cavity forma- tion, a fine spray containing tubercle bacilli is emitted during the acts of coughing, sneezing, laughing, and talking. Ravenel ^ has shown experimentally that tubercle bacilli may be disseminated by cows in coughing. It is highly probable that such spray magnifies the danger of infection from tuberculous cooks and bakers. Occasionally the bacilli attack first the upper respiratory passages (larynx, nose). Usually, however, primary infection takes place in the smaller bronchi in the api- cal area or, less frequently, in a bronchus ; this is shown by the fact that healed lesions in persons dying of other causes are commonly met with in these situations in the dead-house. The bronchial glands may be found to present tuberculous lesions. It has long been supposed that tuberculosis is a contagious affection ; unlike small-pox, scarlatina, and other acute contagious diseases, how- ever, tuberculosis is not transmitted by a single contact with a person ill of the disease. Flick and others have shown that persons who live in close proximity to affected persons frequently fall victims to the disease as the result of prolonged contact. Flick's topographic study of phthisis in the Fifth Ward of the city of Philadelphia, extending over a period of twenty -five years, shows conclu- sively that consumption obeys the laws of infectious and contagious diseases. His researches furnish incontestable proof that tuberculosis is limited to ^ Jour. Anier. Med. Assoc, Sept. 14, 1901. ^ Jour. Compar. J\red.., .Jan., 1901. 238 INFECTIOUS DISEASES. centers, and eacli case owes its existence to previous cases in the same house or locality ; that a house which has had a case of consumption Avill probably have others within a few years, and may have a large number of" cases in rapid succession; and that approximate houses are considerably exposed. The contagious theory of tuberculosis gains support from the fact that husbands have been fre(iuently observed to contract the disease from their wives, and the latter, since they are more constantly con- fined in the house, to become infected yet more frequently from the former. Weber has observed the case of a tuberculous husband who lost four wives in succession, another who lost three, and four others who lost two each. In like manner, the statistical studies of Cornet, Niven, Baer, and others show that the disease spreads through factories, prisons, cloisters, and even among the physicians, nurses, and attend- ants in hospitals for the reception of tuberculous patients, producing a mortality-rate from this disease ranging from 45 to 75 per cent. Sev- enty-three per cent, of nurses up to the age of fifty die of tuberculosis (Whittaker). Those who are engaged in making the beds, dusting and sweeping the rooms of patients are most exposed ; and, on the other hand, better hygienic living among these classes of individuals, and im- proved hygienic arrangements in prisons, institutions, and hospitals, have been found to reduce the death-rate decidedly. This result is to be accounted for as follows : (a) There is thus established a greater tissue- resistance to the bacillus tuberculosis on the part of the persons exposed ; and {I)) the germs are thus more widely disseminated. Obviously, then, in institutions in which the proper sanitary precautions are used there mav be few if any instances ; and from the records of the latter, facts opposed to the contagious theory of the disease can readily be furnished. (2) Infection by Swallowing. — ((/) That the milk of tuberculous ani- mals contains the bacillus, and that the use of contaminated milk may infect the human subject, are well-established facts.' Gerlach and Klebs long since observed the occurrence of the disease in animals fed with milk from cows affected with the so-called "pearl disease." It is not even necessary that the animal infected should have tuberculous mammitis (Ernst), though some are of contrary opinion (Flick, Sidney Martin, and others). The exact frequency of this mode of infection is not known. Infected animals, especially cows and pigs, that suckle their young very frequently transmit the disease to the latter, the infection usually resulting in intestinal and mesenteric tuberculosis. The bacillus is, in this instance, swallowed and finds lodgment in the 'primce vice. Bang has even shown that butter made from the milk of tuberculous cows may be infectious {vide also Bovine Tuberculosis, p. 235). Human tuberculosis is entirely analogous, and hence the tuberculous mother is likely to transmit the disease to her suckling offspring. This explains, adequately, why abdominal tuberculosis is frequent in children. (i) The meat of a tuhercuhns animal {e. g., cow, pig, or fowl) may rarely be infectious, but the bulk of experimental evidence would seem to show that, unless the parts consumed are the seat of tuberculous de- posit, infection does not follow. D. H. Bergey,^ holds that the lower ' See the elaborate statistical studies of Dr. George Cornet: "Die Tuberkulose in den Strafanstalten," Zeii.ochrift fur Hyqiene, Bd. x, 1891. * Saundei-s' Yeai-Book for 1899. TUBERCULOSIS. 239 mortality from this disease shown by tlie Jewish race is ascribable to their careful meat inspection. Again, the possibility of contnmination during the course of preparation for the market, and during transportation, must be recollected. The experiments of Aufrecht, Chauveau, Klebs, Parrot, Trappeiner, and others show that tuberculosis may be commiinicated by incorporating with the food the expectoration from tuberculous patients. The introduction into the stomachs of cattle and goats of a single quan- tity of virulent bacilli is followed regularly in from thirty to forty-five days by the development of tubercles at the tops of the lungs (Calmette and Gu^rin ^). (3) Infection by Inoculation. — Tuberculosis may be transferred by direct inoculation, as shown originally by Yillemin's beautiful experi- ments upon the eyes of guinea-pigs. Infection may take place, though this is rare, through slight cutaneous lesions (cuts, fissures, excoriations), as the result of accidental inoculation of tuberculous matter. In this manner there is produced a local tuberculosis of the skin, as a rule. Rarely, the contagion is conveyed by the lymphatics to the glands in the vicinity. Persons who follow certain occupations are more or less liable to this mode of infection — e. g., butchers, handlers of hides, dissectors of dead bodies, and, rarely, surgeons. Rare instances occur in divers ways (the bite of a consumptive, a cut from a broken spit-glass, or even from his pocket-knife, as I have seen in one instance). The handkerchiefs, body- and bed-linen of the patient may infect by inoculation those who handle or wash them frequently, if they chance to have a fissure or excoriation upon the hand. No doubt lupus also arises in the same way. Czerny has reported 2 cases of infection by transplantation of skin; Ceilings and Murray, 3 cases by tattooing (?). The contact of the lips of tuberculous operators with surgical wounds (as in sucking the latter) may transmit tuberculosis, as in the perform- ance of the rite of circumcision. Ravenel ^ reports 3 cases of accidental inoculation of the skin in man with the bovine tubercle bacillus. (4) Direct Hereditary Transmission. — In exceptional cases the bacillus is found in the fetus in utero. In such instances the disease may remain latent, to break forth during childhood or later in life ; and though the fetus itself may display no evidence of tuberculosis, the fetal viscera may yet be infective to guinea-pigs (Birch-Hirschfeld). Lehmann ' has reported an undoubted instance of intra-uterine infec- tion. The tuberculous mother died of tuberculous meningitis three days after the birth of her child, and the child lived twenty-four hours. In its spleen, lungs, and liver were found nodules resembling tubercles and containing tubercle bacilli in large numbers. Galtier has inocu- lated a pregnant animal with the disease, and found that the ofisprino^ was, in consequence, tuberculous at birth. The views of Baumgarten upon this question should be accorded careful consideration. This author believes that the contagion may be transmitted and become pathogenic at a variable period after birth — first, because the affection is very frequent in young children, even during the first months or weeks of life ; and, secondly, because certain structures, not apt to be 1 Ann. de I'lnst. Pasteur, 1905, vol. xix. ; 1906, vol. xx., 609. ' Proc. Philada. Path. Soc, October, 1900. 3 Berlin klin. WocL, July 9, 1895. 240 INFIX'TTOrS DISEASES. accidentally infected, are commonly the seat of tuberculous lesions in children — the bones and joints. After birth the bacillus may at any time either lose its vitality or take on a luxuriant growth. It is not known, however, in what percentage of these cases the lungs, intestines, peritoneum, and lymph-glands are free from tuberculous lesions. Kiiss disputes the theory of the latency of the tubercle bacilli, and contends that latent foci do not exist before the age of three months ; that they are rare before the first year, Avhen they mature progressively. Two facts deserve to ne here emphasized : First, that a child born of tuberculous parents is more receptive than one born of healthy stock ; and second, that it is more liable to accidental infection. The instances of direct transmission that have been traced occurred through tiibercufpus mothers. The observations of Csokor ^ upon heredi- tary tuberculosis in cattle also corroborate this dictum. Friedman,^ on the other hand, has practically demonstrated the possibility of transmis- sion of tubercle bacilli through the semen. Yignal^ has shown experi- mentally that invasion by heredity is very rare. (5) Dock ami Chadbourne state that mixed modes of infection occur. (6) Baldwin invites forcible attention to the danger of infection from the unclean hands of tuberculous patients. Predisposing Causes. — (1) Race and Nationality. — The effect of nation- ality upon the receptivity to tuberculosis can be studied advantageously in America on account of the cosmopolitan character of the popula- tion. The tuberculous tendency on the part of Indians of this conti- nent, even in the most favorable climates, is universally acknowledged, and the fact that the negro I'ace is highly receptive to tuberculosis is also well known. Osier* gives the following corroborative statistics: "Of the 427 cases of pulmonary tuberculosis at the Johns Hopkins Hos- pital for the two years ending June 1, 1891, there were 41 cases in the colored — i. e. about 1 : 10. The ratio of colored to Avhite of all patients in the wards has been 1 : 7." It is more than twice as common in the African as in the white, and still more prevalent Avith the Indian (AV. L. Hodman). At present the number of tuberculous Indians is 120, 24 per 1000 population. Sears'"^ found that in 200 cases of tuberculosis nearly 50 per cent, belonged to the first and second generations of Irish immigrants. (2) Hereditary Predisposition. — The percentage of cases in which heredity can be traced has been variously estimated at from 10 to 40. As before intimated {vide Direct Hereditary Transmission), a child reared by tuberculous parents runs great danger of being infected acci- dentally ; and again, a person living in an infected house (with or with- out the presence of a tuberculous patient) is very liable to become infected, whether his antecedents give a tuberculous history or not. It follows that a correct estimate of the number of cases of phthisis in which hereditary influence plays an etiologic part cannot be obtained. Too much importance has heretofore been attached to the influence of ' Deutsche mediziitdl Zeilnng, Berlin, Jan. 29, 1892. ' DeulHch. mefl. [Voch., Feb. 128. 1901. ' La Semaine medicate, Paris, Aug. 1, 1892. * Tert-Book of Medicine, p. 204. ^ Boston Medical and Surgical Journal, April 4, 1895. TIWJ'JRCULOSIS. 241 inherited constitutional peculiarities to the exclusion of other potent fiictors, especially an infective environment. Moreover, a similar degree of predisposition may be accpiired as the result of certain debilitating influences (childbirth, defective food-supply, close living- or working-rooms). An inherited tendency to tuberculosis is more unfail- ingly transmitted through the mother than the father. Multiple appear- ance is commoner in families with tuberculous parents (Dock and Chad- bourne). Children begotten of parents who are drunkards, or who suffer from certain chronic incurable diseases (syphilis, cancer, etc.) at the time of the birth of their children, are liable to inherit a condition of the system that greatly increases morbidity, unless the tendency is over- come by a proper environment, together with systematic physical train- ing during the first years of life. Moreover, persons who have the so- called tiiberculous diathesis are frequent sufferers from catarrhal affec- tions, especially of the respiratory organs. The latter condition forms a marked predisposing factor ; yet, on the other hand, tuberculosis is met with in persons of robust figure. The older authors of medical text-books describe two types of con- formation — the tuberculous and the scrofulous. The latter has a heavy figure, thick lips and hands, large, thick bones, and an opaque skin ; the former, a light figure, bright eyes, thin skin, oval face, and long, thin bones. The phthisical type of the chest will be referred to in connec- tion with the physical signs of pulmonary tuberculosis. Here emphasis should be given to Cohnheim's view, which is for the greater part cor- rect, to the effect " that the so-called phthisical habit is not an indication of a tendency to, but actually of the existence of, tuberculosis." Whilst the recognition of a pre-tubercular condition has its practical bearing, it must be recollected also that the term implies merely a " delicacy of constitution, incomplete growth, and imperfect development " (Fagge). (3) Previous Infectious Diseases. — That there is no tendency to the tran- sition of other diseases into tuberculosis, as was formerly supposed, cannot now be questioned in view of the undoubted specific nature of the latter disease. Tuberculosis is, however, embraced among the sequels of many acute infectious and chronic diseases — influenza, measles, pneumonia, whooping-cough, typhoid fever, cirrhosis of the lungs, and diabetes mellitus (the latter disease involving a predisposition to the former) — for the reason that they render the tissue-soil, especially that of the respiratory tract, more favorable to tubercular infection. Dock and Chadbourne have analyzed 100 cases of adult tuberculosis (bacillary phthisis) ; it developed rapidly after influenza in 16, and followed pneu- monia in 9. It seems proper to mention here the fact that certain other diseases are thought by most writers to display an antagonistic effect (chronic valvular disease, pulmonary emphysema, etc.). (4) Age. — This affects predisposition decidedly, though tuberculosis may occur at any or all times of life. Certain forms of tuberculosis are especially frequent in young children (meningeal, mesenteric, and lym- phatic). Pulmonary tuberculosis is most common between twenty and thirty. It is more rare during early childhood and in the aged, and the cases that occur in young children are likely to be rapid in their progress. Tuberculosis in adults usually develops in an organism already infected. (5) Sex. — Predisposition has but slight relation to sex. Females are, 16 242 JNFECTTOUS DISEASES. however, somewhat more liable than males, and pregnancy in particular is a disposing factor. Again, when tuberculous females become preg- nant the progress of the aft'ection is accelerated, and even more so by the period of lactation. Regarding tuberculosis as being pre-eminently a house-disease, females are more exposed to contagion than males, because they are more closely confined in-doors. ((i) Climate and Soil. — Humidity of the soil and«abundant atmospheric moisture increase the prevalence of tuberculosis. It is especially com- mon in regions in which sadden variations of temperature, or protracted cold with dampness, prevail. This increase is most probably associated with a heightened vulnerability, due to an increased tendency to ca- tarrhal affections of all kinds (Osier). It has been .shown that proper drainage of marshv districts has diminished, to some extent, the fre- quency of this disease (Buchanan), and, on the other hand, mountainous districts are often remarkable for freedom from the disease. Local Causes. — (1) Occupation. — Persons whose employment exposes them to different forms of irritating inhalations are particularly liable. In such, however, there is usually first developed a fibroid induration (I'ide Pneumonokoniosis), and the latter in turn is followed by pulmonary tuberculosis. The continual inhalation of an atmosphere laden with noxious particles, such as is met with in ill-ventilated ami overcrowded working or living apartments, renders the tissues more vulnerable. (2) Bronchial Catarrh. — An acute catarrh of the small bronchi pre- pares the soil for tuberculous infection. Frequently, however, this is the first step in tuberculosis, since the latter disease almost invariably begins as a local catarrhal process, involving the smaller apical bronchi. Here may be pointed out that gastro-intestinal catarrh (of protracted duration — H. M. King) increases the receptivity for tuberculosis. (3) Tubercular Pneumonia. — In like manner, pulmonary tuberculosis may follow an unresolved pneumonia, but such cases are, as a rule, instances of tuberculous pneumonia primarily. (4) Hemoptysis. — According to some authors, hemoptysis is potent in producing pulmonary tuberculosis. It is, however, certain that in most instances in which it appears to precede phthisis, and to exert a causative influence, it is in reality a symptom of existing tuberculosis. (5) Pleurisy may be, though rarely, the starting-point of phthisis. Its predisposing effect may be attributable to compression of the lung, thus interfering with the respiratory excursions, or to the bronchitis which is frequently associated. Pleurisy sometimes initiates fibroid in- duration, which may then terminate in a tuberculous affection ; but the fact is to be emphasized that a very large proportion of the cases of apparently primary pleurisy are tuberculous in nature. (6) Intrathoracic Tumor. — Tuberculosis is often associated with intra- thoracic tumors, and especially with aneurysm. Fehde^ has reported 3 interesting cases of the kind. (7) Congenital or acquired contraction of the orifice of the pulmonary artery predisposes markedly to tuberculosis. The lungs are often found to be undersized and ill-nourished from birth. (8) Trauma. — Injuries to the chest-wall, with or without laceration of the lung, are frequently followed by pulmonary tuberculosis. The explanation of this association is to be found in the fact that trauma * " Lungentuberculose mit Brusthohlengeschwulste," Inaug. Diss., Leipzig, 1894. TUBERCULOSIS OF THE LYMPH-GLANDS. 243 increases largely the susceptibility of the parts injured by diminishing phagocytic activity — the natural power of resistance. It is a familiar observation in surgical practice that after injuries to, or operations on, joints, tuberculosis, often acute, frequently ensues — in about 8 per cent. of the cases. Tuberculosis op the Lymph-glands. {Scrofula.) Scrofula implies tuberculous infection, and scrofulous material inocu- lated upon susceptible lower animals, especially guinea-pigs and rabbits, invariably causes tuberculosis. The virus is, however, less virulent than that derived from other sources, and this explains the slow progress and often latent character of tuberculosis of the glandular system. A major predisposing factor is age, this form of tuberculosis preponderating in children. Hecker, from an examination of the records of the Munich Pathological Institute, found that in 147 cases of tuberculosis among children the lymphatics were affected in 92 per cent.; and in young adults tuberculous adenitis is not uncommon. It is rarely met with also during and after the middle period of life. The lesions generally remain limited to the glands first infected — i. e., the cervical, mesenteric, etc., as the case may be — and this for the I'eason that the natural powers of re- sistance in the tissues are often able to oppose the march of the destructive forces. Another predisposing condition is an acute or chronic catarrh of the mucous membranes. The cases are all divisible into two groups : (1) Local tuberculous adenitis, and (2) general tuberculous adenitis. (1) Local Tuberculous Adenitis. — (a) Cervical. — This is the most fre- quent form, and is especially common among children. Etiology. — Of 2035 persons examined by Valland, enlarged cervical glands were found between the ages of seven and nine in 96 per cent. ; between ten and twelve in 96.1 per cent. ; between thirteen and fifteen in 84 per cent. ; between sixteen and eighteen in 69.7 per cent. : and between nineteen and twenty-four in 68.3 per cent. Tubercle bacilli were found in the cervical lymph-glands in about 68 per cent, of adults. Negroes are found to be more prone to the affection than whites. Mode of Infection. — I have stated before that tubercle bacilli are sometimes found on the nasal mucous membrane of healthy persons. The presence of an acute or chronic catarrh of the nasopharynx may now lower the resistance of the tissue-cells, so that the bacilli may gain access to the lymph-current, and through the latter to the neighboring glands, setting up tubercular adenitis. The cervical lymph-glands, how- ever, do not furnish a highly favorable soil for the growth and develop- ment of the bacilli, and hence the tendency toward latency. The to7isils, owing to their free communication with the atmosphere, in which there is a wide diffusion of tubercle bacilli, may be primarily infected. Friedman suggests that primary tuberculosis of the tonsils is usually set up by infection through the food. But here also, as in the case of other glandular structures, there is a tendency for the affection to become encapsulated, for the reason that the tissue-soil after a prolonged contest generally gains the ascendency over the invading bacilli. The latter may, however, under certain favorable conditions, break down the 244 lyFECTIOUS DISEASES. barriers opposed by nature and eftect a lodgement in the cervical glands, or even become widely diffused through the economy. Thus Kinckniann in 64 autopsies found 2.") cases of tuberculosis, in 12 of which the tonsils ■were affected. A third mode of infection of the cervical lymph-glands is through the medium of slight injuries and abrasions of the skin or certain forms of skin-eruptions (eczema, etc.). These serve as doors of entrance for the bacilli, which find their way into the neighboring lymph-glands through the lymph-channels. Compared with infection from within, this mode is most probably much less frequent. Si/mptofiis. — The main feature is a visible enlargement of the af- fected cervical glands, chiefly the submaxillary. At first the glands are too small to be even palpated ; later, they can be felt as small, firm tumors underneath the skin. By and by they appear as visible protuber- ances, ranging in size from that of an English walnut to that of a hen's egg or even larger. The skin over the enlarged gland is freely movable, as a rule ; less frequently it becomes adherent — an indication of suppu- ration. When an abscess forms and is allowed to open spontaneously, there remains a chronic discharging sinus. Suppuration is attended with fever, anemia, and emaciation. In well-marked cases the separate tumors coalesce, forming large and irregular masses. The affection is usually bilateral, though almost invariably it is more marked on one side than on the other. Not infrequently, in addition to the enlargement of the submaxillary, post-cervical, and supraclavicular glands, there is also involvement of the axillary, as was the case in a fatal instance in my own practice. The patient was a male child, eight years of age, who developed pul- monary tuberculosis. It may reasonably be assumed that the bronchial glands also become implicated, and may excite lung tuberculosis. The diagnosis is based upon the history and the associated evidences (keratitis, conjunctivitis, eczema of the face, nasopharyngeal or bronchial catarrh), coupled with the glandular enlargement. Bacilli have occa- sionally been found in the purulent discharge from abscesses. Otis applies the tuberculin-test, and obtains positive reactions in 62 to 69 per cent. The Yon Pirquet cutaneous reaction may be also employed. The course of this affection is exceedingly slow, often extending over a number of years. Many cases, however, recover after timely surgical intervention. On the other hand, neglected cases are a menace to the life of a patient, since they may be followed by diffusion of the bacilli, with the development of a fatal form of disease. {J}) Bronchial. — Tuberculosis of the bronchial glands may be primary, or secondary to infection of the lungs, and it is commonly preceded by or associated with bronchial catarrh, which is its chief predisposing cause. The primary form is met with frequently in young children, the medias- tinal lymph-glands being affected uniformly in 127 cases at the New York Foundling Hospital (Northrup). The bronchial and tracheal glands are the receptacles for all foreign substances, including the tubercle bacilli that are not dealt with by the broncho-pulmonary phagocytes. After infection with tubercle bacilli the lymph-glands become swollen, tumefied, and are the seat of caseous *:hange ; later they may undergo calcification or proceed to abscess-for- TUBERCULOSIS OF THE LYMPH-GLANDS. 245 mation. The latter may rupture either into the lungs, into the trachea or the bronchi, or into a pulmonary blood-vessel. Symptoms. — If a fistulous communication be established with the air- passages, cough and expectoration of purulent material, blood, and caseous matter containing bacilli will be noted. Secondary infection of the lung may occur in this manner. When rupture takes place into a vessel systemic infection promptly follows. Tubercular adenitis involving mediastinal lymph-glands may also lead to infection of the pericardium and then proceed to tuberculous peri- carditis. (c) Mesenteric (Tabes Mesentericd). — This may be primary or sec- ondary, the latter being common as a secondary infection to intestinal tuberculosis. The former is rare, however, and the intestinal catarrh with which it is associated is doubtless tuberculous in the vast majority of cases. The mode of infection has already been pointed out. The lesions pre- sented are similar to those met with in tuberculous bronchial glands. The symptoms are not always distinctive, and may be entirely nega- tive during the life of the patient ; hence the condition is often incident- ally discovered during the post-mortem examination. The local symp- toms when marked are due in the main to an associated peritonitis. The abdomen is painful and more or less swollen. Peritoneal effusion is present, and sometimes sufficient in amount to be detected by the cus- tomary physical signs. Large and small nodules may sometimes be felt. Diarrhea is a marked and an obstinate feature and is usually due to tuber- culous intestinal ulcers. Fever of an intermittent type is almost constantly present, causing emaciation, and the objective changes (pallor of skin, mucous membranes) due to anemia become pronounced. This form of tuberculosis may persist as a local condition, but there is danger of extension to other organs (pleura, lungs). On the other hand, in the adult pulmonary tuberculosis may be followed by involvement of the mesenteric glands without involvement of the intestines, and in such in- stances there occurs an extension by contiguity along the course of the lymphatics that pass through the diaphragm, and finally, in adults, pri- mary tuberculous new growths may be met with in the mesenteric glands. Diagnosis. — A probable diagnosis can usually be made if carefiil at- tention be paid conjointly to the symptoms, physical signs, and course of the aflFection. The detection in a child of a tumor which may be moderately hard, doughy, or even fluctuating will aid materially in the diagnosis, and will also afford evidence of tuberculous disease in other organs. The Von Pirquet cutaneous reaction will be found present. (2) General Tuberculous Adenitis. — This term implies tuberculous dis- ease of the lymph-glands throughout the body, with little if any involve- ment of other organs ; it is a rare condition. The affection may begin as a local tuberculous lymphadenitis, nearly all the rest of the glands of the body becoming secondarily implicated. The primary seat of the trouble is perhaps most frequently the cervical lymph-glands, though in one instance observed by myself the mesenteric glands first became affected, the case terminating in pleuro-pulmonary tuberculosis. Symptoms and Diagnosis. — There is protracted fever, the temper- ature being of the remittent or intermittent type. Wasting and debility 246 INFECTIOUS DISEASES. are progressive until the patient presents a decidedly puny aspect, while the lymph-glands tliat are accessible to inspection and palpa- tion are more or less enlarged and manifest a marked tendency to sup- puration. The affection is usually chronic, though very exception- ally it may exhibit an acute course. One of the chief dangers over- hanging the sufferer in this affection is that, owing to liberation of the bacilli, the meninges or the lungs may become tuberculous ; these cases may also eventuate in death from asthenia. Cases in which the glands are but little enlarged, while the general features are marked, are puzzling. On the otlier hand, when the superficial lyiuph-glands are greatly enlarged, the affection may bear a striking resemblance to Hodg- kins disease. Indeed, certain recent writers hold that generalized tu- berculous adenitis and pseudo-leukemia are etiologically identical [vide Hodgkin's Disease, p. 483). Acute Tuberculosis. This form of tuberculosis is characterized anatomically by the rapid development of miliary tubercles in many and widely-separated parts of the body. In some instances the ncAv growths are pretty evenly distrib- uted through all the organs of the body, manifesting the clinical symp- toms of an aciite general infection. In other instances there is a tend- ency to centralization of tuberculous growths, as, for example, in the lungs (pulmonary variety) or in the meninges of the brain and spinal cord (meningeal variety). Pathology. — The fact is to be emphasized that somewhere in the body there is an old tuberculous focus. Apart from this primary lesion, the anatomic changes consist in the Avidely disseminated miliary tuber- cles. Their most frequent seats are the lungs, liver, and spleen ; less commonly, the marrow^ of the bones, the heart, the choroid, and the meninges. In s6me of the organs, particularly the meninges, lungs, etc., the tubercles may be readily perceived by the naked eye, while in others they frequently cannot be detected without the aid of the micro- scope. It must not be forgotten that in some of the more protracted cases the nodular tubercles may grow into foci of considerable size, ranging from that of a lentil to that of a pea. Ktiology. — This has been, in the main, given in connection with the general etiology of tuberculosis {vide supra), though a few special points remain to be adduced. The acute forms of tuberculosis are decidedly more frequent during infancy and childhood than during adult life, and with few exceptions the cases are secondary to a local tuberculous focus in one or more lymph-glands (tracheal, bronchial, mesenteric) or in the lungs. More rarely a pre-existing tuberculous focus in the kidneys, the bones, or the skin may give rise to the affection, as may the occurrence of certain other acute infectious diseases (such as measles, whooping- cough, and influenza) in children, and typhoid fever and lobar pneumonia (especially with delayed resolution) in adults. Modes of Infection. — Most frequently there is established a fistulous connection between the local tuberculous focus and a vein, especially the pulmonary vein. Under these circumstances there may be large num- bers of bacilli discharged into the blood-stream ; but oftener only small ACUTE TUBERCULOSIS. 247 numbers of bacilli enter and subsequently multiply, inducing general infection (Ribbert and Wild'). A second mode of infc^ction, though decidedly more rare than tlie above, is the rupture of a tuberculous focus into the thoracic duct, in which case the tuberculous material passes almost directly into the subclavian vein. Clinical History. — That miliary tubercles may exist in many organs of the body (liver, heart, etc.) without giving rise to symptoms is a noteworthy fact. Cohnheim and Manz have discovered miliary tuber- culosis of the choroid with the aid of the ophthalmoscope alone. The following forms of the disease may be distinguished : General Miliary Tuberculosis. (a) TYPHOID FORM. The symptoms are those of a general infection of the body, there being in most cases a period of incuhation, during which the patient complains of malaise, headache, chilliness, feverishness, and increasing debility. Rarely, the onset is comparatively sudden. The reaction of the nervous system against the poison, which is now scattered to all parts of the body, is shown by such symptoms as the fever, which rapidly increases, a rapid, feeble pulse, and mental dulness or delirium. The tongue becomes dry, and sometimes also brown. The res2nrations are accelerated, and there is more or less cyanosis, with which symptom is associated a peculiar and characteristic pallor of countenance. Coinci- dently with the febrile exacerbations the cheeks wear a circumscribed blush. Among the rarer early symptoms is epistaxis. The patient soon becomes either profoundly prostrated or anxious : if, as sometimes happens, the course is protracted, weakness, anemia, and especially emaciation are well marked and assume diagnostic importance. These cases some- times pass into the pulmonary or the meningeal form, the patients often succumbing speedily to such localized developments. Fever. — The temperature usually pursues a high range, although there are a few cases in which the entire course is afebrile. Again, it occurs not infrequently that the temperature is normal or nearly so for a short period. The usual temperature-curve ranges at first between 102° and 104° F. (38.8°-40° C), and then continues to rise, with the development of the serious general condition in a way exactly similar to that observed in typhoid fever. In many instances the fever is irregularly remitting, at least at intervals, if not so constantly. Thus, periods of irregular fever may alternate with others of continued, and later deeply remittent or distinctly intermittent, fever. Nervous Symptoms. — In most cases the nervous symptoms are not prominent. In a smaller number headache, vertigo, delirium, and often stupor, become marked at an early stage and may persist. They are due to the general infection. Circulatory System. — The pulse is small, and its rate is out of pro- portion to the fever, varying from 100 to 140 or higher. It may be- come irregular, particularly if the meninges be involved. Respiratory System. — The breath is somewhat hurried and labored : there is a cough, but it is not annoying as a rule; and there is a slight expectoration, which is not characteristic. If there be present simul- 1 Deutsche medicinische Wochensehrift, Dec. 30, 1897. 248 INFECTIOUS DISEASES. taiieouslv in the lungs an old tubevoulous focus, the expectoration may )»e more profuse and typical. The bacilli are also absent from the sputum unless an old tuberculous lesion exists in the lungs. J. A'^ogl states that individual tubercles can be demonstrated on the .r-ray plate. The physical signs are those of a diffuse bronchitis, though signs of consolidation' or pleurisy may develop late in the course of the affection. Such signs, however, may be evidences of an old tuberculous affection. Digestive System. — As before noted, there are anorexia and a dry tongue (s^^mptoms due to the systemic infection), while vomiting may occur at the outset, and excessive thirst is common. The spleen usually becomes enlarged, though only to a slight extent, as a rule. Ocular Symptoms. — The important symptom presented by the eye is the presence of choroid tubercles. Their demoijstration is only possible with the skilled o])lith:ilniologist. Their absence, however, does not militate against the diagnosis of this disease. Tileston has described an eruption, in cases occurring among children, Avhich consists of scattered, discrete j)apules about the size of a pinhead, and on these are tiny vesi- cles Avith cloudy contents or minute pustules, followed by drying, with slight incrustation. Diagnosis. — In the following table I have endeavored to contrast points of dissimilarity between this disease and typhoid fever : Acute General Miliary Tuberculosis. Typhoid Fever. Family history of tuberculosis, or pres- Coexistent with an epidemic or following ence of an old focus. previous cases of typhoid. Evolution of the disease not characteris- Evolution of the disease is character- tic, istic. Epistaxis rare. Epistaxis a common early symptom. Fever-curve of decidedly irregular type. Temperature-curve of the continued ^type- . . , . Pulse rapid, out of proportion to fever. Pulse often dicrotic ; slow in proportion to fever. Respirations rapid and labored. Respiration moderately increased. Face dusky, with peculiar pallor. No duskiness of face. Abdominal symptoms are not suggestive. Abdominal symptoms (stools, enlarged spleen, tympanites, etc.) suggestive. No characteristic eruption. The eruption (appearing in successive crops) is distinctive. Von Piiquet reaction usually positive. Widal reaction present. Knee-jerk may be absent. Knee-jerk never wanting. Choroid tubercles may be detected. Choroid tubercles absent. Tubercle bacilli rarely demonstrable in Cultures from venous blood show typhoid- the blood. bacilli. They may also be found in the stools and urine. Hemorrhage from bowels exceptional. Hemorrhage from the bowels common. Perforative peritonitis absent.^ Perforative peritonitis often present. The tuberculin test may prove an aid to diagnosis in cases pursuing an apyrexial course. (b) PULMONARY FORM. Though all gradations between the typhoid and the pulmonary types occur, the latter should be recognized and briefly described. It may develop suddenly, the ushering-in symptom being sometimes a chilly though more frequently there is a premonitory period, during which ^ See also Differential Diagnosis of Typhoid Fever. ACUTE TUBERCULOSIS. 249 the general health fails materially. Some acute illness, as measles or whooping-cough, in which there has been marked catarrhal bronchitis, often constitutes the point of departure for this variety. The respirator^/ symptoms are early prominent, and later preponder- ate in the clinical picture. From the start there is dyspnea, and this gradually increases until the respirations become rapid (40 to 60 per minute). When dyspnea becomes pronounced, the face presents a char- acteristic cyanotic pallor. The cough at first is moderately severe, but it soon becomes troublesome, being frequent and attended with a slight expectoration, which, however, is non-characteristic. The physical signs are those of broncho-pneumonia, and the latter may or may not be preceded by the signs of generalized bronchitis. With the onset of consolidation there appear spots that yield either dulness or a tympanitic resonance on percussion, and broncho-vesicular breathing with numerous subcrepitant rales on auscultation. The general symptoms are marked from the beginning. The fever is high— from 103° to 105° F. (39.4°-40.5° C.) or often higher. The pulse ranges from 100 to 140, is small, feeble, and sometimes irregular, and it may be more rapid still during the advanced stage of the affec- tion (see Fig. 20). Cerebral symptoms rarely appear. The course, as a rule, is more prolonged than that of general miliary tuberculosis, except in children, in whom it often runs an exceedingly acute course. As the end approaches the signs of suflFocation are gradu- ally intensified, and finally lead to a fatal termination. Dia^^OSis. — The diagnosis is difficult ; but a family history of tuberculosis, a knowledge of the pre-existence of a tuberculous focus or of an antecedent predisposing afiection, will aid in its recognition. Tubercle bacilli are perhaps not demonstrable in the sputum unless an old tuberculous lesion is present. In doubtful cases, however, an attempt should be made to detect the bacilli in the blood. Occasionally either tuberculous meningitis or peritonitis supervenes, and aids in removing the doubt, and in a small percentage of the cases choroid tubercles are detectable. These points, together with the more marked general symptoms, will usually enable the clinician to distinguish this variety of tuberculosis from non-tuherculous broncho-pneumonia. (c) CEREBRAL OR MENINGEAL FORM (TUBERCULOUS MENINGITIS). This variety is of quite frequent occurrence, appearing in not less than 50 per cent, of the cases of miliary tuberculosis. When it devel- ops, the symptoms referable to other organs than the meninges are in abeyance. With reference to the etiology, the fact needs to be empha- sized that most cases occur between the ages of two and seven years ; it may, however, be met with at any time of life. The affection frequently has its origin in tuberculous bronchial glands (Jacobi), and the history of a fall is common. A few cases have been found to be associated with erythema nodosum. Exceptionally, the meninges are primarily involved. Pathologfy. — The chief site of the tubercles in children is the pia mater at the base of the cerebrum (basilar meningitis), while in adults the pia at the vertex is more apt to be involved. The membrane sur- ACUTE TUBERCULOSIS. 251 rounding the tubercles may not be inflamed, there being a simple tu- berculous deposit. On the other hand, more or less inflammation, with sero-fibrinous or fibrino-purulent exudation, is generally present in the region of the base. This exudate is usually abundant in the Sylvian fissures, and may find its way to the external surface of" the hemispheres. It is gray in color, transparent, and gelatinous, and contains in its meshes the tubercles, which appear as grayish-white bodies, and which, in cases of equal severity, may be either numerous or scanty. They may be scarcely visible to the naked eye, but may vary from the size of a pinhead to that of a French pea. The branches of the Sylvian artery may be implicated, either owing to the direct pressure of the exudate or to the obliterating arteritis produced by a tuberculous infil- tration. The pia looks like wet blotting-paper over the quadrangle at the base (Gray). Elsewhere it is thickened and opaque, though easily detachable. Osier says : " The arteries of the interior and posterior perforated spaces should be carefully withdrawn and searched, as upon them nodular tubercles may be found when not present elsewhere. In doubtful cases the middle cerebral arteries should be very carefully re- moved, spread on a glass plate with a black background, and examined with a low objective. The tubercles are then seen as nodular enlarge- ments on the smaller arteries." Involvement of the chief vessels that nourish the walls of the ventricles and the ependyma, and stretch from the vermis cerebelli forward over the quadrigemina, explains the con- stant presence of a turbid fluid in the ventricles, with softening of their walls. As the result of undue intraventricular pressure the cerebral convolutions become more or less flattened, with elfacement of the sulci. The cortex, to a variable depth, is generally the seat of red softening, and more rarely of white softening alone. The tuberculous infiltration involves the cranial nerves. Histology. — The tubercles grow in the perivascular sheaths, which are often distended with lymphoid and epithelioid cells, and there is observed not infrequently a thrombosis of the arteries and of the venules of the pia, obliterating their lumen. The pia mater is gradu- ally thickened through cellular infiltration, and in a small proportion of the cases the spinal meninges are similarly involved, chiefly in the cer- vical portion of the cord. Symptoms. — There is z> prodromal period which lasts one or more weeks, during which the patient (usually a child) is pale, peevish, has headache and photophobia, and grinds its teeth during sleep ; the tongue is coated, appetite impaired, and there may be occasional vomiting, either propulsive or regurgitative. Constipation is present and may be marked. Among rare premonitory symptoms are slight hyperesthesia of the abdomen and a diminished urinary secretion. A tendency to emaciation is quite constant. These prodromal symptoms present varia- tions as to their number and combinations in difi"erent cases. In few instances only is the onset acute. The symptoms usually indicate basic meningitis, and at first there is associated considerable mental excite- ment; later there are pressure-symptoms (caused by the exudate), with total loss of the mental faculties. (1) Stage of Cerebral Excitement. — The invasion is generally gradual, or even quite insidious, its most characteristic phenomena being severe 252 INFECTIOUS DISEASES. vomiting, marked headache, and chills foUoived by fever. Certain other symptoms now arrest the attention, such as extreme irritability, scream- ing, and great obstinacy, and occasionally drowsiness appears early. When the onset is sudden the disease may be disclosed by convulsions, paral- ysis, wild delirium, or coma. The established disease exhibits certain distinctive features. The pain is often most excruciating, causing the child to utter short penetrating screams (hydrocephalic cry), and in rare instances the sharp cries may be continuous and lead to physical exhaus- tion. The headache is increased by light, noise, or movement. Vertigo is common ; the pupils are contracted at this period ; the face pales and then flushes : the pupils alternately dilate and expand ; and the expres- sion is sometimes sad, though more often stupid. Generally hyperes- thesia or dysesthesia may appear, and there may be a slight mind-wan- dering at night, though active delirium is rare. Tdches cerehrales may be obtained, but are not characteristic. The patient is intolerant of every form of disturbance. All the symptoms of the prodromal stage are now aggravated ; slight muscular twitchings and sleep-starts occur ; the vomiting is apparently causeless, and may be frequently repeated ; and constipation persists. Fever is present, but is of slow development, and rarely rises higher than 102° or 103° F. (39.4° C.) in the evening. The shin is dry and harsh. The pulse is slow or moderately accelerated, but soon quickens to 120 or even 130, and later it may be irregular. At times the pupils are unequally contracted, and ptosis is usually an early sign. (2) Second or Transitional Stage, — The symptoms of cerebral irrita- tion now abate, the patient becoming more quiet, while mental dulness often supervenes. The vomiting and headache gradually subside, and the child rarely cries out. The abdomen is now distinctly scaphoid and the head occasionally retracted. Constipation is obstinate. The evidences of localized organic foci, such as slight twitchings of the muscles of the face, followed by strabismus, ptosis, or paralyses of the face or limbs, may appear. Generalized convulsions may occur, and muscular tremors and athetoid movements may appear. Both pupils (or one only) may be dilated as intracranial pressure develops ; patchy flushing of the face is common. The respiration is now irregular and sighing. (3) The Stage of Paralysis. — On account of the exudation the mental faculties are abolished, so that the patient is comatose, though convul- sions or localized spasms of the muscles in different parts of the body (neck, back, limbs, etc.) may be observed. Optic neuritis develops, ■while the paralysis of the ocular muscles above noted deepens. The pupils are dilated, the eyes are partly closed, and the eyeballs at inter- vals slowly and alternately move in a lateral direction. Hemiplegia sometimes develops, and more rarely monoplegia, affecting the face or one of the extremities. There may be paralysis of the third nerve, with involvement of the face, hypoglossal nerve, and limbs on the opposite side (a combination of symptoms first observed by Weber), consequent upon a lesion localized in the internal inferior portion of the crus. Monoplegia of the right side of the face has been observed in a few instances, associated with aphasia. Exceptionally aphasia and brachial monoplegia have been combined. The temperature in the early part of AGVTK TUBERCULOSIS. 25,3 this stage usually rises to 103° F. (39.4° C.) or hifflier, but later it may drop to a subnormal level, and in rare instances as low as 94° F, (34.4° C). Immediately preceding the fatal termination the temperature may rise to 106° or 107° F. (41.6° C), the pulse becoming frequent, small, and irregular. Anesthesia comes on with general muscular relaxation. Occasionally a typhoid state (great prostration, dry tongue, diarrhea, etc.) may develop, and Cheyne-Stokes respiration is almost invariably present, preceding the fatal event. Leukocytosis has been observed. Ophthalmoscopic Examination. — The ophthalmoscopic appearances are — hyperemia of the disk, later the changes belonging to neuritis (swelling and striation) appear, and choroidal tubercles may be detected. Diagnosis. — This is based : (1) On the reaction to tuberculin ; (2) Examination of eyes, which present the characteristic appearance of the choroid coat (Jacobi). Macewen first pointed out that if the patient is caused to assume the upright position with the head inclined to one side, percussion over the pterion gives a tympanitic note which is indicative of internal hydrocephalus. Koplik found this sign present in 34 of 52 cases. Post-hasic meyiingitis gives the same symptoms, and lumbar puncture is the only means of diagnosis. In tubercular meningitis the diplococcus intracellularis is not found. Syphilitic meningitis and men- ingitis due to trauma may bear a close resemblance to the tubercular form, but the history should prevent confusion. Clinical Types. — (a) Mild Type. — The marked or alarming symp- toms (tetanic rigidity of the muscles, convulsions, and paralysis) develop at a late period. In this class should be placed those cases in which the meningitis is but feebly indicated — e. g. when it is but a small factor in the condition of acute general tuberculosis. {h) Malignant or Rapid Form. — This type is comparatively rare, oc- curring most frequently in adult life, while the lesions have their seat almost exclusively upon the convexity. The onset is marked by the most frightful tetanic convulsions, which precipitate a fatal termination in a couple of days. (e) Chronic Type. — Cases pursuing a chronic course are rarely en- countered, and the symptoms usually point to localized cerebral lesions (Jacksonian epilepsy, etc.). Prognosis. — The disease lasts from two to four or five weeks, though chronic cases may continue for several months. When the con- vexity is implicated, however, the duration is only one or two weeks. It should be emphasized that frequently in the course of well-marked cases a decided remission in the leading symptoms occurs, so that con- valescence is suggested ; but this is deceptive, and is almost invariably followed by a renewal of the unfavorable features of the aifection. A few cases only are recorded in medical literature as ending in recovery. Freyhan has reported a case with recovery in which the diagnosis was proved by puncture of the spinal canal and the withdrawal of fluid, in the sediments of which tubercle bacilli were found. A. Jacobi has met with 2 cases that terminated favorably, and Leube has also reported a case in which the symptoms were characteristic, and at the autopsy, some years later, old tuberculous lesions were found in the meninges. It is to be recollected, however, that the course of tuberculous menin- gitis is probably uninfluenced by human agency. 254 INFECTIOUS DISEASES. Acute Pneumonic Phthisis. {Acute Phthisis ; Florid Phthisis : Galloping Consumption.) This may be primary or secondary, the latter form being consequent either upon a localized tuberculous area in the lung, tuberculous pleurisy (acute or chronic), tuberculous peritonitis, or tuberculous disease of some other organ. Acute phthisis may occur at any age. though it is rela- tively more frequent in childhood and early adult life, but whether primary or secondary, the infection of the lungs is rapid. Pathology. — Two forms may be recognized : (1) This reveals the appearances of an acute lobar 'pneumonia, one lobe only being impli- cated, as a rule, though sometimes the whole lung is involved. The process leads to a destruction of lung-tissue, so that a section may show the existence of cavities. The latter are usually small, while surround- ing them may be seen tubercles in hepatized tissue, and here and there caseous masses of a yellowish-white color may be visible. These often indicate old or pre-existing foci. It is sometimes exceedingly difficult to distinguish a tuberculous croupous pneumonia from the ordinary form, and the most careful inspection may fail to reveal the presence of ele- mentary tubercles in the acutely consolidated tissue. In cases in which this disease is suspected, however, the opposite lung, the bronchial glands, the peritoneum, and other organs should be carefully examined. The lesions presented by cases that have run a long course are somewhat characteristic, though not always the same. If the case has had a duration of two or more weeks, apical softening with more or less extensive cavity formation often occurs. Less frecjuently, a lobe or an entire lung is found to be consolidnted throughout, "and converted into a dry, yellowish-white, cheesy substance, in which condition it may remain till the end." (2) Presenting the Appearances of Broncho-pneumonia. — This vari- ety is more common than the previous, especially in children. The evidences of bronchitis aifecting the finer tubes, together with con- solidation of the lobules to which the tubes lead, are striking. As in ordinary broncho-pneumonia, so here, the solidified areas appear as grayish-red masses in the early stage, while later they are of an opaque- white. The products that fill the air-cells may caseate and break down, with the formation of irregular cavities that vary in size. When large areas are involved they are the result of the fusion of contiguous smaller areas of hepatized tissue. The trouble often begins in the upper lobes and spreads downward, though not infrequently the lower lobes are most extensively involved. In not a few cases the masses are small, multiple, and widely dissem- inated throughout the lungs, and miliary tubercles in the lungs or pleurge are associated with the broncho-pneumonic lesions before de- scribed. In nearly all cases signs of pleurisy may be noted, as is shown by pleural adhesions or by deposits of lymph on the pleura. The bronchial glands are also usually infected, and, particularly in chil- dren, are the seat of tuberculous processes. Baumler has called attention to a type of tuberculous inhalation pneumonia consequent upon hemoptysis, the blood and contents of the ACUTE PNEUMONIC PHTJJISLS. 255 cavities being drawn into tlie finer tubes in respirntion. This form of broncho-pneumonic phthisis sometimes follows pulmonary tuberculosis in the early, though more often in its late, stage. On microscopic ex- amination tubercle bacilli are found, though rarely in abundance, in the infiltrated masses and in the walls of the cavities. Clinical History. — (1) Acute Cases. — Preceding the attack, the patient may have " taken cold " or have been in a run-down state ; more often, however, he has been apparently healthy. The onset is sudden, marked by a rig or ^ pain in tlie side ^ fever ^ couyk, aiid systemic prostra- tion, and there may be bronchial hemorrhage which may last one or more days. The total amount of blood expectorated may be consider- able. In the majority of cases the expectoration is mucoid at first, and then becomes rusty-colored, often containing tubercle bacilli, though at first they may be absent and, indeed, not appear until late in the disease. Dyspnea appears early, and may soon become extreme, and the fever quickly rises to 104° F. (40° C.) or over. It may be of the continued type, or it may early assume the remittent or hectic type, and with the latter forms of fever, which usually begin about the end of the first week, are associated night-sweats and rapid emaciation. The prostration of the vital powers is now extreme. The expectoration is more abundant, muco-purulent, and often greenish-yellow in color. In the course of one or two days after the onset we obtain physical signs. Usually, as before stated, there are present the anatomic appear- ances of acute lobar pneumonia — viz., the complete consolidation of one or more lobes, which is usually followed by signs of softening, provided the patient survives the first week or ten days. The physical signs during the stage of consolidation are precisely the same as in lobar pneu- monia. The signs of softening and of cavity will be given in detail below {vide Chronic Phthisis). The course is usually rapid, occupying from two to six weeks on the average, though rarely cases that reach the stage of cavity-formation are protracted to three or even four months. Considering the brevity of the attacks, the extreme degree of emaciation (shown especially by the hollow cheeks and temples, pinched nose, and thin hands) is truly remarkable. The patient usually maintains a hopeful state of mind, notwithstanding the rapid downward course of the affection, and it may be admitted that recovery is possible. The parts involved are in such cases destroyed and replaced by fibrous tissue, and it should be remem- bered that the apex is oftenest involved. It may happen that consolida- tion only is present in the second lobe affected, while in the upper lobe one or more cavities have already been developed. The pleural crepi- tating friction is often audible before consolidation is complete. Diagnosis. — The onset, symptoms, and course during the first week may be those of ordinary lobar pneumonia, but in some cases certain symptoms may arise which will excite suspicion of their tuberculous character in the early stage. Thus, hemoptysis rarely occurs in a pneumococcus infection, and the appearance of the patient, as well as his previous and family history, may also be of a confirmatory character. The points of discrimination have been fully set forth in the section on Lobar Pneumonia (pp. 123, 124). (2) Subacute Cases (rarely acute). — The onset is less sudden than in 256 INFECTIOUS DISEASES. the former type, while the patient's antecedent condition may either be good or below the standard. At the beginning he has repeated chills, though hemoptysis may be the first symptom which indicates a pre-ex- isting tuberculous focus. The fever rises high, and is apt to be irregu- lar from the start ; the pulse and respirations are rapid, and there is a muco-purulent expectoration which may either be profuse or scanty. Occasionally it is fetid, and the sputa may early contain elastic fibers and tubercle bacilli, though more often these are noted after the affec- tion has become fully established. During the progress of the case, also, hemoptysis may arise. Later, drenching yright- sweats increase the exhaustion and emaciation, which speedily reach an extreme degree, and soon or late a typhoid condition of the system is developed. The physical signs are, at first, those of general bronchitis, with or without indications of pleurisy. Later, small areas of consolidation, which often increase in size, are indicated by impaired percussion reso- nance or dulness and by broncho-vesicular (rarely tubular) breathing, with subcrepitant rales. These signs may be unilateral, though more often they occur bilaterally. In many cases softening with cavity-for- mation ensues, with the usual physical signs of this condition. Course and Duration. — For some time the patient may remain out of bed, although in most instances the disease constantly progresses. Less frequently there are exacerbating periods and remissions. Rarely these cases recover Avith a loss of more or less lung-tissue. Again, the condition may pass into chronic phthisis. It is important to recollect that the local lesions may become extensive, as the result of fusion of small consolidated masses, until an entire lobe is involved, and when this occurs the symptoms and course simulate those of the acute type. The duration ranges from two to eight weeks or more. Diagnosis. — This variety is frequently confounded with non-tubercu- lous broncho-pneumonia, and the chief distinctions will be mentioned in connection with the latter disease. Bronchiectasis may be accom- panied by emaciation, fetid expectoration, night-sweats, and the signs of cavity, and this disease has been mistaken for acute phthisis. Im- portant in the recognition of the latter, however, are marked fever and emaciation. MToreover, the physical signs are more frequently referable to the apices, and the disease is more steadily progressive, running a shorter course than bronchiectasis. The sputum contains tubercle l)acilli. Acute Broncho-pneuinonic Phthisis in Children. — The belief that the form of broncho-pneumonia that so frequently follows certain infec- tious diseases (measles, whooping-cough, etc.) is in the majority of instances tuberculous has been steadily gaining. Osier recognizes three groups of cases: (a) Those in which the child suddenly becomes ill while teething or during convalescence from fever, Avith high tempera- ture, severe cough, and the signs of consolidation of one or both apices. Death may occur within a few days. To the naked eye the lesions do not appear to be tuberculous, {b) In this group the children show the ordinary symptoms of broncho-pneumonia, and the cases are more pro- tracted, death occurring about the sixth week, (c) The child feels ill during convalescence from an infectious disease, fever, cough, and dys- pnea being present. The intensity of the symptoms abates within a fort- night, and the physical examination shpws the presence of diffuse bron- CHRONIC TUBERCULOSIS. 251 chitis with scattered minute areas of consolidation. Many of these cases develop into chronic phthisis. Chronic Tuberculosis. {Chronic Pulmonary Tuberculosis; Chronic Ulcerative Phthisis) This form is much more common than the acute, the term embracing sub-varieties to -which attention will be incidentally directed. Its most typical clinical form follows a mixed infection as a result of a septic ele- ment superadded at some time to the primary tuberculous infection. The Causal Factors have been detailed under General Etiology. Pathology. — The pathologic characters of tuberculosis in general have been already presented, but it will be necessary to describe briefly the special anatomic conditions met with in chronic ulcerative phthisis. The post-mortem appearances of the lungs in chronic pulmonary tuberculosis are remarkable for their great diversity, not only in the extent of tissue involved, but also as to the character of the morbid processes. Often the associnted lesions form no unimportant part of the picture. In nearly all fatal cases the most advanced and extensive lesions are found near the apex, and, as a rule, the entire upper lobe of one of the lungs is implicated. In addition, it is observed that the destructive process has extended to the lower lobe of the same side, and later to the apex of the opposite lung. Though both lungs are affected in fatal cases, they represent different stages of the disease. The case is very different in an old and cured tuberculosis of the lungs, such as is frequently met with in persons who have died of some other affection. Here the lesions may occupy but a small part of one lung, and usually near the summit. Kingston Fowler has investigated the question of the points of elec- tion and paths of distribution of the lesions in chronic phthisis, and has found that the primary lesion is not, as a rule, at the summit of the upper lobe, but that it occurs from 1 to 1| inches (3.79 cm.) below this point and near the postero-external borders. Favored by normal respiration, the lesions advance downward, so that on physical examina- tion the first evidences of disease are to be found posteriorly over the lower part of the supraspinous fossa, while anteriorly the early signs are met with immediately below the middle of the clavicle, extending along a line running about 1-|- inches (3.79 cm.) from the inner end of the second and third interspaces. The starting-point, though less fre- quently, may also be indicated by physical signs in the first and second interspaces below the outer third of the clavicle, with subsequent down- ward extension. From personal observation of the post-mortem lesions of this disease, and from my studies at the bedside, I feel convinced that the initial lesion is frequently located anteriorly and near the apex, corresponding on the chest-walls to the clavicle and the supraclavicular spaces. This site has seemed to me to obtain more often on the right side than on the left. Kingsley has shown that when the lower lobe becomes involved the consolidation begins about 1-^ inches (3.79 cm.) below its apex pos- teriorly, and corresponding externally to a spot opposite the fifth dorsal spine. From this point it spreads downward and laterally in a line fol- 17- 258 INFECTIOUS DISEASES. lowing the border of the scapula " when the hand is placed on the oppO' site scapula and the elbow rests above the level of the shoulder," The middle lobe on the right side is usually invaded by direct extension froju the upper. The seat of primary infiltration may even be the lower lobe, but this is rare. Cole ' has found lesions at the root to precede paren- chymal changes. The relative frequency of involvement of the two sides varies accord- ing to different authorities. A careful analysis of my records and those of other observers show that out of a total of 1286 cases 726 occurred on the left side and 510 on the right. In all cases the primary lesions are due to tuberculous infiltration, which at first is confined to certain lobules, though it may later involve extensive areas of lung-tissue {tuberculous broncho-pneumonia.) In most instances the starting-point of the morbid changes is in the smaller bronchi and also, according to Payne, the inside of the alveoli. Soon the bronchioles and the corresponding air-cells become blocked with in- flammatory products. These areas then undergo caseation and present the usual opaque, grayish-yellow appearance, a cross-section of these yellow nodules showing the central bronchus usually plugged Avith exu- date and surrounded by caseous matter. Softening and sometimes complete liquefaction, with expectoration or absorption of the altered morbid products, may take place, and this disintegration is associated with ulceration in the wall of the bronchus, consequent upon secondary pyogenic infection, and a resulting formation of small cavities. Ulcers may form in the bronchioles before necrotic processes supervene, and they are generally shallow, with sharply-defined edges. Recovery may ensue as the result of calcification with encapsulation of the cheesy masses, or the affected area may undergo fibroid transformation — a con- servative process and one that may lead to actual cure. It often happens, however, that old and apparently healed tuberculous lesions undergo ulceration, when the calcareous masses (pulmonary calculi) may be dis- lodged and expectorated, and the more rapidly the caseous masses are formed the more liable are they to softening. Surrounding the healed areas the tissue may be the seat of atelectasis, though more often of emphysema. Destruction of lung-tissue also results from interstitial inflammation with the formation of new connective tissue, the latter in turn compressing and finally obliterating the alveoli. Cavities ( Vomicce). — These result chiefly from progressive necrosis and ulceration. They are formed mostly by dilatation of the bronchi, whose walls are tuberculous and suppurating. But they may also arise independently of the bronchi. Cavities vary largely in number, size, and form. They are often multiple, though usually not far removed from one another, and unite as they increase in size. In this way large cavities, with irregular walls, involving the whole of one lobe and even an entire lung (except the extreme anterior margin), may be formed, and small pockets connecting with the bronchus may thus originate. Vomicse may be classified as (1) progressive and (2) non-progressive. (1) The progressive are divisible into (a) New cavities and {b) Old cavities. (a) New cavities have soft, necrotic, friable Avails so long as the de- ^ Amer. Jour. Med. Sciences, July, 1910. CHRONIC TUBERCULOSIS. 251i structive processes are rapidly progressing, and the same state of things prevails in the cavities of acute phthisis. Thoy may develop near a healed focus or near old cavities with limiting walls, and when situated near the periphery of the lung they may rupture into the pleura, caus- ing pneumothorax. (6) Old cavities, as a rule, have sharply-defined walls that vary considerably in thickness. At first they consist of a fibro-vascular zone, which has an inner suppurating surface ; subsequently the lining of this zone is converted into an exfoliating membrane. The contents of vomicae are muco-purulent or purulent, and often consist of a shreddy and sometimes a bloody fluid. Rarely they are gangrenous. Cavities also contain tubercle bacilli and other micro-organisms. Percy Kidd has studied the question of the relation of tubercle bacilli to tuberculous pulmonary lesions, and states that they are invariably present in newly- developed tubercles and fresh cavities, but frequently absent in old nodules. Trabeculae composed of blood-vessels and remnants of pul- monary tissue often traverse the cavities. In old cavities excavation may be complete, not a vestige of normal or diseased tissue remaining in them, though the blood-vessels, many of which are beaded by small aneurysmal dilatations along their course, are the last to disappear. Their removal is eifected by an obliterating inflammation. Rupture of these miliary aneurysms or the erosion of a large vessel gives rise to copious hemoptysis. Cavities having dense walls may also increase in size by encroaching upon the surrounding tissue, huge cavities often having thin, tense Avails. But, wherever situated, they usually begin toward the summit of the upper lobe. Another common seat is the mid- dorsal region. (2) Non-progressive Cavities. — Quiescent cavities are usually small, though variable in size, according to the stage at which the process of contraction is arrested. Medium-sized and large vomicae do not be- come totally occluded. They may be multiple, though more often per- haps single, and associated with them may be observed dense, fibrous nodules representing healed foci. Their interior may be lined with a smooth, cuticular structure resembling mucous membrane. Interstitial Pneumonia. — In the course of chronic phthisis interstitial inflammation of two sorts will most probably arise : (a) A consolidation excited by the tubercle bacilli themselves, and hence manifesting a de- structive tendency; (h) A slowly-developed interstitial pneumonia which aims at arresting the progress of the afi'ection. It develops in close proximity to caseous masses and around cavities. The new connective tissue thus formed in obedience to the well-known pathologic iaw^ tends to contract secondarily, and thus vomicae are often partly, though sel- dom entirely, obliterated. The shrinking of the connective tissue may also result in compression, and finally in the destruction of pulmonary tissue, just as in a tuberculous inflammation. The process in this in- stance, however, is on the whole conservative and reparative. Disseminated Tuberculosis. — Miliary Tubercles. — This form has for its chief characteristic miliary tubercles, which are scattered not only about the tuberculous area, but also throughout the rest of the lung, and usually in the lower lobe. Most of the tubercles undergo fibroid or fibro-caseous change. These minute, hard gray or grayish-yellow 260 INFECTIOUS DISEASES. nodules vary in size from a niustard-seod to that of a pea, and hing- tissue that is more or less studded with chronic miliary tubercles is apt to look pale, while the surrounding air-cells are emphysematous. The condition may lead to pneumonia, and the whole aspect then becomes altered. Here, as before described, fusion of miliary tubercles results in larger masses which become caseous, and hence the method of cavity- formation is identical with that observed in tuberculous broncho-pneu- monia. In the disseminated form tubercles may also be found in many other organs than those indicated (pleura, trachea, larynx, bronchial and other lymphatic glands, peritoneum, spleen, kidneys, liver, brain, mu- cosa, testes, etc.). Lesions of the Pleura. — This membrane is hyperemic and coated with fibrinous exudation coextensively with the affection of the parts in chronic ulcerative phthisis. The pleural membranes are only more or less thickened by organized adhesions, but in the latter and also in the pleura tubercles or cheesy masses may be found. Simple and other forms of pleurisy are met — sero-fibrinous, purulent, and hemorrhagic. Lesions of the Bronchial Glands, — At first these are enlarged and edematous, containing tubercles, and later they present foci which often undergo purulent disintegration and sometimes calcification. Other lymphatic glands than these may be aft'ected (mesenteric, etc.). Lesions of the Larynx. — The larynx is frequently the seat of tuber- culous infiltration and ulceration, particularly in certain parts, such as the vocal cords, posterior wall, and ary-epiglottidean folds. Lesions of the Heart. — Tuberculous endocarditis is present in about 5 per cent, of the cases, and congenital stenosis of the pulmonary ori- fice is noted in not a few instances (Chevers). The right heart is often hypertrophied or dilated. Other organs may present lesions in chronic phthisis, and these will be spoken of in connection with the clinical history. Tuberculosis of the intestinal canal is a common though late lesion. Amyloid degeneration of certain organs is a not unusual secondary event, especially of the kidneys, liver, spleen, and intestinal mucosa. Enlargement of the liver due to fatty infiltration is sometimes noted. Clinical History. — The modes of invasion are quite diverse, but with few exceptions the onset is either (1) gradual or (2) abru])t, and, as a rule, the health has been previously undermined for a longer or shorter period. (1) Gradual Onset. — (a) The disease often originates in a manner similar to ordinary bronchitis, and the symptoms of pleurisy are some- times associated. Tuberculous bronchial affections often follow certain acute infectious diseases — influenza, typhoid, measles, wliooping-cough — and in this form are rarely curable. The physical signs may be nega- tive for some time, and then appear in the apex region, and the nif)st characteristic grouping of physical signs during the incipient stage may be thus summarized: "Lagging" or defective expansion, as noted on inspection and palpation, a localized increase in the tactile fremitus, slightly impaired percussion-resonance, enfeeblement of the normal vesicular murmur, with (at a later period) prolongation and sharpen- ing of the expiration. The fact tiiat the lesions are commonly detect- able in the suprascapular fossa must be remembered. At this period obvious constitutional disturbances are jjresent (debility, fever). GHRONKJ TUBI'JRCULOSIS. 201 (b) Onset with Pleuriay. — Tliis may be sudden, as in an Mcute pleu- risy with effusion, but often the latter condition develops insidiously. Of 90 cases of pleurisy with effusion, one-third terniinated in chronic phthisis (Bowditch). It nuiy begin as a dry j)lenrisy at tlie apex, either antei-iorly or posteriorly, or the evidence of pleurisy may be associated with the more common bronchitic onset. (c) With G astro -intestinal Symptoms. — There is impaired digestion, and soon the patient becomes anemic, loses flesh, and is debilitated. Later, the first indications of pulmonary tuberculosis develop in the lungs. Close scrutiny of the data entering into the early history of cases of pulmonary tuberculosis usually reveals some perversion of the general health before distinctive pulmonary phenomena arise. {d) With indefinite peritoneal symptoms, lasting for months or years. (e) With Laryngeal Symptoms. — This is a rare form. It begins with hoarseness, more or less aphonia, and considerable cough ; there is also a slight mucopurulent expectoration. Laryngoscopic examinations m_ay detect tuberculosis of the organ, and tubercle bacilli may be found in the sputum before involvement of the lungs is discoverable. (2) Cases with Abrupt Onset. — («) The most important group under this category is heralded by the symptoms and signs of pneumonia, more commonly of the lobular variety. As compared with lobar pneumonias, these present peculiar features : the fever is irregular, the expectoration is more abundant, is blood-stained, and contains bacilli. The signs are usually located in the apical region. Resolution may occur, but recovery is not complete, and the condition may pass into chronic phthisis. (6) Onset ivitli Fever. — Chills and fever generally arise in the ad- vanced stage of pulmonary tuberculosis, but these symptoms may also initiate the attack. There is no mistake in diagnosis more commonly made in malarial regions than to ascribe such cases to paludism. {c) With Hemoptysis. — This symptom may invite attention to lung trouble. Miiller states that hemoptysis was an early symptom in 170 of the 875 patients at the Davos German Sanatorium, and was twice as frequent in the male as in the female. The amount of blood lost is either considerable or repeated slight hemorrhages occur. In a great proportion of cases the clinical picture of incipient pulmonary tuberculosis is revealed, pursuing its accustomed course immediately after the occurrence of the hemorrhage. The physical signs may be latent for a time, and. while they are usually located in the subapical area, they may assume the guise of a pleurisy in the infrascapular region. A slight tuber- culous lesion is present in these cases preceding the occurrence of the hemorrhage. The symptoms are (1) local and (2) general (1) Local. — (a) Pain. — This is absent in many cases of chronic phthisis and in others it may be moderately severe. It is seated usually at the base, laterally or anteriorly, and not rarely there is pain of a lancinating character in the interscapular region in the early stages of the affection. This symptom is of diagnostic worth only after other forms of pain (rheumatic, neuralgic) have been excluded. The most common cause of pain is pleuritis, with or without pleuritic adhesions : it is increased on deep breathing and coughing. Intercostal neuralgia and pleurodynic stitches may also develop soon or late. Tenderness on 262 INFECTIOUS DISEASES. pressure "with the right forefinger (algeoscopy), which causes the patient to exchiim or make a grimace, or merely a contraction in adjoining muscles, was present in 77.0 per cent, of 200 cases studied by Francke, while only one-third of these patients complained of spontaneous pain. {h) The Cough. — This may be looked upon as an essential feature, though in a few instances it may be slight or even wanting throughout. Its severity bears no constant relation to the extent of the pulmonary lesions, but rather to the degree of sensitiveness of the patient. It is dry and hacking at the beginning, and, if the larynx be involved, the cough is marked and of a hoarse quality. It is most pro- . nounced at certain periods of the day — viz., on lying down at night and on awakening from sleep. Paroxysms may occur after meals and induce vomiting. The cough is at times distressing and debilitating in its effects. (c) Expectoration. — At the beginning the sputum is scanty and mu- coid, rarely hemorrhagic, or it may be merely streaked with blood ; later it may become muco-purulent, and the appearance of small gray or grayish-yellow flocculi first suggests the nature of the affection. With the onset of the stage of cavity -formation the sputum becomes more abun- dant and more distinctly purulent, and, after the formation of cavities of any size, airless, opaque, and nummular (coin-shaped) masses are expec- torated. The latter are greenish-gray or greenish-yellow in color, and sink rapidly when discharged into water. They are often mingled with more or less bronchial secretion, and are sometimes observed in pure bronchitis. They may even be absent, and the expectoration be merely purulent. The opening of a fresh cavity may be followed by very free expectoration. The sputum is sometimes fetid, and exceptionally it is horribly offensive, varying greatly in amount in different cases and at different stages of the disease. In certain cases it is absent throughout the greater portion of their course, and is especially apt to be slight in children and old people. In such instances it may be impossible to collect sufficient sputum to examine for bacilli. Microscopic examination discovers alveolar epithelium (particularly in the earlier stages), pus-cells, blood, fat-globules, elastic fibers, and tuhercle bacilli., the detection of the latter being the most important factor in the diagnosis. It may be safely stated that the finding of bacilli in the sputum is prima facie evidence of chronic phthisis ; on the other hand, however, their absence in the early stage does not exclude the disease. It is often needful to make repeated and delicate examina- tions of the sputa. It is also of the utmost importance to select for ex- amination the small grayish masses that are usually to be found, since they early contain the bacilli. In tuberculosis in the aged tubercle bacilli are not always detectable in the sputum. Method of Examining the Sputum. — " A small amount of the purulent portion of the sputum is spread in a thin and uniform layer on a per- fectly clear cover-glass by means of forceps, needles, or the Ohse, which must previously be held a moment in the flame of a Bunsen burner or a spirit lamp, or by pressing a small amount of sputum between two cover- glasses, then sliding them apart. It is then dried in the air, or more quickly by holding the cover-glass with forceps some distance above the CHRONIC TUBERCULOSIS. 263 flame of a burner or lamp. Finally, it is to be passed three or four times through the flame, and so 'fixed'" (Musser). Brown and Smith' rec- ommend antiformin for the cultivation of tubercle bacilli directly from, and also to digest, the sputum. The preparation may be stained with carbol fuchsin (basic fuchsin 1, alcohol 10, 5 per cent, solution of carbolic acid 90), either by dropping a few drops of the stain on the smeared side of the cover-glass and holding it above the flame until it steams, or by floating its face down- ward upon a watch-crystal containing the solution. It must then be decolorized either with a 30 per cent, solution of nitric acid, allowing it to remain until the red color has entirely disappeared (about fifteen seconds), and then washing and counter-staining with methylene-blue, or with Gabbett's solution (methylene-blue 2 gm., sulphuric acid 25 c.cm., water 75 c.cm.), in which it must remain until the red color has been replaced by a faint blue (thirty seconds or more). Instead of car- bol-fuchsin, anilin gentian violet may be employed (add a saturated alcoholic solution of gentian violet to a filtered saturated solution of anilin until a metallic luster appears on the surface). The specimen may lie either several hours in a cold solution or a few minutes in one that is steaming. Decolorize with the nitric-acid solution {^ per cent.), and counterstain with rubin or a saturated aqueous solution of Bismarck brown. It is often much simpler to smear the sputum directly upon the slide, and then examine, when stained, without the intervention of a cover-glass. A much larger amount of sputum can thus be prepared. Fig. 21.— Elastic fibers (after Strumpell). In the microscopic examination use a -j^j-inch (2.11 mm.) oil-immersion lens and Abb^ condenser. If carbol-fuchsin has been used in staining for the bacilli, and methylene-blue as a contrast, the former will be found as red rods in a blue field (background), while if gentian-violet has been used, the tubercle bacilli appear as dark violet rods, with all other bodies brown, if Bismarck brown is used for the contrast stain. There may be visible in the field a few bacilli only, particularly during the early part of the case. In the stage of cavity their number is usually in- creased, and sometimes they are quite numerous. The demonstration of elastic fibers is also an important aid to diag- nosis. Fenwick's method is the following : Boil the sputum with an equal quantity of a solution of caustic soda (gr. xv— 5j — 0.972—32.0) : pour the product into a conical glass and fill with cold Avater. The sedi- ment is subsequently examined with care for elastic fibers. The form and appearance of the elastic threads diff'er according to * Jour, Med. Research, Boston, 1910, xxii., 517. 264 INFECTIOUS DISEASES. their special source. If they come from the alveoli, there is an inter- lacing of tlie fibers ^Yhich may preserve the globular contour of the air- cells. If they come from the blood-vessels, they are single and elon- gated, or two or three of the fibers may be arranged side by side. Elastic tissue derived from the bronchi has a similar appearance. The presence of elastic fibers furnishes incontestible proof that destruc- tion of lung-tissue lias taken place. To show that this loss of structure, however, is due to tuberculosis, we must exclude abscess (rare) and gan- grene of the lungs — diseases in which it also occurs. id) Hemoptysis. — This symptom of phthisis will be spoken of under Diseases of the Lungs, but its importance as a diagnostic feature of this disease makes special reference to it here absolutely necessary. It is present in the majority of cases. Gabrilowisch ^ found tiiat of 380 patients 213, or 5t! per cent , had hemoptysis. The sputum may be merely blood-stained, or the hemorrhage may be excessive and j)rove rapily fatal, though hemoptysis is rarely the direct cause of death in tuberculosis. Slight hemorrhages are usually produced by mere hyper- emia, and are most apt to occur during the early stages ; while severe bleedings are produced by the erosion of a blood-vessel or rupture of a small aneurysm, and are most prone to occur during the stage of cavity. In certain cases hemoptysis is frequent. A third or capillary form of hemorrhage may occur in phthisis with cavity-formation, and in this variety, which is of a rather frequent occurrence, the purulent sputum is uniformly stained with blood. It may also be nummular, but presents a reddish-brown or chocolate color. The exciting cause is seldom obvious, though in not a few instances ag- gravation of the cough, and in others great mental excitement, would appear to excite bleedings. Slight hemorrhages often, and severe ones rarely, afford more or less relief to the pulmonary condition. On the other hand, severe bleedings usually exert an unfavorable influence, being followed by debility and anemia. Moreover, in numerous cases hemoptysis is followed by a more rapid extension of the local lesions, with corresponding aggravation of the local and general manifestations. The fact remains, however, that the effect of severe hemoptysis upon the progress of chronic phthisis is by no means always untoward. In a case of my own there occurred periodically copious spontaneous bleed- ings (in spring and fall) for three years, which were as regularly fol- lowed by marked improvement for a period of three or four months. The physical signs of phthisis then developed. In a large number of cases of pulmonary tubei'culosis the transition from warm to cold or cold to warm seasons corresponds with increased cough, hence with in- creased pressure in the pulmonary circulation ; and so bleeding is also favored, particularly in those having a hemorrhagic tendency. {e) Dysijnea is present, but is not a marked feature, as a rule, despite advanced pulmonary lesions. Perhaps the chief reasons for a lessened demand for oxygen on the part of the system are — first, the slow and gradual manner in wliich the lesions develop ; and second, the pro- nounced bodily wasting. The respirations, however, are moderately increased in rate, averaging from 20 to 30 per minute, and this compen- sates admirably for the diminished breathing-space. The dyspnea may ' Berliner kllnische Woehenschrift, Jan. 2, 1899. CIIJiONIC TUBEUCULOSIS. 265 be greatly intensified, however, as the result of intercurrent pneumonia, pleurisy, active exertion, or great mental excitement, and toward the close of fatal cases the most intense dyspnea mny be manif(;sted. Physical Signs in the Stage of Consolidation. — InHpection gives most important results. The paralytic or phthisical thorax is generally pre- sented to view. It is flat, particularly the upper half; the intercostal spaces are wide; the ribs slope at a sharp angle from the sternum, mak- ing the epigastric angle acute and producing elongation of the chest. The same sharp inclination downward from the vertebral column is observed laterally and posteriorly. The angle of Louis is prominent, and the depressions (supra- and infraclavicular, intercostal) are deep- ened, the costal cartilages being often prominent and the sternum, par- ticularly in the lower part, sometimes much depressed or even concave (funnel-breast). The scapulae stand out prominently and may be dis- tinctly winged. A second type of paralytic thorax is narrow and long. Pulmonary tuberculosis may, however, arise in chests of apparently normal build. The paralytic thorax is often a resultant of developed phthisis. In subjects of obesity the phthisical thorax may be concealed. The deformity due to occupation, as leaning over a desk, may ape the paralytic chest, and, finally, it may be the result of extreme emaciation. With the development of phthisis the depressions of the side affected are relatively deeper, while the clavicle often stands out prominently. Defective expansion is ohserved early, and usually at the apex of the side first affected ; subsequently this may be more general, and finally bilateral. To note the motions of respiration with precision the exam- iner should occupy a position exactly in front of the median line of the patient's body. The difference in the movement of the two sides often becomes more apparent on deep respiration than on quiet breathing, and while at rest the respirations are almost normal, but exertion decidedly increases their frequency. Palpation. — Testing the expansion by palpation gives better relative results than does inspection. To determine the comparative movements of the apices the extended hands should be so placed (by allowing them to diverge below) that the tips of the fingers touch the lower border of the clavicle, and then the patient should be asked to breathe deeply, though slowdy. The expansion in the supraclavicular spaces is tested by standing behind the patient and using the tips of the fingers, or by allowing the two first fingers of each hand to pass parallel with the clavicles. In this way " lagging " over the apex will be the first symp- tom recognized, and may for some time be the onh^ one. Palpation of the vagus nerve on the affected side elicits pain (Mays). Ta.ctile fremitus is early increased with oncoming consolidation, though it is normally more marked at the right than at the left apex. If there be thickening of the pleura, however, it is diminished, and if there be pleural effusion it may be absent. Mensuration. — The difference between the measurement of the chest in inspiration and expiration in any person of average health should be not less than three inches, and a difference below two and a half inches points strongly to tuberculosis. The data thus gained are more impor- tant than the shape of the thorax. Percussion. — Resonance is deadened more and more as consoli- 266 ISFECTIOUS DISEASES. dation progresses. If the consolidated areas are minute, however, the percussion-note may be unchanged, and as the air-cells surrounding the latter are often emphysematous and relaxed, it may be somewhat tym- panitic. The tympanitic sound and deadness may be intermingled, giving rise to the so-called tympanitic deadened sound. Slight dulness is, as a rule, noted hrst below the clavicle, though in not a few cases it is first detected above the clavicle. Impaired resonance, however, may be detected, first, in the su]iraspinous fossa, and less frequently in the inter- scapular space if the subject is not too stout, though slight dulness in the absence of other signs has little diagnostic value. The corresponding regions of the two sides must be compared during a held inspiration and also dur- ing a held expiration. The degree of dulness can sometimes be better esti- mated by comparing the apical note with that obtained lower down on the same side, allowing for the normal topographic differences of intensity. The latter method is especially applicable to cases in which both apices are involved. Light and single percussion blows must be used. As the lung-tissue becomes airless throughout an area of considerable size the note is deadened, until dulness is heard ; finally, with extensive consoli- dation, the note may be wooden and the feeling of resistance increased. Auscultation. — The vesicular breathing may be sharpened, owing to narrowing of the smaller bronchi, but more often perhaps it is dimin- ished by the swelling and secretion. The corresponding regions on the two sides must be compared — first during quiet, and then deep breath- ing — and it should be remembered that prolonged expiration is an early and important diagnostic sign, at first being somewhat sharpened, and later distinctly bronchial. Tuberculous bronchitis may cause interrupted or jerking inspiration at the apex w^ith or without crepitant rales. If heard elsewhere, it has small value. With lobular consolidation at dif- ferent points in the region aff'ected, the conditions favor the transmission of the bronchial sounds, but these are toned down by the remaining intact air-cells; hence there is " transition " or bronchovesicular breath- ing. With complete consolidation pure bronchial breathing is audible, and with the latter two forms of breathing crepitant or subcrepitant rt,les are heard. A clicking rale, although not common, is an almost conclu- sive indication when observed. Sometimes the first rales which accom- pany expiration have a low whistling sound ; with liquefaction they become more moist, are louder (somewhat ringing), and often bubbling, and may be heard on inspiration and expiration. If scanty, they may be audible on inspiration only ; they are increased by coughing. If the moist crepitant and subcrepitant r^les, often due to concurrent bronchitis, be very numerous, the breath-sounds will be obscured, but after free expectoration their quality becomes appreciable. Pleuritic friction-sounds maybe heard, due to accompanying pleuritis sicca, and these may be audible before the bronchial rales reveal the disease. Friction-sounds and rales often occur together. Pleuroperi- cardial friction is present when the "lappet" of lung over the heart is aff'ected, while clicking rSles, occasioned by the heart's systole, are audible when the same area is pneumonic. The vocal resonance increases with the progress of the consolidation, and when the latter is complete, h'oncho- phony (rarely pectoriloquy) is present. In the subclavian arteries a systolic murmur is not uncommonly heard, the latter being supposed to be due to pressure exerted by the thickened pleura upon these vessels. CHRONIC TUBERCULOSIS. 267 Physical Signs of Cavity. — Inspection shows a more marked retraction and a more decided lack of local motion than duririf^ the previouH stage. The degree of shrinking is proportional with the extent of fibrous-tissue formation. Palpation corroborates inspection as to lack of motion, and gives increased tactile fremitus if the cavity connects with an open bronchus and if it contains but little secretion. Excessive secretion interferes with conduction of sound. Percussion. — Resonance is generally more or less impaired in con- sequence of the consolidation of the surrounding lung-tissue. The note may be somewhat tympanitic, but varies with the position of the cavities, the amount of fluid secretion contained by them, the condition of their walls, and the vibratory capacity both of the latter and of the individual thorax. Cavities of the size of a walnut situated in the apices usually give a distinctly tympanitic note, while cavities of the same dimensions, or even larger, in the lower portion of the lung do not. The metallic tone is especially noticeable over large cavities with smooth walls. The tympanitic sound may be deadened by closure of the connecting bronchus and by temporary filling of the cavities with secretion, and, again, if they are surrounded by thickened lung-tissue or by a large thickened pleura, there may be impaired resonance or absolute dulness even. Certain special conditio7is change the tympan- itic sound over a cavity. Thus the note will be louder and exalted in pitch when the mouth is opened wide, and lowered when the mouth is closed (Wintrich's sign), there being dulness when the mouth is closed and tympanitic resonance when the mouth is open. If the cavity com- municates freely with the bronchus, a tympanitic note may change in pitch with change in posture (Gerhardt's change of sound). If the patient changes from the dorsal to the upright position, resonance may give way to more or less flatness over the lower portion of the cavity, since the fluid contents of the latter are thus brought into contact with the chest-wall ; this, although an almost certain sign of a cavity when present, is exceedingly rare. The so-called cracked-pot sound is often elicited over large parietal cavities with thin walls ; but, since it also occurs in many other pathologic conditions, its diagnostic significance is subordinate. There may even be normal resonance if the cavity is covered by a layer of unaffected air-cells of considerable thickness. Auscultation over small vomicae with lax walls reveals cavernous (low-pitched) breathing, while over large cavities with tense walls (if parietal and communicating with a tracheo- bronchial column of air) it gives amphoric (higher-pitched) respiration. Moist rales (bubbling and gurgling, according to the consistency of the secretion) may be pres- ent, and these correspond in the main to the amphoric breathing, hence being heard most frequently over large, smooth-walled and periph- erally-located cavities. The gurgling and slushing sounds caused by the air bubbling through the secretion in a cavity are always intensified by coughing. The sounds of falling drops (metallic tinkling) may be heard over large vomicae with tense, smooth Avails containing thin secretion. Pec- toriloquy and amjyhoric ivhispers are the vocal sounds heard over huge cavities. Whispering pectoriloquy was present in 55 out of 58 cases at 268 INFECTIOUS DISEASES. the Pbipps Institute, but other p:ith()h>gic conditions may cause this sign, '^ notably consolidation about a bronchus'" (Landi^). Fig. 22.-1. bmaU cavity near periphery, with thick relaxed walls, containing secretion and communu-ating with a bronchus (vide subjoined table). 2. Large parietal cavity, with thin, tense, smooth walls, communicating with a bronchus (vide table). Physical Signs. {a) Percussion-deadness on a strong blow, mere impairment of resonance on a light blow -, Wintrich's inter- rupted change of sound, detectable only when patient is upright. (6) On auscultation low-pitched cavern- ous (hollow) breathing ; gurgling r§,le-. (c-) Pectoriloquy indistinct, owing to small size of cavity and the con- tained fluid. Physical Signs. (o) Amphoric percussion-resonance, cracked-pot sound, and Wintrich's change of sound. (6) On auscultation, high-pitched phoric (musical) respiration metallic rPiles. (c) Amphoric (musical) voice and phoric whisper. am- and General Symptoms. — (a) Fever. — Whilst the disease is progressing fever is a constant, significant, and, it may be, the earliest, symptom. If a two-hourly record be kept for a few days, from time to time an accurate conception of the course and type of the fever can be formed. In the first and middle stages the highest temperature occurs about 4 or 5 P. M., the lowest about 4 or 5 a.m. The fever may be continuous, remitting, or intermitting, and in a general way these types, in the order named, correspond to the stages of tuberculization, softening, and cavity -forma- tion. Modified types, due to the fact that the lesions may simulta- neously represent different stages, are also observed. Apyre.xial periods are met with in the early as well as the late stages of chronic phthisis, and indicate cessation of the processes of tuberculization and caseation. A continued fever is most apt to 1)0 met with during the initial period, the evening temperature sometimes registering but a degree higher than the morning. A similar curve may be presented at any later time if acute pneumonia supervene, though it is to be recollected that the remis- sions in such cases are usually greater than in primary lobar pneumonia. A remittent fever is more common than the preceding type. It may be present from the start, but is oftener seen in the middle and less fre- quently in the advanced stages. It points to softening (see Fig. 23). CHRONIC TUBERCULOSIS. 269 An intermittent fever is also frequent, and is invariably associated with cavity formation. The temperature may be intermittent from the 104° 103 102° 101 100° 99 98° 1 I A A A l\ /\ /\ 1 I /\ / \ / I A / \ / \ / \ A /\ / \ / \ / \ A A /\ /\ / 1 / ' / A /\ \ / ' / \ / ' /\ / \ / \ / / ' / \ / / / \ / , i / \ / \ / \ \ , \ / / ' \ 1 \ , \ \ / \ / / / \ \ / \ \ ; \ / \ / \ , / \ \ \ \ / \/ \/ \ / \ / \ \l V \ / \/ \/ \ / \ \/ V V \ / \ \/ \/ \ V V \ \ \ Fig. 23.— Temperature-chart of a case of phthisis. Quiescent cavity in right apex, and com- mencing excavation in left apex. Robert G , aged 21 years ; dyer. start, suggesting malaria to the unguarded ; but it is due to sepsis, the temperature rising during the day, beginning usually shortly before F 105° 1 O. '- — ?- . irt° CO 7\ T t ^ c a. nj _l I o : 1 7 I "" K I t ^ -Q° 109° B Q f o9 102 1 ^ ^^ ^ "^ t < -1 ^ t ^ I J U -4 X ^ 4 ° t V J ' ^ H inf -s t X t i\ J ;- H t-^ t t °- V- -. t t X '^- J ^ -J X -t \ A -v." -^ I t J X t ^ ^ im° ^ t X i ^ L L_ ^U ± 100 r tit t 3 v A 4 '" I- 4 J ^^ . ^ t j . '^ ^ t i -4 4 J \-= ^ qQ° 4 I U 4 4 t X< ^^t X t • -S tfe X -t = 2 r,-° __ A<_ _ ^5_ \M - t _ ^' ^3 < W — ^ M^ 4^ 98 * g it IT I Fio. 24. — Temperature-chart of a case of phthisis. Cavity in left apex, giving cracked-pot sound, Wintrich's sign, etc. George C , aged 22 years ; glass-worker. noon, and reaching; its maximum at from 5 to 8 P. M. It now falls slowly until about 4 or 5 a. m., and then rapidly reaches the minimum — a sub- 270 INFECTIOUS DISEASES. normal point — usually at from 6 to 10 A. M. For a considerable portion of every twenty-four hours the temperature may be below the normal (see Fig. 24), sometimes dropping as low as *d5° F. (35° C). (h) Night-sweats occur in a large majority of cases. They may appear during any part of the course of phthisis, though most apt to occur and be most marked during the process of cavity-formation ; they show themselves in the early morning hours simultaneously with the rapid decline in the temperature, and may appear during sleep at any period of the day. They may be light and limited to the neck and upper por- tion of the thorax ; on the other hand, they are often excessive, saturat- ing the bed-clothes and inducing great exhaustion. The drenching sweats are dependent partly upon the fever and partly upon the existing weak- ness, though slight exertion may also engender free perspiration. (e) Emaciation occupies a prominent place in the symptomatology, the muscular and fatty tissues being involved to an equal degree (Striimpell); the extremities and soft parts of the thorax are most affected. An ex- alted grade of emaciation, however, may be a precursory state. In nearly all cases an extreme degree of emaciation is reached before the end. The causes of emaciation are chiefly the persistent fever, the loss of appetite, and the feeble digestive and assimilative powers. It is an almost invari- able rule that during the afebrile periods, associated as they are with improved appetite and digestion, the patient gains in flesh and strength. Unilateral atrophy of the muscles of the chest may be observed. ((/) The pulse is increased in frequency, is of good volume and regular in rhythm, though of low tension (soft). When suppurative fever sets in it becomes frecjuent and compressible, and the capillary pulse is often observed ; rarely venous pulsation is seen in the hands. (c) Anemia is one of the symptoms evidencing impaired nutrition. It is often associated with an afternoon rise of temperature, impaired digestion, and loss of flesh and strength (chloro-anemia). The objective changes pointing to anemia are pronounced (pallor of visible mucous membranes, and skin). The Mood presents nothing characteristic. In the early stage it may be chlorotic in type, the hemoglobin being decidedly deficient; but when there are cavity formation and hectic fever, consider- able leukocytosis, as many as 50,000 leukocytes per cubic millimeter, may be observed. The differential count shows a great excess of the polymorphonuclear cells. Early lymphocytosis, however, may be of con- siderable diagnostic value. The condition is due to secondary infection by the pus-forming organisms. Absence of eosinopliile cells would appear to be an unfavorable prognostic sign, while an increase indicates a tend- ency to arrest the progress of the disease (Swan). Tubercle bacilli can- not, as a rule, be found in the circulating blood (Ravenal and Smitli). On the other hand, Kurashige found them in every one of 155 tubercu- lous patients in various stages. General dehilif;/ is complained of in all cases, and is progressive. Symptoms and Complications Presented by Other Organs. — [a] The Heart. — With retraction of the upper lobe of the left lung the area of the heart's impulse is obviously increased, particularly upward, so that pulsation may be visible in the fourth, third, and even second interspaces, near the sternum, while the normal apex-beat may be wanting. The physical signs noted may be rarely those of displacement of the heart to the right, while the necropsy may show the heart to be in its normal posi- CHRONIC TUBERCULOSIS. 271 tion. Functional murmurs })otli at the apex and at the pulmonary orifices are often audible. In about 7 per cent, of" tiie cases with murmurs, mitral regurgitation, dependent on weakness of tlie heart muscles, was diagnos- ticated/ Disease of the tricuspid segments is not infrequent in phthisis, and pulmonary stenosis predisposes tf) the latter disease. Conversely, there is perfect agreement among writers that left-sided valvular heart disease has a retarding influence upon the progress of chronic phthisis. In cases in which the valve lesions and the compensatory hypertrophy are propor- tional, a prognosis for an unusual length of days can be ventured, but "when this harmonious balance is disturbed an early fatal termination may be expected, principally from the cardiac complaints."^ In com- bined cases dyspnea is more pronounced and hemoptysis a more common initial symptom than in non-cardiac forms. {h) Gastro-intestinal Tract. — The tongue may be furred ; more often it and the mouth and throat are red, showing increased irritability. The pharynx may be the seat of tuberculous lesions, which may interfere with deglutition. Aphthous ulcers and thrush may also arise. The ap- petite is impaired or lost ; thirst is annoying and the symptoms of chronic gastritis often obtain. A catarrhal ulceration and dilatation may be asso- ciated conditions. Vomiting may be troublesome during the later stages. A study of the gastric secretion gives variable results, there being an early hyperacidity, while later the secretion is subacid. Croner found normal motility present in the early stages. The causes of gastric symptoms are not clear. The mucosa is the seat of venous engorgement, and thus occa- sions the catarrhal changes that are present in many instances. Anatomic changes may be absent. The intestinal symptoms are important. During the early stage con- stipation is a frequent condition. Diarrhea is prone to appear at an ad- vanced period, and may pursue an intermittent course. Occasionally it alternates with periods of "hectic fever," and late in the affection a watery discharge may develop {colliquative diarrhea). The intestinal lesions are of three sorts : (a) catarrhal, (b) ulcerative, and (c) amyloid. These often arise in the order enumerated, but may be combined in vari- ous ways. Hemorrhoids and anal fistulse are among the complications, (c) Genito-urinary Organs. — There is frequently an albuminuria that may either be febrile or due to chronic nephritis {productive and non- produGtive). Chroyiic nephritis is usually a late development; it gives rise to albuminuria, tube-casts in the urine, and dropsy. The total nitro- gen excretion is lower than the normal. Amyloid changes may set in toward the close with their characteristic symptoms. Tuberculous 25?/e?i7/.s and cystitis, with the appearance of pus and blood in the urine, may de- velop. Hematuria may also result from temporary congestion. The testes should be routinely inspected (Osier). {d) Cutaneous System. — Cyanosis occurs, but, being of a moderate degree, it is often veiled by a decided pallor. The cheeks often wear a "■hectic flush," and the skin, late in the affection, is apt to be dry, harsh, and scaly. Among the cutaneous appearances are pigmentary stains over the chest (chloasmata phthisicora) and brown stains (pityriasis ver- sicolor). Rarely, simple purpura and purpura hemorrhagica develop as ^ "A Study of Murmui-s in Pulmonary Tuberculosis," American Journal of the Medical Sciencen, June, 1910, by C. M. Montgomery. ^Anier. Jour. Med. Sci., Jan., 1902, by the writer. 272 INFECTIOUS Dlii EASES. late complications. Tlie /uiir over the chest often hecomes gray ; that of the head and beard, long and harsh. The Jiii<./t'r-ends are often bulbous (clubbed), with incurved nails, though this is not peculiar to chronic phthisis, and cracking of the tinger-nails is also often observed. (f) Nervous System. — The mental attitude is characteristically hopeful and buoyant, even in the advanced stages. Hence the patients are read- ily encouraged by the unscrupulous to believe that their condition is im- proving: they may be in an utterly helpless state, and yet confidently e.xpect to recover. The cerebral tfi/inptonts are rarely marked, and the mind, as a rule, is exceptionally clear. Tuberculous meningitis and me- ningo-encephalitis may develop near the close. Focal lesions, due to the presence of tubercles, may produce forms of paralysis (aphasia, hemi- plegia) according to their location. Rarely peripheral neuritis (usually an extensor paralysis of the leg) and insanity are observed. There may be early unilateral dilatation of the pupil, due to enlargement of the bronchial lympli-nodes on the corresponding side. (/) Chest-muscles and Mammary G-lands. — The former are abnormally irritable, and sometimes even painful on percussion, and the mammary gland is in rare instances hypertrophied, m;iles suftering most ; but, as pointed out by Allot, the affection is a chronic non-tuberculous mammitis. Diagnosis. — The early recognition of chronic pulmonary tuberculo- sis often tests severely the diagnostic acumen of the physician. The general and local symptoms, including the physical signs, may afford merely a strong suspicion of the existence of phthisis, and in such in- stances repeated examinations of the sputum for the bacilli are impera- tive, and only when they are found is the diagnosis set at rest. Repeated staining of the sputum may be necessary for the detection of tubercle bacilli. It is also desirable to determine whether they are constantly present by re-examinations at intervals. There are cases in which the physical signs are obvious, yet the bacilli are either not detectable or only so after several examinations. An absence of the bacilli, however, does not justify a denial of the existence of pjithisis. and is of little negative value. Philip and Porter conclude that tubercle bacilli are almost con- stantly present in the stools, whether the patient be expectorating bacilli or not. The symptoms of greatest diagnostic value are cough, expecto- ration, fever, progressive emaciation, and the constant presence of certain physical signs in the subapical region on one side (flattening of the chest, defective expansion, slight deadening of the percussion-note, enfeeble- ment of the vesicular murnmr, prolonged expiration, with or without ad- ventitious sounds). Skiagrajihs that show the presence of tuberculous deposits and pleuritic exudates may, at times, give the earliest positive information in regard to these conditions.^ Again, more reliable knowl- edge can be gained in the initial stage, if the lesions be deep seated, by the fluoroscope tliau by practising the physical signs. Thus enlarged bronchial glands and peribronchial iniiltration are detectable. The tiibercuUn-te-st is Avarmly commended by Ti-udeau, Otis, Klebs, and others. It is ftiirly accurate, and out of a total of 1470 injections in dubious cases, 71.9 per cent, reacted positively.^ Its use should be I For illustrative cases see " Diagnosis and Treatment of Prehacillary Stage of PuL raonarv Tuberculosis," The Journal of the Amer. Med. ^s.sor., .Jan. 12, 1901, by the writer. ^ "The Value of the Tuberculin-test in the Diagnosis of Pulmonary Tuberculosis," by tlie writer, New York Medical Journal, June 23, 1900. CimONIO TUBERCULOSIS. 273 limited to patients who have symptoms and signs of this disease, since latent tuberculosis gives the reaction, after other methods of diagnosis have failed us, and medium-sized initial doses are to be employed. A positive reaction demands an elevation of temperature to 101° F., and this rise usually occurs within twenty-four hours, but it may be delayed until thirty-six or even forty-eight hours. The possibility of reaction occurring in cases of syphilis, leprosy, chlorosis, hysteria, actinomycosis, and other affections will not lead to error if it is noted that such reac- tions are less intense. Calmette's ophthalmic reaction, which consists in dropping 1 to 2 mimims of a 0.5 to 1 per cent, solution of tuber- culin into the eye, produces hyperemia of the conjunctiva (at times actual conjunctivitis) in from three or four to twenty -four hours without constitutional disturbance. The symptoms subside in from twenty-four to forty-eight hours. Von Pirquet applies the tuberculin with gentle friction to the slightly abraded skin. If the patient be tuberculous, a reaction occurs in from 6 to 48 hours ; this is especially valuable in the diagnosis of tuberculosis among children. In adults, however, other signs of tuberculosis must be present to render it of any diagnostic worth. The opsonin test is useful in the diagnosis of early tuberculosis, the index to the tubercle bacillus being very low or very high, the former suggesting predisposition, the latter shoAving infection against which the resisting powers are raised in defense (J. C. DaCosta). Airlong and Courmont ^ describe a method of serum diagnosis, but from the reported trials of other observers its results are too irregular to be of value. A slight rise of the evening temperature (99.6° F. — 37.5° C. or over) is, if associated with any disturbance of health, an almost infallible diagnostic symptom. In the more advanced stages of phthisis the diagnosis is rarely difficult. In the very early stage the local condition may be obscured by the symptoms of impaired digestion, loss of flesh and strength, fever, and pronounced anemia (chloro-anemia, vide p. 270 ; also Modes of Onset). Differential Diagnosis. — Bronchial catarrh is with great difficulty dis- criminated from beginning phthisis. If the temperature is elevated from 2 to 5 P. M., and not at all or only slightly above the normal night temperature in the evening, the probabilities are greatly in favor of tuberculosis (Barlow). In bronchial catarrh there is no dulness, and moist rales, that vary in intensity from one day to another, are heard equally on both sides. From time to time rales may also be heard at the bases in bronchitis. In phthisis one apex is more involved than the other, the moist sounds not being heard equally low, and after repeated coughs with subsequent deep inspiration the rales are more apt to remain than in ordinary bronchitis. In phthisis, also, there is a gradual loss of flesh and strengh, and repeated microscopic examination of the sputum will demonstrate the presence of the bacillus. A negative re- action, obtained repeatedly, from the Falk and Tedesko test,^ is evidence that the disease process is limited to the bronchi, while a positive reaction indicates pulmonary involvement (tuberculosis). According to Armstrong and Groodman^, however, this test is unreliable. If hemoptysis be the first symptom observed, then all other causes for the spitting of blood ^Deutsche med. Woch., Nov. 29, 1900. 2 Wiener Minische Woch., Vienna, July 8, 1909. ^Jour. Amer. Med. Assoc, ]May 27, 1911, p. 1553. 18 274 lyFECTIOUS DISEASES. should be patiently excluded, unless the associated evidences of com- mencing phthisis are conclusive. Phthisis in the stage of cavity may be confounded with bronrJuecfasis (vidf Diseases of the Lungs). Pseudo-tuberculosis.— By this term is meant a distinct form of pulmonary infection caused by the strcptothrix Eppingeri or a closely related species, and clinically resembling pulmonary tuberculosis. Warthin and Olney ^ report 5 cases, and point out that the frequency of occurrence, tlie symptomatology, and the thera])cutics of this form of streptothricosis remain to be worked out. The clinical picture presented is that of tuberculosis or bronchopneumonia. The diagnosis, however, demands isolation of an acid-resisting streptothrix. The tubercle bacillus is absent, but streptococci and staphylococci are found in association, and some of the cases may be of primary streptococcus infection. Fibroid Phthisis. Definition. — Fibroid phthisis implies induration followed by con- traction of the affected lung-tissue, due to an increase in the connective- tissue elements. There are cases in which it cannot be distinguished pathologically from chronic pulmonary phthisis, but they differ clmically. The majority of instances are primarily tuberculous, though manifesting a strong tendency to the formation of fibrous tissue — a conservative process ; in other instances the fibroid change may be primary, followed by tuberculous infection (vide Pneumonokoniosis). The usual form arises variously as a sequel of other morbid processes, such as — (1) Pneumonias, lobar (rarely) and catarrhal (commonly). (2) Pulmonary lesions — tubei'cle in the stage of consolidation or cavity. (3) Chronic tuberculous pleurisy. (4) Bronchial catarrh from inhalation of irritants (steel-, coal-, or mineral-dust). Pathologfy. — The process in the beginning is very often localized in one apex, and less frequently in the middle portion of the lung or in the bases. It may remain circumscribed, but more often it extends down- ward, and gradually invades the entire lung. It is unilateral. Second- ary to the induration and contraction there is dilatation of the bronchi. The lung-tissue is hard and dense, the alveoli being obliterated. It resists cutting and creaks, and the section presents a smooth, dry, gray, often marbled aspect, though the fibrous tissue may undergo caseation. The pleura is thickened, as a rule, often to a marked degree, and its layers are adherent ; the unaffected portions of the lungs frequently be- come emphysematous. The right ventricle is, as a rule, hypertrophied. Symptoms. — These may be briefly stated, since they do not differ from those of cirrhosis of the lung (vide Diseases of the Lungs). The onset is insidious : a persistent cough, occurring in severe paroxysms in the mornings, and a, purule7it expectoration are for long the leading fea- tures. If bronchiectasis is present, the sputum may be fetid. Dyspnea is marked, particularly on exertion. Fever is slight or absent, hence emaciation progresses slowly or may even be absent. The physical signs are identical with those of fibroid induration of the lung {vide infra). The course of this disease is long, ranging from ten to twenty or even thirty years, and both lungs may become involved. Again, as in chronic 1 " Pulmonary Streptothricosis," Amer. Jour. Med. Sci., vol. cxxviii., No. 4, pp. 637-649. FIBROTI) PHTHISIS. 275 pulmonary tuberculosis, prolonged suppuration may lead to amyloid changes in the liver, spleen, kidneys, and intestines. JJrojjHy^ (hie to secondary dilatation of the right ventricle, often closes the scene. Differential Diagnosis. — Chronic bronchitis may be mistaken for fibroid phthisis. In the latter disease, however, there are unilateral retraction and the signs of consolidation or of an apical cavity, and the sputum-test may settle the doubt. Complications of Pulmonary Tuberculosis. — Lobar jmeurno- nia, and less commonly lobular pneumonia^ may develop and cause a fatal ter- mination. In a study of 100 cases H. M. King found the principal compli- cations of a non-tuberculous character were lobar pneumonia and nephritis. Erysipelas may arise in the course of chronic pulmonary tuberculosis, though the proportion of cases is not formidable. Out of 1165 cases of erysipelas, 15 coexisted with pulmonary phthisis.^ Some contend that its occurrence in this disease may be beneficial, but my own observations show that the gravity of both conditions is increased. Typhoid fever may rarely be met with in sufterers from chronic phthisis. Out of a totality of 249 autopsies in cases of typhoid fever, only 19 (7.6 per cent.) showed the presence of tuberculous lesions.^ This contradicts the opinion that typhoid fever predisposes to tuberculosis. Chronic nephritis and pulmonary tuberculosis are often found in the same subject, and with these arterio-sclerosis is quite commonly combined. Intercurrent acute hemorrhagic nephritis may develop. Chronic endocarditis, particularly of the tricuspid segments, may also occur iu phthisis, and from time to time cases of valvular heart-disease are reported, in which it is evident that passive congestion must have ex- isted for some time before the tuberculous condition developed. The old doctrine of the mutual antagonism between disease of the left heart and pulmonary tuberculosis finds support from these cases, as in a large pro- portion a tendency to encapsulation of the tuberculous lesions exists. Course and Duration. — Both as to course and duration this dis- ease exhibits unusual variations. If not promptly treated during the incipient stage it frequently progresses with more or less rapidity toward the grave. It is common, however, to observe periods during which the disease is arrested or improved. Generally, the improvement, though followed by an exacerbation, endures for a long time, and permanent cures, even in the advanced stage, are by no means rare. The duration of pulmonary tuberculosis varies exceedingly, though from the collective investigations of different authors and from all the statistics available I find the average duration to be about three years. The late Austin Flint long ago directed attention to the innate tendency of a considerable per- centage of the cases to spontaneous recovery — a fact that simply indicates a victory for nature's silent defensive processes in the struggle for su- premacy. In fatal cases death is by (a) gradual asthenia (most frequently), with retention of consciousness until the end approaches. (h) Complicating conditions (bronchitis ; pneumonia ; pleurisy ; pneu- mothorax ; amyloid degeneration of the intestines, liver, spleen, kidney ; Bright's disease ; diabetes, etc.). ^ " Points in the Etiology and Clinical History of Erysipelas," Journal of the Americaj) Medical Association, July 2, 1893. * Amer. Jour, of the Med. Sci., May, 1904, by the writer. 276 INFECTIOUS DISEASES. {e) Tuberculosis of other organs, particularly the meninges, intestines, and genito-uriuary tract. (d) Hemorrhaye, due commonly to rupture of an aneurysm in the lung- cavity ; less frequently to erosion of a large vessel. Fatal hemorrhage may, when the vomica is of large size, occur without hemoptysis, as in a case of Roland G. Curtin's at the Philadelphia Hospital. {e) Syncope. — Though of comparatively rare occurrence, there are a number of events that may lead to sudden, fatal syncope — e. g. hemor- rhagic embolism or thrombosis of the pulmonary artery, pneumothorax, thoracentesis for pleural effusion, walking about in a moribund state, etc. (/) Asphyxia often closes the scene in acute pneumonic phthisis, and rarely in chronic phthisis complicated with pneumo-thorax, or with a large undiscovered or neglected empyema, or with sero-fibrinous pleurisy. Tuberculosis of the Alimentary Tract. (1) Lips. — Whilst tuberculosis of the lip is quite rare, the possibility of its occurrence must not be forgotten. It assumes the form of a small ulcer, and the diagnosis is made by an examination of the labial mucus. It is usually associated with laryngeal or pulmonary tuberculosis. In diagiwstieating the condition, chancre and epithelioma must be excluded, the former by the history, and the latter chiefly by a microscopic ex- amination for tubercle bacilli. (2) Tongue, Palate, and Tonsil. — The work of Orth, Hanan, Schlen- ker, Kruckman, and others has shown that the tonsils, owing to their frequent inflammation, serve as the door of entrance of the tubercle bacilli. The fact that tuberculosis of the tonsils has repeatedly been found, and when other lesions of the disease were absent, points to the not infrequent occurrence of primary tuberculosis in this site. The infiltrated areas often present small grayish spots, but the appear- ance of the ulcers is not characteristic, frequently bearing a strong resemblance to epithelioma and to the syphilitic ulcer. The diagnosis demands either inoculative experiments or a microscopic examination of the oral mucus, the latter bemg oft repeated if necessary. E. D. Smith records 5 rare cases of tuberculous ulceration of the soft palate. (3) Pharynx and Esophagus. — Both miliary tubercles and ulcerative lesions may rarely arise on the posterior wall of the pharynx by direct extension from laryngo-pulmonary tuberculosis or as the result of second- ary inoculation. The chief symptoms occasioned are the excessive secre- tion of pharyngeal mucus and muco-pus, and painful deglutition. Tuber- culosis of the esophagus is extremely rare. (4) The Stomach. — Tuberculous lesions of the stomach are of excep- tional occurrence. Marked gastric symptoms, however, are common, and they may be due to involvement of the larynx. I have been able to find reports of 4 cases of tuberculous gastric ulcer in addition to the 12 collected by Marfan.^ The ulcers may be single (as in Musser's case) or multiple (as in Osier's case). The symptoms are not characteristic, but hematemesis occurring in patients suffering from tuberculosis of other organs should excite a strong suspicion of the existence of ulcer. Pain coming on soon after meal-time is more marked in tuberculous ulcer than » Paris Thesis, 1887. TUBERCULOSIS OF THE ALIMENTARY TRACT. 211 in ordinary gastric lesions. Perforation may take place. Four cases are recorded in which the pylorus was found encircled with a flat, gran- ular ulceration, operated on under the diagnosis of carcinoma (Alexan- der^). The process was isolated and tiie symptoms all pointed to pyloric cancer. (5) Intestines. — The lesions may be (a) primary or [h) secondary. (a) Primary tubercle of the intestines is chiefly met with in children, for the reason that they are more likely to swallow the tubercle bacilli with their food, and especially in milk. The intestinal route of infection is, according to my own observation, more common in adults also than is supposed. Many cases during life present the features of both intesti- nal and peritoneal tuberculosis, and it is often impossible to determine which of these was the primary condition ; and the same difficulty arises when the cases come to autopsy. I have never seen an instance (post-mortem) of intestinal tuberculosis in which the peritoneum and mesenteric glands were not involved to an equal degree. (h) The secondary variety occurs in more than one-half of the cases of pulmonary tuberculosis, the chief seats of the lesions being the lower part of the ileum, the cecum, and the upper part of the colon. The rectum is also the seat of secondary tuberculosis in a small proportion of the cases of chronic phthisis and it may be rarely a primary seat of the aff'ection. The morbid process begins in the solitary glands in Peyer's patches, where at first grayish, firm tubercles grow and form little prominences. These caseate, becoming yellow in appearance, and then soften and disin- tegrate, producing ulcers. Osier thus describes the characteristics of the tuberculous ulcer: "(a) It is irregular, rarely ovoid or in the long axis, more frequently girdling the bowel ; (5) the edges and base are infil- trated, often caseous ; (f) the submucosa and muscularis are usually in- volved ; and {d) on the serosa may be seen colonies of young tubercles or a well-marked tuberculous lymphangitis." In ^Macule cases the sur- face-lesions show little tendency to repair (Senn). In chronic cases attempts at healing are the rule ; and the cicatrices are extensive and often pigmented, and as they undergo contraction may produce incomplete or even complete stricture of the bowel. At a point corresponding to the seat of the ulcers local peritonitis invariably develops. The serosa is thickened and adherent, and the ulcer may penetrate through this coat without causing perforative peritonitis, Avhile rarely a fistulous connection is established between the diff"erent parts of the intestine. Symptoms. — In children the symptoms are those of a protracted catarrh of the intestines, or they may be absent. Among prominent features are diarrhea, colicky pains, and the presence in the stools of pus, blood, and particles of mucus resembling sago-grains. In many cases there is constipation, which may be due either to peritonitis or cicatricial stenosis. The general symptoms are irregular fever, wasting, and a lack of development ; they are especially valuable for diagnosis. In adults intestinal tuberculosis generally gives rise to srmptoms similar to the above, and when they arise in the course of pulmonary phthisis they are highly significant. If diarrhea be present, it stub- bornly resists treatment, and it must not be forgotten that it may also ^ Deutsches Archivf. Minische Med., Berlin, Ixxxvi., Nos. 1-3, 1906. 278 IliFECTIOUS DISEASES. be due either to, catarrhal colitis or to amyloid cliange, both of which processes may be associated with chronic phthisis. Constipation is common and often marked, and local tenderness and colicky pains are complained of frequently. The pulmonary signs, however, may be in abeyance. If the abdominal and oreneral symptoms are such as to excite suspicion of this disease, then a rigid physical examination of the lungs should be made. The chief seat of the lesions mav be for a long time in the cecum, or in the appendix, when the symptoms — both local and general — will be those of appendicitis. The diagnosis of primary intestinal tuberculosis is beset with special difficulties. Sawyer ^ has in special instances demonstrated the presence of clusters of tubercle bacilli in the rectal mucus, and in this way the recognition of intestinal tuberculosis at an early date, or before diarrhea sets in, is rendered possible. The mucus is obtained after placing the patient in a position as if to examine for piles, and directing him to bear down as though at stool, by gently removing a small quantity from the everted membrane with a sterile loop. It is then spread upon a clean cover -glass and treated exactly as sputum in the ordinary examination. The same method is applicable to cases of secondary intestinal tuberculo- sis, but here the history and associated tuberculous lesions usually serve to remove all doubt. Tuberculosis of the Serous Membranes. General tuberculosis of the serous membranes secondary to pulmonary and intestinal tuberculosis is of common occurrence, and that a primary form of tuberculosis of the serous membranes also occurs is undoubted. Unfortunately, accurate means of discriminating the secondary from the primary form are wanting, since often in the secondary variety the primary lesions in other organs are insignificant. The anatomic alterations resemble those of ordinary inflammation of these structures, plus the presence of nodular tubercles. The latter may be observed, as a rule, only over small, scattered, circumscribed areas, though not infrequently they are both numerous and diff"use (gen- eral miliary deposit). The effusion is in most instances sero-fibrinous, though sometimes it becomes purulent, and not uncommonly it is hemor- rhagic. Most instances of so-called hemorrhagic pleurisy are due to pleural tuberculosis. Clinically, cases are divisible into (1) acute serous membranous tuber- culosis and (2) the chronic form. The acute form results from inocula- tion of the peritoneum or pleura, induced by limited foci in the bronchial, tracheal, or mediastinal lymph-glands, or in the Fallopian tubes in women. The chronic type is apt to result from a direct extension of a tuberculous process from some organ adjacent to the pleura or peritoneum, though it may attack the serous membranes primarily. Belonging to this class of diseases are two groups of cases : those attended by sero-fibrinous or sero-purulent effusion and the presence of caseous masses, and those in which there is a tuberculous deposit with increased density and great 1 Medical Nevjs, May 23, 1896. TUBERCULOSIS OF THE SEROUS MEMBRANES. 279 thickening of the pleural layers, and slight exudation. The pericardium may be similarly involved. (a) Tuberculous meningitis has been described fully in the present section [vide Miliiiry Tuberculosis). [b) Tuberculous Pleuritis. — This subject will be referred to in the section on Diseases of the Pleura. Its import, however, is such that brief special consideration is demanded, and from a clinical view-point the cases may be grouped under two heads — namely, acute and chronic tuberculous pleurisy. The acute form often has a sudden onset, the initial symptoms being a rigor or repeated fits of chilliness, a stitch-like pain in the side affected, shallow, catching breathing, a cough, and fever. The ushering-in symp- toms sometimes suggest lobar pneumonia, and a fatal termination is not uncommon, though apparent recovery or a transition into chronic tuber- culous pleuritis also occurs. Chronic tubercular pleurisy is vastly more common than the acute form, and it is sometimes primary, though more often secondary to pul- monary tuberculosis. In all cases of the latter disease in which the per- iphery of the lung becomes involved the visceral layer of the pleura is invaded. This leads to plastic pleurisy with adhesion, and the membranes contain disseminated tubercles, or to sero-fibrinous tuberculous pleurisy. As above stated, the effusion may be hemorrhagic and may also become purulent. When the tuberculous pulmonary focus perforates the pleural sac, pyopneumothorax is produced. In tuberculous pleurisy, as opposed to simple pleurisy, there is usually an absence of leukocytosis. Symptoms. — The onset is very insidious and often unnoticed. There may be few symptoms, and yet a physical examination reveal a large sero-fibrinous exudate. The cough and other symptoms are frequently due to a coexisting tuberculosis of the lungs, and the presence of sub- crepitant and dry rales is strongly confirmatory of tuberculous pleurisy. By and by the evidences of pulmonary tuberculosis are of diagnostic importance, or the supervention of acute general miliary tuberculosis makes clear the nature of the case. The subacute variety with effusion may terminate, after absorption of the exudate, in chronic adhesive pleurisy with great thickening of the membrane. The latter may also originate as a primary proliferative process. (c) TUBERCULOSIS OF THE PERICARDIUM. The morbid lesions are analogous to those of tuberculosis of the pleura. The effusion may be enormous on the one hand or insignificant on the other, and it is often hemorrhagic, while in the chronic form there is marked thickening of the membrane with the deposit of tubercles and cheesy masses. The affection is less common than tuberculosis of the pleura, yet not so rare as was formerly supposed, and occurs in the acute and chronic forms. Acute tuberculous pericarditis is rarely a primary affection, and. as a rule, originates secondarily to pulmonary, pleural, or glandular tubercu- losis. It is especially prone to arise in tuberculosis of the bronchial and mediastinal lymph-glands, and, as the latter condition is frequent in young children, so tuberculosis of the pericardium is relatively frequent at this period, though it may occur at any time of life. Pericardial 280 INFECTIOUS DISEASES. tuberculosis also results from direct extension from a contiguous focus. The symptoms -will be detailed in the discussion of Pericarditis. In the diagnosis of the affection the history and any associated tuberculous pro- cesses detectable must be taken into account, and a point of some diag- nostic value rests in the fact that tuberculous pericarditis does not show the usual inflammatory leukocytosis. Chronic Tuberculous Pericarditis. — This may be a part of the general tuberculosis of the serous membranes, or it may follow an infection of the bronchial and mediastinal glands (most frequently), lungs, pleura, or peritoneum. Cases of primary origin also occur, but they are exceed- ingly rare, the neighboring lymph-glands being genex'ally involved. This form is also dependent upon direct extension from the spine and sternum. From personal observation I am convinced that the cases naturally fall under two heads, when considered clinically : those without effusion, in which the pericardium is adherent ; and those with more or less effusion. The former are the more frequent, though often entirely latent, the adherent pericardium leading to hypertrophy of the heart, followed sooner or later by dilatation. The signs are therefore those of adherent pericardium, with the occasional difference that the dulness may extend higher up over the sternum, in consequence of the presence of firm, cheesy masses at the base of the heart and also encircling the aorta. The smaller group of cases (in which the effusion is present) resembles dilata- tion of the heart in its clinical manifestations. I recall one instance of this sort that occurred in a male aged about sixty years at the Episco- pal Hospital, the autopsy revealing extensive pulmonary tuberculosis and chronic tuberculous pericarditis, with the presence of eight ounces of hemorrhagic effusion. (d) TUBERCULOSIS OF THE PERITONEUM, This is dependent upon infection by means of the bacilli circulating with the blood, or upon extension of tuberculous inflammation or ulcera- tion from adjacent organs. In 11 per cent, of 3405 autopsy records Cum- mins ' found there was peritoneal involvement. Mention has already been made of the fact that the intestines are often invaded by tuberculosis, and that the serosa is quickly involved in such instances. The condition may rarely be primary. This involvement may remain circumscribed and undergo spontaneous cure if the intestinal lesion cicatrizes, as post- mortem findings frequently indicate, but in extensive peritoneal involve- ment spontaneous resolution is out of the question. These cases may be subdivided into acute and chronic. The ver^ acute cases are those form- ing a part of acute general miliary tuberculosi-s, or due to perforation into the peritoneal sac from adjacent organs, and Adlebert's classifica- tion is as follows : («) The ascitic form, (6) the ulcerous form, and (c) the fibroid form. Though these groups do not present sharp clinical distinc- tions, the courses they run vary considerably, as do the results of treat- ment. In the asritic form the exudate is purulent or sero-purulent, and is often encapsulated. In the ulcerous the tuberculous new-formations, which may be quite large, undergo caseation and ulceration, the latter process being progressive, so that it may perforate the walls of the intes- tines. This and the ascitic variety may be combined. 1 University Med. BuUelin, December, 1905. I TUBERCULOSIS OF THE SEROUS MEMBRANES. 281 In the third or fibroid form the peritoneal surfaces are adherent. There is little exudation ; the tubercles may be numerous and difi'use, or found only in scattered localized areas. The lesions may represent the concluding stage of acute or subacute tuberculous peritonitis. !^tiology. — Most cases are produced by extension of tuberculous inflammation from adjacent organs, and of 107 cases analyzed by Phillips the lungs were involved in 99, the pleura also in 60, and the bowel in 80. Children are frequent victims to intestinal tuberculosis, and the bacilli often reach the peritoneum through the intestines, as they are also apt to do in adults suffering from chronic phthisis. Extension from the pleura to the peritoneum is frequent (pleuroperitoneal), but from tlie pericardium is rare. In females the starting-point is often the Fallopian tubes (Mayo, Murphy), and in either sex it may be the appendix. Predisposing Factors. — Age. — During the period from fifteen to forty years the incidence is most frequent, although it is not uncommon in chil- dren under ten years, nor between the fortieth and fiftieth years of life. Subsequently, it rapidly decreases in frequency. I agree with Osier in stating that in America negroes are more prone than whites. Sex has a tolerably potent disposing influence. Abdominal surgeons have taught us that the disease occurs more frequently in females than males, owing to the fact that the Fallopian tubes are a favorite seat for primary tuberculous infection. The ratio based upon sex is as 8 to 2 in favor of females. Symptoms. — Some cases develop abruptly with severe symptoms, as fever, marked constitutional disturbance, rapid small pulse, abdominal pain, vomiting, and sometimes diarrhea. The temperature may be quite high (103° to 104° F.— 40° C), or it may be only slightly elevated even in the worst cases. There follow quickly such symptoms as anemia, marked emaciation, and a pronounced typhoid co7idition. The signs of peritoneal effusion (rarely large) are soon in evidence, and are attended sometimes by a suppurative type of temperature, sweats, etc., indicating the presence of pus in the peritoneal sac. A few cases are unattended by effusion, and here nodular masses are palpable, while on auscultation friction-sounds may be audible in the umbilical region. Tympanites, due to intestinal paresis, is common in cases having an jicute onset. The acute stage may be absent, the affection then being marked by slight local and general symptoms (low fever, anemia, slight belly-pains, and a sense of distention). The skin is sometimes pigmented, and usu- ally in patches. There are not a few instances in which the aff"ection is latent, and in one case of this sort with ill-defined general symptoms pig- mentation of the skin first directed my attention to the peritoneum. The physical signs of moderate ascites frequently, and those of en- larged mesenteric glands sometimes, are present. These conditions are often combined in children, constituting the so-called tabes mesenterica. I cannot conceive of the occurrence of this association of symptoms with- out simultaneous involvement of the peritoneum, and doubtless co-involve- ment of the latter membrane and intestines usually occurs. Hamman emphasizes the great frequency with which more than one serous membrane is affected (multiple serosites). The tuberculous new growth in the peritoneum may also form a distinct tumor not unlike that produced by glandular enlargement, while the intestinal coils 282 INFECTIOUS DISEASES. with their now thickened walls are sometimes knotted together so firmly as to simulate a dense new growth. The exudation may be loculated owing to adhesions between peritoneal layers of the intestinal coils, etc., producing a localized tumor varying in size and position. Such saccu- lated exudations most frequently occupy the pelvic or umbilical regions, though they may also be found elsewhere in the abdomen. They may be multiple, and are not infrequently too small to be recognized by the physical signs, being often discovered during laparotomy. On the other hand, they may occupy a large portion of the abdomen. An omental tumor of characteristic elongated form (produced by a shrinking and curling up of this membrane) is demonstrable, its long axis generally taking a transverse direction just above the umbilicus. Gardiner has observed this tumor to disappear by spontaneous resolution in children. The dry, fibrous variety, which is not infrequent, is often latent, and the condition may be general or localized. It is decidedly more frequent in adults than in children. The syyyiptoms are far from characteristic. Among local features are pains, abdominal distention (giving rise to a tympanitic note on percussion), tenderness on pressure, and sometimes a tumor-ridge extending across the upper abdominal region. Among gen- eral symptoms are usually anemia and emaciation, with or without fever. Indeed, the temperature may be subnormal, and these cases may show a tendency to spontaneous recovery. Diagnosis. — Unless tuberculosis of other organs can be demon- strated the diagnosis is often impossible. This is particularly true in cases in which there is no abdominal pain, which is the most important local symptom, nor tenderness. Fever and the presence of a tumor, especially if the latter be elongated and lies transversely in the umbili- cal region, are important aids ; but if tuberculosis of the lungs, pleura, pericardium, appendix, and the tubes, in women, can be excluded, the rectal mucus and the urine should be examined for tubercle bacilli. From the acute form, several aflfections must be discriminated : (a) Internal Hernia. — This comes on suddenly ; the pain is strictly localized and paroxysmal ; stercoraceous vomiting appears in a few hours; the constipation is absolute, and tympanites is marked, but ascites is absent. (6) Similar symptoms belong to volvulus and to the quick incarcera- tion of loops of intestine under bands of adhesions; on comparison they will be seen to differ from those of acute tuberculous peritonitis. (c) Enteritis is discriminated /rom acute tuberculous perito7iitis by the presence of copious mucous discharges, and by the absence of associated tuberculous lesions, peritoneal exudate, tumors, and the phenomena of the typhoid state. Chronic tuberculous peritonitis often closely simulates cancerous perito- nitis, owing to the fact that the elongated omental tumor may be met with in both, associated with effusion, abdominal pain, and slight fever. In carcinoma, however, there is an absence of the tuberculous history and lesions, and the presence, sometimes, of a gradually increasing tumor of primary growth, the slowly oncoming intestinal obstruction from pres- sure, and the cancerous cachexia. Moreover, tuberculous peritonitis occurs more commonly in younger subjects, and is more apt to be inter- rupted by periods of improvement, followed in turn by rather alarming symptoms. The tuberculin test is to be used in dubious cases. TUBERCULOSIS OF THE OENITO-URINARY SYSTEM. 283 Locular exudations must be distinguished from ovarian tAimorn, and here the history, together with tuberculous lesions elsewhere in the body, the occurrence of febrile attacks, and intestinal disturbance with pain, are of great diagnostic significance. Such cases should be examined by a gynecologist, since, however expert the examiner, when the saccular exu- dations are located in the pelvic region ar exploratory laparotomy must often decide the nature of the condition. Finally, it must not be forgot- ten that the vast majority of cases of chronic peritonitis are tuberculous. Tuberculosis op the Liver. The liver was formerly overlooked in many instances of tuberculosis, because the lesions, particularly in acute tuberculosis, are often micro- scopic. In the chronic disseminated variety, however, grosser changes are observed, the organ being slightly enlarged, pale, and fatty, and pre- senting an irregular surface like that of an orange. On section, the par- enchyma cuts with great resistance, being very dense (tuberculous cir- rhosis). Minute gray and larger yellow masses are seen, especially just under the capsule, and small cavities, the result of a breaking down of the cheesy masses and containing pus and bile, are also observed. These changes are most pronounced about the bile-ducts. Etiology. — The liver is implicated in all instances of acute miliary tuberculosis. It is also involved secondarily in chronic tuberculosis of the lungs, pleura, peritoneum, spleen, lymphatics, etc. Symptoms. — This is a common condition, the organ being appreci- ably enlarged and its surface presenting irregular, palpable prominences. The clinical features of perihepatitis and peritonitis are often found in combination. Ascites may be present, but is rare. Here may be mentioned that occasionally the spleen seems to be the primary focus of tuberculosis. Tuberculosis of the Genito-urinary System. (1) Tuberculosis of the Kidneys. — This may be primary or secondary, the secondary form being the more common, and it may be either unilat- eral or bilateral. Pathology. — The process begins in the calices and apices of the pyr- amids (papillae), thence proceeding to the pelvis of the kidney, so that early the condition may be pyonephrosis. The morbid changes then ex- tend to the ureters, and sometimes to the bladder and prostate, and in- stances are even met with in which the process seems to have crept from below upward, starting from the bladder or prostate. The tubercles pass through the usual stages of caseation, necrosis, and suppuration, and de- struction of the renal tissue to a greater or lesser degree occurs, with the formation of cysts containing cheesy material in which lime-salts may be deposited. When the process invades the kidneys through the blood, it may be limited largely to the cortical layer and give rise to nodular tuberculosis with caseous masses, yet with little loss of renal substance. H. A. Kelly ^ believes that the infection of the kidney is almost always hematogenous. While it is difficult to judge of the relative ages of the lesions in different organs, I cannot escape the conviction that in a ^ British Medical Journal, June 17, 1905, p. 1319. 284 INFECTIOUS DISEASES. sumll group of cases renal tuberculosis is an ascendmg process and fol- lows ureterocystic tuberculosis. Although both kidneys are finally involved in most instances, for a considerable period the disease is uni- latei'al. Hall^ and Motz found one kidney alone aflected in 89 out of 132 cases. In acute miliary tuberculosis, both kidneys show disseminated tubercles. Caseation and necrosis, however, seldom occur. Etiology. — Of disposing factors age and sex deserve especial mention, most cases occurring during middle life, though they are by no means rare both at an earlier and a later period. The disease is more frequent in males than females. The bacilli reach the kidneys with the blood-stream, producing pri- mary renal tuberculosis (hemogenic infection), through the lymphatics (lymphogenic infection) and direct extension from adjacent structures. Symptoms. — In many cases there are either no renal symptoms or none until a late stage is reached, but the symptoms of pyelitis are usu- ally present. Pyuria may be the only symptom for a long time, and this symptom, according to certain authorities, points directly to cystitis. When the latter condition is present, however, the micturition becomes frequent and there is vesical tenesmus. Pain in the side chiefly affected is complained of, and is sometimes not unlike renal colic ; hematuria is not rare, and it may be the initial symptom. Braasch found hematuria in 60 per cent, of 203 cases, and bladder irritability in 86 per cent. Cys- toscopic examination may show the blood to be of renal origin (Tuflfier). It is useful also in showing the state of the bladder-mucosa. The dem- onstration of tubercle bacilli in the urine, especially if arranged in S-shaped groups, is diagnostic (Frisch). When the bacilli cannot be found, inoculation-experiments upon guinea-pigs and rabbits furnish an accurate criterion, though it must not be forgotten that tubercle bacilli may find their way into the urine from more distant tuberculous foci. Catheterization of the ureters may determine which kidney is involved. Tubercle bacilli are not found in the urine in the miliary form. Polyuria is sometimes present, as well as alhuminuria ; the urine may also show tube-casts (rarely) and pus-cells. Macroscopic cheesy masses are occa- sionally found. Roentgenographs after injections of 20 c.c. of a 10 per cent, solution of collargol are of much diagnostic value. The general features are often marked, but not until the affection' becomes advanced, chills, fever of a suppurative type, emaciation, and increasing debility being the principal symptoms. A good general appearance often accompanies an extensive lesion. Associated tuber- culous lesions, especially of the lungs, are constantly observed. Physical Signs. — Inspection may show a tumor-like prominence on the side chiefly affected, though rarely of large size. Renal tumor was palpable in but 20 per cent, of Braasch's cases (vide supra). Paljiation often detects tenderness, and the outline of the organ may be defined by careful firm pressure with the finger-tips. Diagnosis. — It is difficult to discriminate calculous pyelitis. In the latter, however, the pain is severer, the tumor-mass larger, and the hemor- rhage more frequent than in tuberculous nephritis. The discovery of tubercle bacilli or the demonstration of tuberculosis of the lungs or other organs would remove all doubt. The tuberculin test may be used. Chevassre ^ recommends the antigen reaction of Debr6 and Paraf. 1 P/-e.s.se Medicate, February 28, 1912, xvii., 173. TUBERCULOSIS OF THE FEMALE OENITAL ORGANS. 285 (2) Tuberculosis of the Ureter and Bladder. — 'I'his is almost always secondary to tuberculous disease of the pelvis of the kidney above, or of the deep urethra, testes, or prostate below. When primary, as rarely happens, the process extends from ureters to bladder. The HymptoniH are those of chronic cystitis, and in all cases in which no other cause for the latter can be found the primary tuberculous lesion must be sought for and the urine carefully examined for bacilli. The smegma bacillus, sometimes prestjnt in normal urine, can be distinguished by decolorizing with absolute alcohol, which will take place in about two minutes, while with the tubercle bacillus a very much longer time is required. Others say this is not sufficient, and that only their methods of culture-growth or inoculation will distinguish them. A catheter specimen should be obtained if possible (Ogden). With the development of ulcerative lesions hemorrhage is apt to arise. (3) Tuberculosis of tlie Vesiculse Seminales, Prostate, and Testes. — The prostate gland and testes are frequently invaded in genito-urinary tuber- culosis, and the vesiculse seminales somewhat less frequently. The mor- bid process leads to the formation of cheesy nodules, which may, though comparatively rarely, disintegrate, causing excavations or perforation. Rarely, the tubercle does not pass through the stage of caseation, but merely shows the presence of numerous embryonic cells. Etiology. — The condition is usually secondary, but the existence of primary tuberculosis in these organs cannot be denied. Testicular tuber- culosis may begin at any period of life, and is of rather frequent occur- rence in infants. When it occurs in the latter, it is part of a more gen- eral tuberculous infection, and is in many instances undoubtedly congen- ital. In some cases it may be a late hereditary affection. Symptoms. — In the testicle, tuberculosis, as a rule, induces a pain- less, protracted orchitis, though when cavernous lesions occur the symp- toms are more acute. In prostatic tuberculosis the bladder is highly irritable, there is great distress felt in the thigh and groin, and micturi- tion is very painful. Catheterization, particularly if the urethra (as is very rarely the case) is the seat of tuberculous ulceration, causes most excruciating suffering, and there may be signs of stricture. Rectal palpation detects in the prostate firm nodules varying in size from a pea to a bean, together with enlargement of the organ. Diagnosis. — The diagnosis of tuberculosis of the prostate is easily made from the vesical symptoms, the presence of tuberculosis in other organs, the result of rectal examination, and the detection of bacilli in the urine. Syphilitic involvement of the testicle is sometimes excluded with difficulty ; in the latter disease, however, the surface of the swollen organ presents greater irregularities, and is even less painful than in tu- berculosis. The absence of the history of syphilitic infection and the presence of tuberculosis in other organs, particularly in the uro-genital system, are valuable points in the discrimination. Tuberculosis of the Fallopian Tubes, Ovaries, and Uterus. Tuberculosis of the tubes in women is a not infrequent condition, and may be primary. Btiolpgy and Pathology. — The tubes, as a result of infiltration, 286 INFECTIOUS DISEASES. are thick, hanl, and bound down by false membrane. Their ends are generally closed, but the intervening portion is dilated, and contains mucus, pus, and cheesy material. A catarrhal salpingitis is generally in association. Uterine Tubirculos/s is rare, and its origin is usually attrib- utable to similar involvement of the tubes. The disease is most common during the period of greatest sexual activity, but young children may suffer {inde literature of Hennig), and in them the ovaries and uterus may be implicated without participa- tion of the tubes, as in cases reported by Gusserow. At any period of life the lesions may be microscopic ; they usually, however, excite marked local peritonitis, -which may become gen3ral, with the development of ascites. The process may extend to the vagina. Diagnosis. — The age, family history, and signs of the tuberculous diathesis must be noted. The disease does not distinguish itself from other tubal tumors by anything characteristic on bimanual palpation. Cases occur with ascites and also without, and m the latter variety plaque- like thickening of the subperitoneal tissue is an aid to diagnosis. The uterine secretions should be examined for bacilli in all obscure cases. Ashton advises an exploratory incision or puncture and examination of the contents of the peritoneum or tubes for bacilli. Tuberculosis of the Mammary Glands. This is rare ; the affected glands present fistulas and ulcers, with indu- ration of the organ and retraction of the nipple. Warden ^ reports the finding of 58 authentic cases in the literature. Nearly 90 per cent, of the patients were females, and most cases developed in the third decennium. The si/mptoms are sharp and lancinating pains radiating to the arm, and tumor, the latter consisting of one or more nodules. Pyogenic secondary infection, leading to obstinate fistulae, is common. The axillary glands are often enlarged. A positive diagnosis rests crucially upon the finding of the bacilli in the pathologic secretions. Tuberculosis of the Brain. Pathology. — Tuberculosis of the brain occurs in two forms, one of which, acute tubercular meningitis, has been previously described, while the other is a chronic tuberculous infection, usually localized, of the meninges and cortex, and causing meningo-encephalitis. Very rarely the membranes remain intact. The so-called solitary tubercle is an irregularly round mass, varying in size from a small pea to an apple or even larger. It is generally single, though sometimes there are two, and rarely even three, nodules. The tubercle may be imbedded in, and be contiguous with, the brain-substance, or may be separated from the latter by cysts. The peripheral zone is formed largely of connective tissue, is lighter in color (often translucent), and may contain miliary tubercles, while the central portion, which is cheesy as a rule, may liquefy and thus form a small cavity containing a purulent-looking material. They are seen with greatest frequency in the inferior portions of the brain. The new growths may compress the longitudinal sinus, inducing throm- bosis; they may interfere markedly with the circulation, causing cerebral 1 Medical Record, October 1, 1898. TUIiKIlCULOSIS OF TIll<: IIKAIIT. 287 softening; and, finally, they may excite acute tuberculous meningitis. Tuberculosis of other organs is usually found as an associated condition. histiology. — The disease occurs with especial frequency in young subjects, and, according to the statistics of Pribram, in about three- fourths of the cases before the fifteenth year, ^fhe symptom-picture is identical with that of brain-tumor {({. v.). Tuberculosis of the Spinal Cord. The lesions are those of solitary tubercle of the brain. It is an ex- tremely rare condition, and almost invariably secondary. (For symptoms, vide Spinal Tumor and Meningitis.) Tuberculosis of the Heart. (a) The Myocardium. — Tuberculous myocarditis, though compara- tively rare, is more common than has been supposed. It may be pri- mary, although practically always secondary to a focus in some other tissue, and transmission to the heart generally occurs by way of the lymphatic system. Infection through the agency of the pericardium is also common, and rarely it may be by the blood. Three pathologic varie- ties (here mentioned in the order of relative frequency) are recognized : {a) Large tubercles ; [b) Miliary variety ; and (c) Diffuse form, or tuber- cular infiltration. Generally speaking, the smaller nodules are found usually in the ventricles, and the larger masses in the auricles, chiefly the right. In miliary tuberculosis scattered gray granulations or semitrans- parent areas are formed. The literature furnishes a total of 72 cases, nearly one-half of which have occurred in persons under fifteen years of age, and is quite rare after the forty-fifth year. The diagnosis is exceedingly difficult, and rarely possible. In addition to the sus- picious features, such as syncopal attacks of short duration or sudden collapse, with comparative well-being in the intervals, that may be present, the existence of generalized tuberculosis and pericardial tuber- culosis, one or both, are essential to a diagnosis. Death may occur suddenly.^ {h) The Endocardium. — True tuberculous endocarditis is a rare con- dition. It is most apt to occur in acute miliary tuberculosis. The endo- cardium is to an unusual degree resistant to the tubercle bacillus. In tubercular invasion of the mediastinal glands the endocardium may become involved by extension of the morbid process. Infection of the endocardium also takes place through the blood supply to the heart structure. Vegetations occur on the valves, and in cases in which the lesions are of the ulcerative variety secondary pyogenic infection prob- ably exists. Clinically, the cases of tuberculous endocarditis are extremely diflScult of recognition. The history of the case, however, may be of diagnostic significance. " If it can be shown that the cardiac aff"ection developed subsequent to undoubted pulmonary tuberculosis, and if rheumatic and other forms of infectious endocarditis can be eliminated, and especially if there have been neither previous arteriosclerosis nor fibroid degeneration of the viscera, then a reasonably certain diagnosis of tuberculous endocarditis, given the usual signs and symptoms, can be 1 "Tuberculous Myocarditis," Journal of the American Medical Association, Nov. 1, 1902, by the writer. 288 INFECTIOUS DISEASES. made.'"i Of 1232 cases studied by N. G. Seymour, 62, or 5 per cent., were complicated by cardiac disease, of Avbich 25 "were cases of mitral incompetency. Tuberculosis of the Arteries and Veins. This may arise from extension of an adjacent tuberculous process into the vessel, as in chronic phthisis. It causes infiltration of the arterial ■wall, resulting in thrombosis, or the vascular tubercles may caseate and soften, thus leading to hemorrhage. In tuberculous meningitis tlie arte- rial lesions are conspicuous. The perforation of a vein by an old focus is followed by a distribution to all parts of the body of numerous bacilli and the production of acute miliary tuberculosis. Infection of the arte- ries may also occur through the blood. Of 1778 cases of pulmonary tuberculosis, thrombosis occurred 19 times, most commonly in the veins of the lower extremities (H. Ruhl and Hierokles). General Prognosis. — The prognosis is best reached as in other infectious diseases — namely, by taking into account [a) the severity of the type of the disease ; {h) the presence or absence of frequently associ- ated diseases or complications ; and (c) the numerous circumstances con- nected with individual patients. (a) The Severity of the Disease. — Though there are no accurate cri- teria, we may judge of the severity of the disease by its progress, by the result of proper treatment, and from certain symptoms. If the fever be high, the prostration marked, and the local lesions rapidly advancing, we may safely infer that the disease is of aggravated type. With these cer- tain other considerations are closely connected — the stage of the affection and the extent of the local lesions. Thus at an early stage the prognosis is more hopeful than at a late period, and, similarly, when the lesions are strictly localized at one apex it is more hopeful than when they have reached the stage of extensive cavity-formation or are bilateral. As already stated, a certain proportion of the cases manifest an inherent tendency to spontaneous arrest or even cure, and this may occur even after the stage of excavation has supervened. Notwithstanding this truth, however, it is well to make in all undoubted instances of the dis- ease a guarded prognosis. A common error is the mistaking of a tem- porary for a permanent arrest of the tuberculous process, and in the nat- ural history of the aifection the fact was emphasized that its course was interrupted by periods of comparative comfort and noticeable improve- ment, followed by sharp exacerbations. (6) Associated Diseases and Complications. — These unfavorably modify the prognosis — marked toxic symptoms {e. g., rapid pulse, high tempera- ture, rapid emaciation), chronic nephritis, gastric complications, intestinal and laryngeal involvement. Some of the accidents of the disease may precipitate a fatal result {vide Modes of Death). The appearance of intercurrent acute pneumonia is indicative of danger. The detection of secondary infective agents in the sputum renders the outlook worse. Other complications have been detailed in the Clinical History. (c) Circumstances Connected with Individual Patients. — (1) A feeble, delicate constitution, either acquired or inherent (tuberculous diathesis), increases the morbidity of tuberculosis. (2) When the fever subsides and the patient gains flesh and strength, ^American Journnl of Medical Sciences, January, 1902, by the writer. TIIKA TMKNT OF TUBKR(JUJJ)S1S. 289 the outlook at once brightens. Maintenance of the weif^ht curve while the patient is in his- usual environment is a favorable indication. Kon/el- mann has observed a number of instances in which a tuberculous process of the lungs healed under the influence of a pleural efiusion, the theory being that the affected lung is given rest. The temperature and local symptoms often promptly subside. A high polymorphonuclear percent- age gives a bad prognosis, while an increasing lymphocyte percentage denotes favorable progress. The course of the disease is unfavorable in cases showing tubercle bacilli in the blood (Hilgermann and Lessen). (3) Hygienic Surroundings. — When the hygienic regimen under which the patient lives is the best, the prospect is more hopeful than when it is faulty. A proper diet aids favorable progress, while a defec- tive one often turns the scales against recovery. Equally influential for good is a pure atmosphere, while, ^er contra, a vitiated one is injurious. (4) Age. — In young subjects from five to fifteen years of age tuber- culosis often pursues an acute course and the mortality-rate is exceed- ingly high. Chronic tuberculosis may, however, form a sequel, and under appropriate surroundings may lead to recovery. In chronic phthisis "the younger the patient the shorter the duration." I have observed that patients who give a history of pleurisy early in life do not bear chronic phthisis well. Naegeli ^ found, as the result of 500 autopsies at Munich, Fig. 25.— Pasteboard spit-cup for receiving infectious sputum. WJien used tlie pasteboard can be removed from the steel frame and burned, that in persons over thirty years of age every one had been more or less successfully attacked by the bacillus tuberculosis ; bu*^ from the fact that most deaths had occurred in subjects under thirty, he concludes that the adult body is, as a rule, w^ell able to resist the attack. '• The absence of a tuberculous family history has but slight, if any, favorable significance" (Bonney). During old age pulmonary tuberculosis is usually more or less latent, and, owning to coexistent emphysema and chronic bronchitis, pur- sues a slow course.^ (5) The gravity of tuberculosis may be determined with some degree of accuracy by the use of creasote in gradually ascending doses. Hence this agent has a prognostic value. (6) Romer and Joseph ^ claim to have demonstrated beyond question that one infection with the tubercle bacillus confers a certain protection against subsequent infection. Treatment of Tuberculosis. Prophylaxis. — (1) This embraces thorough and prompt disinfection of the sputum as the best preventive element. To this end the patient must be taught to expectorate at all times into a spittoon or spit-cup which ^Hyg. RimchcK 2, 1901. - A physician should not neglect to examine the sputum in suspicious cases for bacilK. 3 Beitrdge zur Klinik der Tuberkulose, AVui'zburg, xvii., Xo. 3, p. 2S1. 19 290 INFECTIOUS DISEASES. contains a proper disinfectant solution, and when tlie break ing-doAvn stage has arrived ])ortable flasks {e. g. DettAviler's) containing an antiseptic so- lution must be -worn by the patient, even -while out of doors. Stokes and Schmitz advise a combination of alkaline solution of sodium hypochlorite (antiformin) and phenol. Afterward the sputum is to be destroyed by boiling or burning and the spit-cup sterilized. The sweat of tuberculous patients should be removed at intervals, and the surface of the body bathed with appropriate antiseptics. (2) Isolation. — After the stage of softening is reached the patient should invariably occupy a separate apartment, since, despite great care, the room and bed occupied by the consumptive become in time a source of infection. Hence, unwashable hangings and upholstered furniture, as well as other objects that facilitate the harboring of the bacilli, should be removed from the sick-room. The floor of the apartment should not be carpeted, but may in part be covered with rugs that can be fre- quently taken up and shaken in the open air. For like reasons, special hospitals and sanatoria for the treatment of the tuberculous poor are a necessity. Flligge's important researches {vide supra) shoAv that phthis- ical patients should wear a mask day and night, that should be removed only for eating and to expectorate. Tuberculous patients in the infec- tious stage of the disease should be retired from occupations in which they may infect others (Flick). Kissing by the patient must be pro- hibited and all things used or worn by him should be kept apart from those used by the family or his friends. The prevention of auto-infection, which often results from the swallowing of sputum, is most important. (3) Compulsory registration of tuberculous (pulmonary) patients is desirable. This insures thorough disinfection by health officers of houses in which deaths from phthisis have occurred, and serves to cut off many of the varied channels of transmission of the tubercle bacillus, provided that the measures applied be not rigorous. (4) Government Inspection of Dairies and Slaughter-houses. — This is the serious business of the State, and, since infection through food, espe- cially milk, is quite common in infants, skilled veterinary inspection of dairies is of prime importance. Of the greatest benefit would be the killing of all tuberculous cattle, and of less though decided efficacy the confiscation at the abattoirs of all carcasses that present marked lesions. (5) The popularizing of information relating to the dangers of, and the means of stamping out, this great scourge. This may be in part accomplished by mural placards, stating simple, plain facts about the way in which the disease is spreading. Armaingaud suggests the placing in the homes of the people printed matter in a form suitable for preservation. (6) The Removal of Knovm Predisposition to the Disease. — The tuber- culous diathesis, whether inherited or acquired, must be overcome, if at all, by vigorous measures or by better hygienic living. In attempting to remove the phthisical tendency the physician must place chief reliance upon the most favorable environment attainable. The value of a change of residence — from the city to the countr\\ the seaside, or the mountains, in selected cases — cannot be overestimated. It often renders predisposed persons immune. For some, and particularly young subjects, an equable climate (Southern California or Florida), that Avill enable them to live an out-door life is to be preferred. Attention to the food must not be forgotten. Milk and raw eggs are excellent and should be used freely. TREATMENT OF TUBERCULOSIS. '^01 Daily sponging of the neck and thorax with oohl water is hcncficial, and appropriate liglit gymnastics should be instituted if the subject be ohl enough. In-door occupations are to ]/e forbi(hlen, and tlie ventilation of living- and bed-rooms must be looked after carefully. Tuberculosis is apt to develop especially in children while convalescing from acute fevers, and hence during this period the child should be strengthened by vigorous feeding, pure air, and tonics. In children predisposition often results from obstructions in the nose and from persistently enlarged tonsils ; and they should be promptly removed. All local foci of tuberculosis in children — glandular, osseous, and artic- ular — must be attacked surgically. Treatment of the Disease. — The treatment of tuberculosis, re- garded as a parasitic disease, presents two leading indications. One has reference to the destruction of the specific cause, the tubercle bacilli, by the use of antiseptic inhalations or of some parasiticide taken internally. Of the numerous substances used by inhalation, few have given satisfac- tory results, this being largely due to our inability to convey them to the smaller bronchi in a sufficient degree of concentration. They are best adapted to, and most efficacious in, cases in which the larynx is involved. The inhalation of antiseptic substances may be accomplished in various ways — by inhaling vapors, by the use of the steam atomizer, or by some form of " respiration-inhaler." I have long employed the Robinson in- haler, the sponge of which is moistened with a few drops of a mixture made of equal parts of creosote, chloroform, and alcohol, the patient wear- ing the inhaler when not eating or sleeping. Unfortunately, most patients object to the constant use of this instrument. When hemoptysis is pres- ent, turpentine may be added to the above mixture. The chief among other antiseptics thus employed are carbolic acid, terebene, terpin hydrate, thymol, formalin, and oil of peppermint. The most common, because least objectionable, mode of introducing this class of substances is by internal administration. According to the results reported from all quarters of the world, creasote thus employed alone enjoys the confidence of the profession ; and in common with nu- merous other observers I have found its continued use to be followed by lessened cough and expectoration, lessened fever, and by a lessening or cessation of the night-sweats, with a gain of strength and weight as the natural consequence. It must be borne in mind that the dose is to be gradually increased to the point of gastric tolerance, which in my experi- ence rarely exceeds 15 to 20 drops (0.999) three times a day. Following, in the main, the practice of Trudeau, who has used this drug quite as extensively as any other American physician, after reach- ing the point of tolerance I gradually reduce the dose to and maintain it at 5 or 6 drops (0.333), three times daily. Among the best vehicles are hot milk, hot water, and diluted alcohol. Recently I have ordered it in capsules, which the patient himself fills at the time of using, and have found it a popular and ready mode of administration. When creasote is not well borne by the stomach and its inhalation is seriously objected to by the patient, it may be given by enema, the dose being 20 to 30 drops (1.332), in peptonized milk or mixed with a little egg-white. It has also been employed hypodermically in a 10 per cent, solution in oil of sweet almonds, the dose of which is 1 dram to 11 drams (4.0-6.0). Lastly, it has in rare instances been employed by inunction. 292 INFECTIOUS DISEASES. Guaiacol. particularly in the form of the carbonate, has of late been (juite extensively employed in place of creasote, of which it is the chief active principle. It may be administered in pill or capsule, the dose being slightly less than that of creasote. It is well tolerated by the stomach, and is broken up in and absorbed from the intestinal canal. Among other remedies prescribed for their supposed parasiticidal effect are arsenic and mercuric chlorid, but they are clearly inferior to creasote. I am of the opinion that all antiseptics used internally in this disease have for their chief influence a modification of the soil-conditions on which the growth and multiplication of the bacilli depend. They are, in truth, of great value in fulfilling the second leading indication of treatment, which is to overcome the bodily receptivity for the specific bacillus, or to aid the natural defensive processes in limiting the destruc- tive work of the latter. All forms of tuberculosis, however, may heal spontaneously in any stage, especially the local varieties so common in children, affecting the lymph-glands, joints, and bones. Old pleuritic lesions, a large proportion of which are tuberculous in nature, are constantly met with at autopsies in persons dying suddenly of other diseases. Spontaneous recovery is seen oftenest in cases that have not progressed to the stage of cavity formation. Indeed, in the instances in which vomicae of considerable size have formed, cicati'iza- tion or complete cure is out of the question, though they may become encapsulated (quiescent). The percentage of cases in which encapsulated and obsolete lesions have been observed at the postmortem table in per- sons dying of all causes difters widely with the statistics of different observers. If we consider the cases that are latent from an early period in life, together with those of all ages after childhood, it is doubtless true that in more than 50 per cent, of the human family the bacilli effect a lodgment. Since about 14 per cent, of the deaths from all causes can be ascribed to tuberculosis, there must be manifested a strong tendency to limitation and healing. In removing the diathesis medicines are unquestionably of less value than the hygienic treatment, the latter in the widest sense of the term aiming to reinforce Nature's efforts at spontaneous recovery, and embrac- ing four main elements : (1) Climate ; (2) Feeding ; (3) Special Eeme- dies ; (4) Treatment of Leading Symptoms. (1) Climate. — The all-powerful influence of environment has already been pointed out. Experience and observation have shown that certain climates, selected with particular reference not only to the stage of the affection, but more particularly to the individual, are useful modifying influences of the tissue-soil. In any case of tuberculosis that climate is most suitable in which the patient " feels well, eats well, sleeps well, and gains flesh and strength " (Delafield). Until the patient finds such a climate, or if he finds no single climate to produce these results, he should travel from place to place, unless special contraindications (excessive de- bility, etc.) exist. If active tuberculosis has existed, the stay in a suitable climate should not be less than two full years. The climatic requisites for a consumptive are (a) purity of air, (b) equability, and {c) abundant sunshine. Less beneficial, though impor- tant, are [d) dryness and (t;) altitude. (a) Purity of Air. — This requirement is of paramount importance, TREATMENT OF TUBERCULOSIS. 203 and thus is expl;i,ined the fact that mountain air and that of the virgin forest are so helpful in phthisis. Forests, and particularly pine-groves, favor atmospheric purification, since they generate ozone, which oxidizes the impurities contained in the air. (b) i^quability has I'eference to the absence of rapid variations of tem- perature. On the whole, a relatively low is better than a high tempera- ture, the former being stimulating, and the latter sedative, in effect. It should be pointed out that forests also greatly favor the quality of equa- bility,^ both as to temperature and relative humidity. They tend to maintain an almost unvarying degree of moisture in their vicinity, thus minimizing the diurnal variations of temperature — a point that is of far greater importance than the question of seasonal variations. Forests intercept and temper the bleak Avinds of winter, while by their shade and leaf-surfaces they afford a cooler temperature in summer. {c) Abundance of sunshine is demanded by the consumptive. The advantages of sunshine are obvious frorn the observations made by Munn ^ in the year 1892, when in Denver there was sunshine in 62 per cent, of the possible hours during which it could occur. A dry atmosphere has advantages, but that dryness is not an essential element is shown by the fact that patients often do well at places having comparatively high rela- tive humidity, such as Florida, Southern Georgia, Southern California, and the resorts on the south coast of England. The rarefied atmosphere of high altitudes, on account of its stimulating effect upon the respiratory function, aids in producing good results, but the pulmonary changes in- duced (enlargement of the air-cells, with augmentation of the size of the chest) make it necessary for patients to remain for the rest of their lives. That it is not an essential factor is shown by the excellent results obtained in the ofttimes purer atmospheres at lower levels. Cases in which hem- optysis is severe and of frequent occurrence, those complicated with weak hearts, and neurasthenic subjects should not be sent to the high altitudes. The essential climatic factors mentioned are found in certain American and European resorts. Of the former, the Adirondack region, Colorado, Arizona, and New Mexico are especially to be mentioned, combining as they do in winter a uniform cold, much sunshine, and purity of atmo- sphere. A camp- or tent-life in the open air is strongly advocated. Ac- cording to my own experience, the Adirondacks meet the indications best in early cases or in patients who have strength enough to lead an outdoor life, and in whom the breaking-down stage is not too far advanced. Some cases, in the early stage, also do well at Thomasville, Ga., South- ern California, and at Lakewood, New Jersey. Some of these resorts possess the added advantage of affording an opportunity of gaining a liveli- hood. Among foreign resorts, Davos possesses about the same advan- tages as may be met in Colorado, New Mexico, and the Adirondacks, while the resorts in Southern Italy and France are comparable to South- ern California, Southern Georgia, Florida, and the Bermudas in this hemisphere. Good culinary and home comforts are considerations of no less importance than the climate. Briefly, the atmosphere of forest resorts possesses certain unmistakable advantages for this group of sufferers. Hence they should be sent into the neighborhood of the nearest forest in mild latitude (if they cannot enjoy the advantages of more remote resorts), where reasonably good ^ Houserflants as Sanitary Agents ; Sanitary Influence of Forest Growth, p. 31 2, by the writer. ^ Medical News, Aug. 18, 1894. 294 INFECTIOUS DISEASES. food and other comforts of life are obtainable. The superior value of the highly ozonized and torebiuthinized atmosphere of the pine-groves in largngeal tuberculosis cannot be too strongly emphasized. Sanatoriiua Treatment. — While it is essential to send patients to suitable resorts, the most satisfactory results are obtained from the com- bined climatic and sanatorium treatment. Sanatoria are warmly advo- cated by Trudeau, Knopf liowditch, and others. Of 237 early cases, treated in the Sharon Sanatorium, 81 per cent, were known to be alive and in excellent health for at least one year after leaving the institution.^ They should take the form of cottages and pavilions. The principal ad- vantages oifered are due to a rigid system of hygiene under the close supervision of competent medical officers. There xwe four groups of cases among the middle and lower classes that recjuire institutional treatment: Group I. — The numerous cases that have progressed to an advanced and practically hopeless stage and the acute forms. These require every comfort and kind care, such as can be furnished by special Jiospitah for consumption in a healthful urban locality. Grouj) II. — Incipient cases among the pauper element. For these, sanatoria located close to large municipalities, though with special refer- ence to such factors as purity of atmosphere and protection from chilly blasts, by natural elevations or the woodland, should be provided. Group III. — Phthisis pulmonalis among the middle and working class, or persons having small means. The members of this group will find themselves compelled to depend principally upon private philanthrop\% and probably to some extent also upon semi-State institutions ; they need sanatorium treatment in the best climates, and there is no valid reason Avhy the combined sanatorium and climatic treatment should not be attempted, since such an undertaking could be made almost self-sustaining.' Group lY. — " A settlement for patients with arrested consumption where they can be employed on work adapted to their strength" (PowelP). Among home sanatoria are the Adirondack Cottage Sanatorium, the Sharon Sanitarium, near Boston, the Loomis Sanatarium, at Liberty, N. Y., the Winyah Sanitarium, at Asheville, N. C, the White Haven Sanitarium and Mont Alto in Pennsylvania. Foreign sanatoria are to be found at Falkenstein, near Frankfort-on-the-Main, Goerbersdorf, and llohenhonnef. Solaria, in connection with city hospitals for advanced cases, would, I am certain, yield gratifying results. Home sanatoria can be readily improvised by stocking living apartments Avith growing plants. The beneficial influences arising from the presence of the latter are ascribable to two functions — the generation of ozone and transpiration.* Tuberculosis dispensaries and classes ai'e highly recommended in the treatment of tuberculosis among the poor and persons having small means. The class method is useful as an object lesson to teach the essentials in the home that ai'e taught to the individual in a sanatorium (Wood). Open-air Treatmevt at Home. — This method is now widely practised. It is of inestimable value to patients who must perforce be treated at home. They are kept constantly in the open air, and for the most part 1 V. Y. Bowditch and W. A. Griffin, Jour. Amer. Med. J.ssoc, Dec. 24, 1912, 2132. 2" Sanntoria and Special Hosjiitals for the Poor Consumptive and Persons Avitli Slight Means," by tlie writer. ^Lancet, Jan. 6, 1906. ^ Ibid, by the writer, p. 168. TREATMENT OF TUJJERC'ULOS/S. 295 at rest. At night tlie bed-room windows should be open, even in severe weather. Indeed, sleeping in the open air on a veranda, poreh, or the roof, is to be advised and encouraged, and ingenious contrivances have been invented whereby the patient can occupy a bed out-of-doors at all seasons of the year. With warm clothing, abundance of good food, especially raw eggs and milk, and a careful regimen, surprising results are obtained even in large cities. In my opinion, however, most tuber- culous patients, at all events, require the rigorous discipline of a sanato- rium for a variable period of time so that they may acquire proper habits of living. Such a sanatorium for the reception of indigent patients should be situated in their home climate. The experiment has already been made in Chicago and other cities with complete success. When the tempera- ture is above 100° F. (38.7° C.) the patient should be kept at rest. Flick, Minor, and Coleman are of the opinion that tuberculosis patients can be successfully treated in their homes and other places than sanatoria. (2) Feeding. — The diet should be both nutritious and generous. Too close attention cannot be bestowed upon the feeding. Above all, when the remedies prescribed (cod-liver oil, creasote) embarrass in the slightest degree the function of the stomach they must be stopped. Such albuminous articles as milk, eggs, flesh, fish, and fowl, together •with an abundance of fats, should be taken. The hydrocarbons are urgently needed, but they must be taken with care lest they derange the digestive function. Over-alimentation with raw eggs and milk is strongly advised. The eggs are to be slightly beaten and stirred into the milk and the quantity is to be increased until from eight to twelve eggs and as many glasses of milk are taken daily. One-half of this amount may be used during the morning hours and the other half during the evening hours. At mid-day a generous meal composed of easily digestible solids is allowed. In advanced cases it is often needful to resort to a rigid sys- tem of feeding, giving a small quantity of food, such as milk, meat-juice, egg-white, and the like, at brief intervals. The French method of forced feeding deserves a trial if there be absolute loathing for food. It consists of first washing out the stomach with cold water, and then introducing the following mixture thrice daily : 1 liter of milk, an egg, and 100 grams of very finely powdered meat. As a rule the patient cannot be induced to swallow this, and it then must be poured through a stomach-tube. In a minority of the cases the appetite is ordinarily keen, often as a result of change of air, and these usually pursue a favorable course. The fol- lowing combinations will be found useful in assisting the appetite: ]^. Sodii bicarb., 3jss (6.0); Tr. nucis vomicae, f^ijss (10.0); Glycerini, f^j (3.75); Inf. cascarillge, q. s. ad f§iv (120.0). Sig. 3ij (8.0) t. i. d., in water, fifteen minutes before meal-time. Other simple bitters and mineral acids may be tried, and there are some cases in which the judicious use of stimulants, particularly wines and malt liquors, aids the appetite and digestion matei'ially. The chief indications for the exhibition of alcohol are loss of appetite, feeble di- gestion, and weak, rapid action of the heart. Brandy or whisky in the form of milk-punch may be given freely in the advanced stage. Strych- 296 INFECTIOUS DISEASES. nin is a valuable remedy in the later stages. Lavage has helped some of my cases immensely. Lastly, an orderly method and sound judgment must be bronghr to bear in arranging the diet and drink. (o) Special Remedies. — The treatment of tuberculosis by mercury has been \videly adopted. Wright ' recommends the succinimidum, and the details follow: " One injection of hydrargyrum succinimidum, grain -l, is given every other day until 30 injections have been given. Then injec- tions are discontinued and potassium iodid. grain iij to x, is given "well diluted Avith water one-half hour after meals for two weeks. Then potas- sium iodid is discontinued and no medicine is given for one week. Injections are then resumed as follows : One injection every other dav until 30 injections have been given, on alternating injection days giving hydrargyrum succinimidum, grain i and -^^, respectively. After the thirtieth injection the same course of potassium iodid is given as followed the first series of injections : then a week free from medication. The injections are then resumed again, the succinimide. grain jL^ being given every other day until 30 injections have been given. By the end of this third series experience will direct any necessary further treatment." Cod-liver oil is another special remedy of great value. It may rarely cause further impairment of the appetite and digestion, or set up intes- tinal disturbances, when its effects are harmful. The commencing dose should be small (oj — 4.0, once or twice daily, to be increased after a time to oij — S-'-^ two or three times daily). It should be taken about meal- time. AVhen the oil is not well borne, it may be given in combination with an alkali (lime, soda). As a substitute for cod-liver oil, cream, preferably Devonshire, may be tried (sij to 5ss — 8.0 to 16.0, three times daily). The hypopliosphites are especially serviceable in a certain proportion of the cases. The dose is oj to ij (4.0-8.0) thrice daily, after food. Arsenic is warmly advocated for its general influence in this disease. The dose should be small, so that it may be given for a long time without interruption. As sodium cacodylate, its use has increased of late. Jacobi speaks highly of digitalis in tuberculosis in children. Iodoform- or europlien-inundions are warmly commended by Flick, who asserts his belief that incipient cases almost always can be cured in this Avay, and that advanced cases can be improved. Crofton advises the use of iodoform intravenously (gr. \ to j — 0.0162 to 0.0648, dissolved in ether with a little liquid paraffin added) two to five times a week. Serum-therapy. — The definition of this term embraces also the em- ployment of toxins and modified toxins produced in various media for the establishment of artificial immunity. Kochs tuberculin. Rosenbach's tuberculin, and Paquin's antitubercle-serum have been highly recom- mended as remedies in tuberculosis by certain clinicians. Dr. Trudeau prefers antitoxic immunity, and considers tuberculin habituation its es- sential feature and the best guide to dose ; this requires long-continued and almost iiuporceptible progression in dosage until a maximum is reached without causing general or local reactions. A. E. Wright rec- ommends Kochs tuberculin, claiming that in patients so treated the for- mation of opsonins is stimulated, as shown by a remarkable increase in the phagocytic index. Penrose^ first obtains a good tolerance dosage of tuberculin, then administers a course of succinimid of mercury, and later alternates the tw^o remedies with a view to using larger doses of tuberculin 1 Jour. Am^r. Med. Assoc, Nov. 28, 1908. "^ New York Med. Jour., June 11, 1910. TREATMENT OF TUBERCULOSIS. 297 without risk. Vaccines made from associated organisms isolated from the sputum are of marked vahie in the treatment of tuhei-culosis,' Escoyer chiims 53.8 per cent, of radical cures from the use of Cu^'uillere's serum. Brauer, Wellman,^ and others recommend artificial ];)ncumothorax in the treatment of selected cases of pulmonary tuberculosis. A limited in- volvement of one apex may present an indication for either surgery, or the injection of nitrogen into the pleural cavity which may be the more effective (Mumford). Bayle claims to have cured 75 per cent, of 172 patients with spleen organotherapy. Tlie advent of an acute diseaae may arrest and cure a tuberculous process. Thus, the symptoms and signs of advanced tuberculosis have disappeared after an attack of virulent small~pox and acute rheumatism (Harris and Beales). Hysteria also exercises an ameliorating effect upon pulmonary tuberculosis, according to the observations of Gibotteau,^ who advises against treatment of the former disease in tuberculous persons. Treatment of the Acute Forms. — The treatment of acute tuberculosis is an expectant one. The special measures recommended above should be tried, but are rarely effective, and a change of climate is inadvisable. Supportive measures, such as stimulants and nutritious aliment, are re- quired. The medicinal treatment must be adapted to the acute febrile condition, but all depressants are to be avoided. Special symptoms may be relieved in accordance with general principles. In renal tuberculosis, recent experience confirms anew the importance of prompt nephrectomy. When this is impossible, for any reason, coui'ses of mineral waters may prove useful. Castaigne reports 5 cases in which he used tuberculin or Spengler's immunizing bodies, or both, with ulti- mate success. Barney recommends epididymectomy in cases of tuber- cular epididymitis. In tuberculous peritonitis, Hoffmann reports good results from opening the peritoneal cavity, evacuating the fluid, if present, and painting the peritoneal surfaces of the gut and abdominal wall with 10 per cent, tincture of iodine. In tuberculous adenitis, the Rcintgen rays should be employed early. (4) Treatment of Leading Symptoms. — {a) Cough. — This is often quite annoying. The special cause or causes of the coughing should be deter- mined before any attempt is made to treat it. When attributable to catarrhal irritation of the upper air-passages, it is best treated by topical applications. The following substances may be inhaled : compound tincture of benzoin, combined with paregoric or carbolic acid ; formalin ; creasote, alcohol, and chloroform in equal parts. For local applications by means of the spray sedatives and narcotics should be preferred, and a solution of cocain is sometimes most efiicient. The cause may be found in pleurisy or pleuritic adhesions, and for this condition counter-irritants, as iodin, sinapisms, etc., may be used. Pleuritic coughs often demand codein or even morphin in moderate-sized doses. The cough is in most instances occasioned by the tuberculous bronchitis, and to a lesser ex- tent by the vomicae. Cough-mixtures as usually formulated are apt to disorder the digestive function, and in so far as they have this effect they are positively harmful. Syrups should be omitted from their com- position. Creasote by inhalation is the remedy par excellence for tuber- culous bronchitis, combined with spirits of chloroform and alcohol. iSee also Neio York Med. Jour., Nov. 11, 1911, hv G-. Sanders. ^Beitrdge zur Klinik der Taberkulose, Wiirzburg, Dec. 10, 1910, p. 2100. 3 The Practitioner, October, 1894. 298 INFECTIOUS DISEASES. When expectoration is copious, preparations of terebene, terpin hydrate, and tar may be resorted to ; and Avheu the cough becomes distressinji, I employ codein (gr. |-^ — 0.008 to 0.016, every three or four hours) in the form of a granule. In the later stages morphin is alloAvable, since it is at this time that constant coughing or severe paroxyms of cough, if not restrained lead to utter exhaustion. Heroin, in doses of gr. -^ to -^\ (0.01-0. 005), three or four times a day. acts beneficially in allaying the cough th»t accompanies phthisis. Stimulant expectorants may be needful, and ammonium carbonate in the infusion of wild-cherry bark is perhaps most efficacious : a few drops of the deodoi'ized tincture of opium or spirits of chloroform may be added. {b) Fever. — Creasote has found a new field of usefulness in the treat- ment of the fever of tuberculosis. In my experience at all events, the cases in which it has been used, as above indicated, have shown a greatly diminished febrile movement. Cold or tepid spongings of the body at intervals of one, two, or three hours, according to the intensity of the fever, should be tried. Internal antipyretics are rarely advisable, since during the period of high temperature the cardiac action is much enfeebled ; but if urgently called for, the following may be employed : acetanilid (dose gr. ij— iij — 0.129—0.194). phenacetin (gr. iij-v — 0.194- 0.324). These are to be administered about two hours before the com- mencement of the daily rise in temperature, and repeated every three or four hours if necessary. Other antipyretics worthy of trial are the min- eral acids and zinc oxid, but not quinin, which has utterly failed in my hands. Keeping the patient at complete rest wlien there is fever is of the utmost importance, though he should be wheeled into the fresh air for as long a time as possible during the day. (e) The Niglit-siveats. — Among remedies that control the sweats most successfully may be mentioned — atropin (gr. xi'^^eV — 0.0005-0.001) ; zinc oxid (gr. ij— v — 0.129—324); sulphuric or gallic acid; muscarin (TTLiij-vj — 0.399 of a 1 per cent, solution) ; agaricin (gr. -i— 1 — 0.008- 0.016). Sponging with equal parts of alcohol and tincture of bella- donna is very effective, but my own best results have been derived from the use of atropin (gr. y^o~9V — 0.0005-0.0007) in combination with agaricin (gr, -1 — 0.008). {d) Secondary Anemia. — Bullock and Peters recommend subcutaneous injections of citrate of iron (0.05 gm. injected daily). Barlow and Cun- ningham advise the subcutaneous or intramuscular injection of arsenic or iron, or of the two in organic combination. {e) Dysphagia may be a troublesome symptom, especially from in- volvement of the larynx, and it is best met by local applications of a solution of cocain in glycerin and water (gr. x to 5J-0.648 to 32.0), thrice daily before meals. In advanced cases I have resorted to hypo- dermic injections of morphin (gr. -| — 0.008) before meal-time. (/) Gastric Disturbance. — In nearly all cases of phthisis dyspeptic symptoms come on sooner or later, and for this gastric disorder nothing is so important as a proper regulation of the diet. Perhaps the medical treatment of the stomach symptoms has been dealt with at sufficient length, save that of vomiting, Avhich may come on after meals and con- stitute a distressing concomitant. Those remedies giving the best results may be adduced as follows: cerium oxalate (gr. v— viij — 0.324-0.518), in capsules before meals ; calomel and soda in fractional doses ; hydrocyanic LKI'ROSY. 299 acid (TTLij-iij — 0.133-0.190) ; uiid chipped ice with hriindy sprinkled over it, taken at short intcrviils, but es{)ecial]y sliortly before rneal-lirne. i^g) Diarrhea. — The most important factor in the treatrwent of this symptom is a properly restricted dietary. Alum whey, mutton and chicken essence are of service, but curds of milk, beef-tea, and solids are not suitable. Of the numerous medical measures that have been employed, the most useful are bismuth subgallate, lead acetate, opium, thymol, salol, benzo-naphthol, and naphthalin. To these may be added the following acid diarrhea-mixture, each dose containing — 3^. Acid, acetici dil. X^x (0.666); Morphinse acetat., ' gr. |- (0.008) ; Plumbiacetat., gr- j-ij (0.0648-0.1296). Complications when they arise must be dealt with according to accepted therapeutic principles. LEPROSY. {Lepra). Definition. — A chronic, contagious disease, caused by the bacillus leprse. It is distinguished by constitutional depression and, pathologi- cally, by tuberculous masses in the muco-cutaneous surfaces, and by changes in the nerves. Historic Note. — In 1889, Morrow stated that in India alone there were certainly not less than 150,000 lepers, while at present it is estimated that there are over 250,000. Its geographic distribution probably covers more than one-third of the entire surface of the globe. It is common in Africa, Brazil, in the East, and in Norway. In the Sandwich Islands the disease is of comparatively recent origin, and yet of great and increasing prevalence, a leper settlement having been established consisting of more than 11,000 cases. Leprosy is not unknown in America, and in Mexico it has existed ever since the time of Cortes (Morrow). Blanc states that there are 75 to 100 lepers in Louisiana alone. It was introduced into California and Oregon by the Chinese, and into Illinois, Iowa, Wisconsin, and Minnesota by Scandi- navian immigrants. It has been imported from the Sandwich Islands to Salt Lake City, and from Normandy to Tracadie on the Gulf of the St. Lawrence, where the " disease is limited to two or three counties which are settled by French Canadians" (Osier). Sporadic cases have been met with in most American cities. The Commission on Leprosy reported in 1902 the records of 278 cases, of which 145 were native born Americans. The disease appears to be lessening in the United States. Pathology. — The bacilli grow and develop in clusters in the tuber- culous nodules in the skin and in the anesthetic and pigmented areas, residing within the epithelioid cells and leukocytes. 'Ihese so-called lepra-cells are probably derived from the lymphatic vessels or capillaries, having been transformed by the bacilli. Surrounding the granulomatous masses is a layer of connective tissue. The bacilli are aho found in the lymphatic glands, the spleen, and liver, but rarely in the blood. The nodular tumors form projections from the skin-surface, and, being poorly supplied with blood-vessels, they soon undergo caseation and absorption 300 INFECTIOUS DISEASES. or are obliterated by dense connective tissue (fades leontina). The pus- organisms generally exercise an influence in causing suppuration with ulceration, which may manifest a marked destructive tendency. Similar changes occur in the internal organs or in the mucous membranes. Nerve-Jesiong are induced by the presence of the bacilli within and around the nerves. Here they set up an irritation with hyperesthesia (neuritis), leading to atrophy, with marked degenerative changes. Ktiology. — Bacteriology. — In 1880 Hansen discovered the bacillus leproe, since proved to be the special agent of the disease. It strongly resembles the tubercle bacillus, but differential stains have been suggested by Unna and others. Bordoni-Uffredozzi was able to cultivate a bacillus which difi'ered from the lepra bacillus in its morphology, although staining in a similar manner. His results have been confirmed by Czaplewski. Inoculation experiments on animals have not as yet succeeded. Predisposing Causes. — Everyone is susceptible to leprosy. E. B. Goodhue, however, claims that a natural immunity exists. The disease is most frequent between the twentieth and fortieth years, and is rare in childhood. Sex and latitude have little if any influence. Hereditary transmission probably influences about one-fortieth of the instances (Zambaco). Heredity is denied by both Hansen and Raminez. As pointed out by Bidenkap, leprosy is often rare in large cities, even though prevalent in the surrounding rural districts. Modes of Infection. — The disease is transmitted by contact ; but Widal and others, Avho have studied the disease as it exists in the Hawaiian Islands, think that leprosy is contagious only by inoculation. Long's experiments point to transmission by means of the bed-bug. Morrow's view, that, like syphilis, leprosy is generally transferred by sexual intercourse, receives support. Hansen holds that the infection atrium is unknown; he thinks it probable, however, that the mouth and nasal cavities are the avenues of entrance. Sticker also regards the nasal mucous membrane as the primary focus, and finds in it constant lesions. The bacillus has been found in the floors and w^alls of houses in leper colonies, and also from the urine and even the milk of patients. Clinical History. — Two forms are recognized, the tubercular and the coiest/ietie, but neither of these runs its entire course without develop- ing into a third or mixed form. The incubation is usually long (three to five years — Hansen). It may rarely be shorter or much longer. Vague prodromes are present for years (drowsiness, chilliness, recurring attacks of fever, debility). (1) Tubercular Form. — In the first stage there is a patchy, cutaneous erythema with a slight hyperesthetic elevation of the affected areas (mac- ular leprosy). These are oftenest seen on the face, the extensor surfaces • of the arms and knees. They may vanish and leave the skin pigmented and anesthetic, and later the pigment may disappear, while white spots of corresponding size remain (lepra alba). When the disease progresses less favorably tuberculous nodules (dusky red or almost brown in color) develop in addition to anesthesia. The small ones soon disappear, while the large ones are either absorbed or break down and ulcerate — changes which, as they advance together with the slow healing process, produce marked deformities. The skin is greatly thickened and presents a scaly surface, and there is loss of sub- stance in certain parts, while others are enormously enlarged (eye- LEPROSY. 301 brows, nostrils, lips, etc.). Airiong the many syrnptonis pointing to in- volvement of tlie mucous membrane :ire ozena, hoarseness or even aphonia, and the signs of inhalation-pneumonia. Blindness often ensues as the result of extension of the process. To ulcers extending deeply into the mucosa of the pharynx and larynx, death may often be ascribed. (2) Anesthetic Form. — In this variety the local symptoms point usu- ally to implication of the nerves. At the onset there are jjain and patchy hyperesthesia., while minute bullae, due to trophic changes, put in an ap- pearance on the arms and legs. The muscles supplied by the branches of the affected nerve-trunk waste, and the superficial nerves feel thick- ened and nodular. Bright-red patches of vaso-motor congestion appear and soon become anesthetic, while the maculae disappear. Anesthesia may proceed without the latter eruption. Dry, yellowish-white, scaly patches upon the trunk and extremities are also visible. Early their centers alone are anesthetic, but subsequently the loss of sensation spreads even to healthy portions of the skin. Trophic alterations reach an extreme degree. Bullae appear, and, bursting, leave perforating or destructive ulcers, usually upon the extremi- ties. As the result of absorption, wasting, and necrosis great deformi- ties are produced. The hands often take on a claw-like form, and the fingers and toes may disappear (lepra mutilans). Diagnosis. — The early diagnosis rests upon the presence of patchy erythema with hyperesthesia, followed by the development of anesthesia, with a disappearance of the muscular eruption. Nodular neuritis is pathognomonic of anesthetic leprosy. Scrapings of the skin lesions frequently show the specific bacilli. In the advanced stages of either form confusion could scarcely arise. The nodular form of tubercular syphilis is distinguished by the distribution of the lesions, the history, the frequent sensory nerve-lesions, and by incising the tubercle and com- pressing serum from it — when lepra bacilli are found in the exudate — bacilli may be found in the nasal secretion. Zambaco and others have claimed that syringomyelia and Morvans disease are in most cases but forms of leprosy ; but this has been disputed by Hoffman, Schlesinger, and Sahli. Syringomyelia depends on lesions of the central nervous system, while leprosy has its nervous lesions in the peripheral nerves. The first symptoms in syringomyelia are localized usually in the upper extremities, while in leprosy they are generalized. In leprosy the tactile sense is usually lost, in syringomyelia usually not lost. Shoemaker and Boston ^ report an advanced case where lepra bacilli were found in the blood, and collected reports of 20 similar cases from the literature. Prognosis. — Leprosy runs a very chronic course, lasting sometimes two, three, or more decades. The prognosis as to the final issue is hope- less, but the patient may live in comparative comfort for many years before the ravages of the disease cause great mutilation. Treattnent. — Certain diseases are supposed to exercise a retarding effect on leprosy (erysipelas, pneumonia, variola, phthisis). Antagonistic inoculation, however, as practised by Beaven Rake and others, has been practically negative in its effects ; and the same is true of the treatment by Koch's tuberculin. The disease has thus far resisted all methods of treatment. Matthews^ treated 7 cases representing both kinds of leprosy 1 Proceedings of the Philadelphia County 2[edical Societi/, Jan., 1903. ^ " Treatment of Leprosy with x-rays and High Frequencv," Indian 3fedical Gazette, Aug., 1908. 302 INFECTIOUS DISEASES. with .r-ravs and high frequency, and concludes that it is the only method Avhich has produced any real effect on the progress of the disease. In- ternaUy, chaulmoogra oil has been employed with excellent results, the dose being from 1 to 2 drams (4.0-8.0). It is sometimes administered in pearls (each containing tUiij to v— 0.199-0.333), in ascending doses, until the limit of tolerance is reached. Surgical interference may become necessary, Manson advises free excision if only one tubercle, and no signs of a general invasion, be present. Segregation of lepers has been instituted in certain localities with encouraging results. Calmette's anti- venomous serum, while not a true antidote, may produce a marked tem- porary improvement or even cure in uncomplicated cases. The Nastin treatment (dose 1 c.c. by injection) has given variable results. Rost advises Aveekly injections of vaccine. GLANDERS. [Farcy.) Definition. — An infection of equine origin, caused by the bacillus mallei. Two forms are recognized — true glanders andfa7'ef/. Pathologfy. — The characteristic lesions are new growths (granu- lomata, according to Virchow), which are usually nodular in character, though they may be diffuse. These masses soften and form ulcers when they occur on the nasal mucosa, and abscesses when they are situated subcutaneously. Microscopically, the nodular tumors are composed of cells — lymphoid and epithelioid — together with the specific bacillus. etiology. — The morbid changes above described are caused by a specific organism, the bacillus mallei, Avhich resembles closely the tuber- cle bacillus, though it is a little thicker as well as shorter. It is non- motile. It can be readily grown, and as readily inoculated into horses, in which it produces the disease with every characteristic symptom. Perhaps the simplest method of staining the bacillus mallei "is to treat a cover-glass preparation with warm carbol-fuchsin (preceded by acetic acid), and then wash it off with a 2 per cent, solution of nitric acid." Modes of Infection. — The virus is, as a rule, transferred directly from the infected animal to man, hence the disease occurs almost invariably among males and persons who come in contact with horses (hostlers, coachmen, soldiers, veterinarians, and farmers). Transmission from man to man has been observed, but rarely. The medium of conveyance is either the pus or the nasal secretions, which may drop or be blown from the animal's nostrils upon a wound in the skin or mucous membranes, however slight, and be absorbed. Immunity. — The disease is rare in man because of natural immunity. Singer has produced artificial immunity by intravenous injections of sterilized cultures of the glanders bacillus. Clinical History. — The duration of the incubation-period is from three to five days, and rarely longer. Both glanders and farcy may be acute or chronic in their course. (1) Acute Glanders. — At first the signs of inflammation develop at the point of infection, lymphangitis and swelling of the adjacent lymphatic glands being associated. Fever and other evidences of general disturb- ance soon appear, and at the end of two or more days the nasal mucosa OLANDEJIH. 303 becomes implicated, ulcers forming, from which a fetid muco-pnrulent (sometimes blood-streaked) discharge takes place. NoHP-lleed is com- mon. Later an eruption comes out on the face, the trunk, and the ex- tremities, particularly about the joints. It is papular, quickly becoming pustular, and the pustules may dry up while fresh papules are develop- ing — a characteristic feature. The /ace, particularly the nose, now swells, and a bluish-brown tumor covered with vesicles appears. Impli- cation of adjacent mucous membranes — conjunctivae, pharynx, mouth, etc. — is usual, and less frequently the bronchial and gastro-intestinal mucous membranes are involved. The ulcerative processes may extend to the bones, setting up necrosis. True arthritis occurs in 10 per cent, of the cases (H. Morel). Broncho-pneumonia is a common complication. (2) Chronic Glanders. — A rare disease with mild but vague general symptoms, as muscular and arthritic pains, fever at intervals, asthenia, and progressive wasting, and the local features of nasal catarrh, with a bloody muco-purulent discharge. Cough may be present. (3) Acute Farcy. — In this form the virus is inoculated into the skin, which presents the chief symptoms, the nasal condition being in abey- ance or absent. The primary lesion is of an aggravated type, accom- panied by numerous cutaneous boils and abscesses, often following the line of the lymphatics. Their favorite seat is in the vicinity of the joints. The constitutional symptoms simulate those of acute pyemia. (4) Chronic Farcy. — Granulomatous tumors, resulting in abscesses, constitute the chief clinical peculiarity. The abscessps are situated primarily in the subcutaneous tissues, and often near the joints. As a rule they open spontaneously and discharge, first a thick, creamy pus, and later a thin, fetid material. They sometimes form distinct ulcers, extending in depth until the bones are involved. The general symptoms simulate those of chronic glanders, the fever- curve being of the hectic type. In advanced cases emaciation and prostration become extreme. The duration varies from ten to eighteen months, though death may result earlier from some associated disease. Diagnosis. — The diagnosis cannot be made without a clear history of contact with an animal known to be affected with the disease. In doubtful instances some of the suspected material should be injected into the peritoneal cavity of a male guinea-pig. Pus is soon formed in the tunica vaginalis testis and from it bacillus mallei may be recovered in pure culture. One of the products of the bacillus mallei is so-called "mallein," which has been used by Nocard and others as a diagnostic agent in animals. Its injection into horses suffering from glanders is followed by a febrile reaction. Schindelke found that a reaction of 3.5° F. (2° C.) is almost positive proof of glanders ; while a rise of 1.25° F. (1° C.) is suspicious.^ Wade recommends the complement-fixation test supplemented by the agglutination test on all negative serums. Differential Diagnosis. — Cases of acute glanders have been mis- taken for variola; but the history of exposure, the mode of onset, nasal symptoms and the course of the eruption all differ from those of the latter disease. Pyemia may be eliminated by the history of ex- posure and inoculation experiments. The chronic forms must be dis- tinguished from tuberculosis and sypJiilis. Prognosis. — Acute glanders and acute farcy are almost invariably 1 Saunders' Year-Book for 1896, p. 1013. 304 INFECTIOUS DISEASES. fatal. The chronic forms, however, and particularly chronic ftircy, end in recoverv, under appropriate treatment, in nearly one-half the cases. Treatment. — The primary lesion should be dealt with surgically, and thorough disinfection followed by cauterization is highly recom- mended. Bayard Holmes advocates the opening of fresh abscesses and the scraping out of old ones under an anesthetic. A supporting plan of treatment, by generous feeding and judicious stimulation, is to be adopted, and the symptoms are to be met as they appear. The product, ''mallein," has been recommended as a specific, but its curative proper- ties have not yet been demonstrated. Bristow reports a case of human glanders treated by an autogenous vaccine, with recovery. ACTINOMYCOSIS. ( ' ' Big-jaw, " " Lumpy-jaw, ' ' etc, ) Definition. — An infectious disease of cattle, less frequently of man, caused by the ray-fungus (actinomyces), which grows in the tissues, de- veloping a mass with secondary chronic inflammation and metastatic growth as well as a secondary pyemic infection. Historic Note. — In 1877 Bollinger gave the first description of the ray-fungus, which he had observed in the disease- known as " big- jaw "in the ox. Israel of Berlin discovered the fungus in man one year later. In 1879, Ponfick showed clearly that actinomycosis in man and cattle was one and the same disease. Murphy, who described the first case of actinomycosis hominis in America, states that up to the present date more than 500 cases have been reported. Pathology. — A macroscopic mass is produced, consisting of a cen- tral fungous mass from which threads of mycelia radiate in all directions, producing the ray form of growth. Individual growths are of the size of a millet-seed, but their aggregation may result in masses as large as an orange ; they are of a sulphur-yellow color and of tallowy consistence. Induration and infiltration may extend far into the surrounding tissues. 3IicroscopicaUi/, the little or single ray-like tumors show straight or wavy branching filaments {supi-a). Their development is accompanied by the growth of dense adjacent connective tissue. In addition, ab- scesses containing yellow granules in the pus occur, but these are sec- ondary. In man the lesions consist of nodular growths with secondary abscess f iriuation. diff"erini: from those described as occurrincr in beasts. Bacteriology. — The organism of the disease belongs to the cladothrix variety of fungus, and may be cultivated, though with diflliculty. The finer threads may readily be stained with anilin colors. The club-shaped projections, however, do not take these stains. Pus from whatever source should be examined for the actinomyces even though cocci are present. Rabbits and cows have been successfully inoculated. Pyogenic organisms are commonly in association. Modes of Infection. — Infection generally takes place in young subjects through the mouth, teeth, and pharynx ; and rarely the infection atrium is the air-passages or the skin. The infecting microbe is generally intro- duced with the food or drink, and Bostroem, from a study of 82 cases, concludes that the poison enters the economy by means of the ingested grains of some cereal (barley). Clinical History. — (1) Oral Actinomycosis. — The patient often com- ACTINOMYCOSIS. 305 plains of toothache, dysj)hagba, and of difficulty hi opening the javK The latter symptom may be owing to induration of adjacent muscles, and is a very characteristic sign (J*artsch). At the angle of the jaw a swelling appears, which quickly passes into suppuration ; later it opens (first externally, then into the mouth) and discharges pus containing little yellow masses. If not properly treated, extension of the process takes place in a downward direction, even to the abdominal organs. The upper jaw may be the primary seat of infection, and if so the base of the skull may be perforated and the disease attack the meninges and brain. Bollinger has seen primary actinomycosis of the brain. In these instances caries of the spine may result from extension. (2) Pulmonary Actinomycosis. — I am satisfied that primary pulmonary actinomycosis is comparatively rare, although Karewski and Butler have each recently reported an instance. In Butler's case the disease fol- lowed an injury by a falling board. The disease begins with pain in the side, often the left, due to pleurisy. There are cough and a pecu- liar (fetid) expectoration, together with general wasting. A microscopic examination of the sputum, if made with care, reveals the actinoniyces. In some instances the symptoms are identical with those of disseminated tuberculosis of the lungs (Brigidi), though generally the disease is unilat- eral. There is irregular fever, due to suppuration. The physical signs may be those of chronic bronchitis merely ; but there are, in not a few cases, extensive destructive changes of variable character (abscess, broncho-pneumonia, etc.), which modify the signs accordingly. In primary pulmonary actinomycosis an extension to ad- jacent organs and also metastatic growths and abscesses occur. Wood and Eshner^ found the so-called sulphur granules in a pleural exudate. (3) Intestinal Acttaomycosis. — The condition may be primary or sec- ondary. The organism grows upon the mucosa of the intestine and excites a proliferation of the underlying connective-tissue cells, and the formation of submucous nodules. The latter ulcerate, and perforation of the serous coat of the bowel may occur, inducing peritonitis. Peri- cecal abscesses have been formed in like manner. The symptoms point to intestinal catarrh, there being some gastric dis- turbance, with recurring attacks of diarrhea. The actinomyces has been detected in the stools. Secondary metastatic growths (rarely) and ab- scesses may arise in other organs (liver, spleen, ovaries, etc.). The viscerae may also be the primary seat of infection. (4) Cutaiieons actinomycosis rarely occurs. The skin presents chronic suppurating ulcers which show the presence of the ray-fungus, and the condition bears a close resemblance to a lupus patch. Diagnosis. — This rests solely upon the finding of the actinomyces. The wooden hardness of the tissues beyond the borders of the ulcers or sinuses, the hardness of the neighboring muscles in oral actinomycosis, and the yellow granules in the pus are all significant, but merely cor- roborative. To detect the actinomyces, says Warren, sections may be stained with Ziehl's carbol-fuchsin from fifteen minutes to half an hour, and then decolorized in a 1 per cent, picric-acid solution until the whole section has a yellow appearance. Dehydrate and mount. The fungus appears as a brilliant red aster, while the surrounding tissues are yellow. The points mentioned above will serve to distinguish this disease from ^Medical Record, June 4, 1910. 20 306 INFECTIOUS DISEASES. tubemilosis, si/philis, clironic pyemia^ ami sarcoma. AVidal * diiferentiated actinomycopis hy the sero-reaction in 8 eases. Course and Progrnosis. — The course is chronic. Mild cases may recover in from six to nine months or earlier, the oral form being per- haps the most favorable. Pulmonary actinomycosis may terminate in recovery, though rarely. Death usually results from pyemia, amyloid degeneration, and wasting. Treatment. — This is mainly surgical. The removal of the parts involved and disinfection with acid-sublimate solution are the best meas. ures. Billroth in a case of abdominal actinomycosis communicating with the bladder effected a cure by the use of fifteen tuberculin injec- tions. Kinnicutt and Mixter have used vaccine made from actinomy- cotic pus in 8 cases with encouraging results. Internally, the potas- sium-iodid treatment, as first recommended by Thomassen in 1885, and recently emphasized by DaCosta,^ is often attended with success when decided iodism is produced. ANTHRAX. [Malignant Pustule; Splenic Fever; Wool-sorter's Disease, etc.) Definition. — An acute, infectious disease, caused by a special ba- cillus and clinically accompanied by the development of a characteristic pustule (boil) and blood-poisoning {external anthrax). The disease like- wise aifects the gastro-intestinal tract and the lungs {internal anthrax). Both forms are derived principally from the herbivora, it being especially prevalent among sheep and cattle. The occurrence of anthrax in the United States is much more frequent than has been held to be the case. Pathology. — Post-mortem rigidity is marked. The blood is dark and thick and coagulates poorly, and in it, particularly in the spleen, as well as in the liver, kidney, and lungs, one may find the spores. Besides the local lesions of the skin (?'. e. ulceration, gangrene, edem- atous infiltration), and besides the degeneration of the heart, kidneys, and liver that is common to the severe and rapid infectious diseases, the especially striking lesion is the constant and great splenic enlargement. The bowel may show hemorrhagic infiltration and gangrene, and the mesenteric and retroperitoneal glands may be enlarged and hemorrhagic. l^tiology. — Bacteriology. — The special agent is the bacillus anthra- cia. Gratia and Jonne give as the microscopic characteristics of anthrax, as seen in the blood, the following : (1) The anthrax bacillus has the form of a rod of a length varying from bfj. to 20^, and in breadth from 1/i to 1.5/i. It is broken up into short articulations from 1.5/^ to 2^ long, placed end to end like the sections of a tenia, the ends of each articulation being slightly swollen, giving the appearance of a bamboo cane ; (2) clear spaces, appearing like a biconcave lens, exist between the ends of the articulations, and result from the slight concavity of these ends ; (3) a capsule, often distinctly marked, surrounds thp rod, seeming to form a protoplasmic support for the individual articulations. These threads of anthrax bacilli stain best with Lofiler's blue. They grow readily on various media (agar, gelatin, potatoes, etc.) into inter- ^Bull. de I' Acad, de Med., Paris, May 10, 1910. ^ Proc. of the Assoc, of American Physicians, 1900. ANTHRAX. 307 lacing thread-like filaments which distinctly show sporo-formation. the threads assuming the appearance of strings of beads. They resist desic- cation, many of the germicides, and boiling water even for a few min- utes. Inoculations are followed by the production of the pustule of anthrax. Conradi ^ affirms that it is highly improbable that the anthrax bacilhis produces a toxin. Modes of Infection. — The virus (spores) gains entrance into the human body through the skin (slight wounds, abrasions, or scratches), the intes- tines (with food), or through the lungs (rarely). The sting of insects (mosquitoes, flies) may also transfer the poison to man. Predisposing Causes. — Occupation is most influential : persons who come into direct contact with infected animals (hostlers, butchers, shep- herds), and workers in factories who handle the hair or hides of such animals, being liable. Immunity. — Pasteur's well-known protective inoculation with attenu- ated virus has been extensively practised in anthrax localities, with very favorable results. Peterman, however, reinvestigated the question of immunity by the albumose of anthrax, and found it without protective action, except in the case of cultures on ox-serum, which, when injected in large quantities into the veins, conferred temporary immunity. Clinical History. — The period of incubation is from one to three days. Two leading clinical types are distinguished : (1) External Anthrax. — {a) Malignant Pustule. — At the point of infection (the hand, arm, neck, or face, or other exposed part) a small papule first appears, and develops into a vesicle of considerable size with bloody contents. This vesicle breaks, leaving a characteristic dark- bluish or black scab (anthrax), and encircling the primary vesicle an areola of miliary vesicles may be noticed. The base of the original ves- icle now becomes swollen and indurated, and this brawny edema spreads rapidly to the adjacent tissues until an extensive area is involved. The neighboring lymph-glands may or may not be inflamed ; if so, they are apt to be connected wdth the pustule by red lines (lymph-vessels, veins). Severe general disturbances accompany the local disorder in the course of a couple of days, and comprise fever, decided prostration, sweats, splenic enlargement, and delirium tending toward coma. If recovery occur, the edematous swelling subsides and the black scab is cast ofi". In unfavorable instances collapse develops, and the case ends fatally between the fourth and eighth days. In such instances intestinal symptoms (diarrhea) or nervous phenomena of aggravated type may attend. (6) Anthrax Edema. — In a certain proportion of the cases the sys- temic infection is out of proportion to the local disturbance, the latter consisting of an edematous swelling without the presence of an eschar. The eyelids (commonly), lips, tongue, and upper extremities may be the seat of extensive swelling, though there is no change in the color of the skin. This is a dangerous condition, and may result in gangrene. (2) Internal Anthrax. — (a) Intestinal Mycosis. — In tnis form certain general, indefinite symptoms are the primary features, such as headache, pains in the limbs, anorexia, languor. Soon acute gastro-intestinal features supervene, sometimes preceded by a chill. As a rule, vomit- ing occurs, followed by abdominal pains and diarrhea, and the stools often become bloody. Hemorrhage may also occur from other outlets. 1 Zeitschri/t J'iir Byg., June 14, 1899. 308 IXFF.CTIOUS DISEASES. Other symptoms, as dyspnea, marked cyanosis, and restlessness, are noted, followed sometimes by stupor, general convulsions, or spasms of single muscles or groups of muscles. There is moderate fever, and the spleen is enlarged. Death is preceded by collapse. Interesting epidemic outbreaks of internal anthrax have occurred, due both to drinking-water derived from infected wells and also to dis- eased meat. Murisier has related the history of an epidemic in which 200 persons fell ill after eating meat from a certain cow. The animal was quartered by a butcher who had previously slaughtered an ox afflicted with anthrax, and had not disinfected his instruments ; four days after this 25 persons were attacked by the disease. ih) Wool-sorters' Disease. — This occurs among the operatives in fac- tories in which imported wool or hair, mostly from Russia and South America, is sorted, and to produce the typical affection the infection must be swallowed or inhaled in the form of dust. Mixed cases, or those showing both external and internal anthrax, may be met with among workers in curled-hair establishments and the like. The onset is sudden, with a chill that is accompanied by pains in the back and legs, prostration, and a sharp rise of temperature to 102° or 103° F. (39.4° C). The local symptoms may either be chiefly pulmonary or gastro-intestinal. The former consist in dyspnea, chest-pains or feelings of constriction, cough, and rarely the physical signs of bronchitis ; the latter comprise vomit- ing and a diarrhea that is followed by collapse, Avith marked lividity. Nervous symptoms, delirium, convulsions, or coma are often prominent in serious forms ; but a fatal ending may occur while the mind is un- clouded. The course ranges from one to five days. (e) Rag-pickers' Disease (" Hadernkrankheit "). — This has been identified by Eppinger as the same form of disease as "wool-sorters' anthrax." It occurs among the rag-sorters in the paper-mills near Graz. Infection occurs in the respiratory tract. The symptoms observed are high fever, followed by collapse, with depression of the body-heat, pain- ful and paroxysmal cough, cyanosis, very weak heart, together with the signs of pleuritic eflFusion and consolidation of the lung. Diagnosis. — The history (occupation, etc.) and the appearance of the malignant pustule in external anthrax leave little room for doubt. The diagnosis, however, should be confirmed by an examination of the contents of the pustule for the presence of bacilli, and if found they should be cultivated and inoculated upon a guinea-pig or rabbit. Internal anthrax may be suspected if the more characteristic pul- monary or. gastro-intestinal symptoms, together with those of systemic intoxication, develop in persons whose occupation entails exposure. In doubtful cases the presence of bacilli in the blood must be shown. Prognosis. — In external anthrax occurring in healthy persons the disease often pursues a favorable course ; moreover, radical surgical measures have decreased the death-rate decidedly. Internal anthrax, however, is a deadly aff'ection. As regards '' Avool-sorters' disease," those who survive for one Aveek usually recover (Bell). Treatment. — Prophylactic measures embrace the sterilization and destruction of the hair, hides, wool, etc., of infected animals as well as the cremation of their bodies. Subsequent disinfection of the infected premises and the prohibition of grazing in infected pastures are matters of the utmost importance. In the carbuncular form, if seen early, the HYDROPHOBIA. 309 best treatment is excision of" the affected area, including a considerable amount of surrounding skin. In the edematous variety, early excision followed by cauterization is indicated. If impossible, as is the rule, injections of carbolic acid in a solution of water and glycerin (1: 10) into the surrounding tissue have given the best results, llallopeau recommends that in order to prevent extension the neighboring structures be bathed with a 10 per cent, solution of carbolic acid (first dissolved in alcohol) in oil or gly- cerin. Internally, stimulants, antiseptics, and nourishing food constitute our chief reliance. In internal anthrax efforts at treatment avail nothing. Several sera have proved valuable in the treatment of anthrax, the best being that of Sclavo, which is obtained from the sheep or ass (Emery). • HYDROPHOBIA. [Rabies.) Definition. — A specific, infectious disease peculiar to carnivora and to a less extent to herbivora, which may be communicated to man by direct inoculation. It is characterized by slight fever, spasm of the larynx and pharynx, delirium, a short stage of paralysis, coma, and, in the great majority of cases, a fatal termination. Pathology. — The facies, pharynx, and esophagus may be con- gested, the latter organ being sometimes markedly edematous ; pulmo- nary congestion has also been noticed. The mucous membrane may show here and there points of hemorrhage, and Fitz has observed blood- extravasations into the perivascular spaces of the brain. Soft thrombi may fill the cerebral vessels, especially the veins, while the blood has a dark color and its clots lack firmness. Balzer, Benedikt, Kolesnikoff', and Schaffer made studies of the changes in the nervous system. Later, Babes described the ^^ tubercles rahiques^'' which consist of pericellular accumulations of embryonal cells, the latter finally taking the place of the destroyed cell. More recently Van Gehuchten and Nelis discovered lesions in the cerebro-spinal and sympathetic ganglia ; they " consist in the atrophy, the invasion, and the destruction of the nerve-cells brought about by new-formed cells derived from the capsule, which appears between the cell-body and its endothelial capsule. These new-formed cells increase in number, invade the protoplasm of the nerve-cell, and finally completely occupy the entire capsule." Rarely, the kidneys may show cloudy swell- ing. il^iology. — Pasteur has found the poison abundantly present in the nerve-centers, and has transferred the disease by taking bits of brain- substance or medulla derived from an infected animal and inoculating them into healthy subjects. Bacteriology. — The micro-organism of the disease has not yet been determined, though Spenelli, Rivolta, Foil, Ferran, and others have described a bacillus. Memmo ^ believes he has established its claims as the specific organism, and reports successful production of the disease in dogs, rodents, and birds, wuth the typical diff"erences characteristic of each. The usual mode of infection in man is through the bite of a rabid animal, the virus being contained principally in the saliva, and in an immense majority of cases (about 90 per cent.) the dog is the off"ending ^Centrcdbl. f. Bakt., Abt. i., Bd. xx., 17, 18. 310 INFECTIOUS DISEASES. party. The cat, wolf, cow, and horse also suffer from the disease, and in rare instances they communicate the disease to man. The skunk is also liable, and its bite has often transmitted rabies, especially to per- sons sleeping in the open air or in tents which the animal can enter. The virus gains access to the system through the broken skin. Susceptibility to the poison e.xists in about one-half the instances in which persons are bitten by rabid animals, though in some cases this ap- parent immunity may be owing to slight or even non-infection. Clinical History. — The incubation-period lasts from six weeks to three or four months, though in youn^ subjects and in cases in which the infection is severe the symptoms develop earlier. Certain prodro- mal symptoms are majiifested, as a rule, and generally last only a day or two ; I have, however, seen two instances in which melancholia, due probably to the dread of what might follow, showed itself immediately after the reception of the bite and persisted. The usual premonitory symptoms are headache, loss of appetite, sleeplessness, great depression of spirits, and sometimes darting pains that radiate from the seat of the bite. The adjacent lymph-glands may become swollen, and slight difficulty in swallowing is experienced. Following the invasion are two stages : (1) The Stage of Excitement. — The patient wears an expression of the most intense anxiety. Hyper- esthesia is present and attains to a marked degree, and the special senses exhibit the keenest vigilance, a noise or a draft of air often causing great psychic disturbance or a violent reflex spasmodic contraction of the larynx. Quite early the mere sight of water is dreaded by the pa- tient, and forms a characteristic feature of the disease. This symptom has given the name hydrophobia to the disease, and springs from the fear of inducing a painful spasm of the larynx. The patient has thirst which he cannot assuage. There may be maniacal excitement, and the spasmodic contractions of the larynx may become so strong as to excite urgent dyspnea, with the emission of curious sounds. The muscles of the mouth may also exhibit convulsive movements, causing the patient to make snapping sounds ; these, however, are secondary. There is asso- ciated great restlessness, with frequent lateral rolling of the head, and foaming saliva may be ejected from the mouth. The symptoms occur in paroxysms, and during the intervals the patient is generally free from excitement. There is fever as a rule, the temperature ranging from 100° to 102° F. (37.7°-38.8° C.) or over, but it may be absent; the pulse is moderately accelerated and is sometimes irregular, and to- ward the end of this stage the reflex spasms of the respiratory apparatus develop spontaneously. Mental aberrations and melancholia may ensue, and often lead to suicidal tendencies. (2) The Paralytic Stage. — In the concluding stage the patient passes into actual unconsciousness or coma, without spasms. This lasts from twelve to eighteen hours, ending in death. In man there is a paralytic form of rabies, but it is rare as compared with the delirious or psychic tj^pe. Thirty cases have been reported by GamaMia, and it is apt to follow deep and multiple bites. The paral- ysis begins near the part bitten, and spreads until it becomes general, finally involving the respiratory centers. In rodents quiet madness ('• dumb rabies"), without maniacal excitement, is the rule. Diagnosis. — The hyperesthesia, the fear of water, the reflex spasms HYDE OPHOBIA . 311 on attempting to swallow, accompanied by dyspnea and great mental agitation, form a very characteristic grouping of symptoms. Bits of brain-substance or medulla of the rabid animal that has inflicted a bite should be quickly obtained, and a subdural inoculation of a rabbit be made. If virulent, the paralytic form of the disease will ensue in from fifteen to twenty days. Ravenel and McCarthy,^ following the method ^ of Van Gehuchten and Nelis, conclude that when present the capsular and cellular changes in the intervertebral ganglia, taken in connection with the clinical manifestations, afford a trustworthy means of diagnosis of rabies in the animal. When these changes, however, are absent (as happens in early stages of the disease), rabies cannot be excluded. Hysteria may be misleading, but here the previous history suffices. The name lyssophohia has been given to cases that simulate, but have no relation to, hydrophobia, and Mills has advanced the warning that, however suggestive the symptoms following a dog-bite, the given case cannot be assumed to be a case of hydrophobia until other possibilities are excluded. It is highly probable that there is a form of hydrophobia which is the result of the wide publicity given to genuine and suspected cases alike. The characteristic symptoms may be present, but the affec- tion does not develop. This so-called pseudo-hydrophobia appears only in neurotic and hysteric subjects. Recovery is the rule. Burr reports an interesting case of the kind that occurred in Osier's clinic, attended, however, with recovery. Prognosis. — Few if any cases of rabies in man recover if the dis- ease be allowed to develop. Treatment. — Prophylaxis. — Upon the reception of a bite thorough disinfection, followed by cauterization of the wound with caustic potash, or, better still, excision, if important structures be not involved, is a measure that can be quickly carried out. The wound is then to be kept open for a period of four or five weeks. Dudley advises that a tourni- quet should be applied if the bite be on an extremity. Systematic muz- zling of dogs is to be encouraged and advised. Preventive inoculation as perfected by Pasteur is a precautionary measure of the utmost importance. He showed that the virulence of the virus which is obtained from the nervous system undergoes modification by passage through animals. Thus the potency, of the virus is increased by its inoculation from rabbit to rabbit (by placing bits of spinal marrow beneath the dura mater), the period of incubation at the same time growing shorter, till at last it is but seven days. On the other hand, the virulence is decreased or attenuated as the result of similar experiments upon the monkey. Pasteur also found that if frag- ments of the spinal cord were suspended in a dry atmosphere they lost ' Proc. Path. Soc. Phila., March, 1901. * This is as follows : The ganglion is put at once into absolute alcohol, in which it is left for twelve hours, the alcohol being changed once. It is transferred for one hour to a mixture of absolute alcohol and chloroform ; next put for one hour into pure chloroform ; then for one hour into a mixture of chloroform and paraffin, and lastly in pure paraffin for one hour. The sections are put in the oven for a few minutes, then passed through ivlol, absolute alcohol, and 90 per cent, alcohol, after which they are stained for five minutes in methylene-blue according to Nisei's formula, diflerentiated in 90 per cent, alcohol, dehy- drated in absolute alcohol, and cleared in essence of cajuput and xylol. Ravenel and McCarthy found that the capsular changes were best brought out in sections stained by hematoxylin and eosin. Since these latter changes are the most essential diagnostic features in the sections, they suggest that material unfit for the Nissl method will still show the capsular changes when stained by hematoxylin and eosin. 312 INFECTIOUS DISEASES. gradually their virulence and finally became inert. From these an emulsion is prepared which is employed in the antirabic inoculations in man. In this way he secured a virus of known and reliable strength, and with this he could readily render the dog refractory by inoculating with very weak virus ; then, by increasing from day to day the virulency of the inoculations, complete immunity was established. Protective Inoculation. — '' The patients are first inoculated with a cord fourteen days old, and the inoculation is repeated daily for nine days, each time with a cord one day fresher. In winter the oldest cords used are five days old, and in summer cords that have been drying for four days are also employed " (Warren). For patients who have been bitten on the face, hands, or bare feet, as well as for those w ho have been bitten long before commencing treat- ment, the special preventive method, the so-called " intensive treatment," is applicable. Briefly, this consists in eliminating some of the inocula- tions of intermediary strengths, thus lessening the number of injections, and also in administering the latter at shorter intervals than in the usual method of treatment. The success of the Pasteur method is universally attested. Pottevin gives the following summary of figures from the Pasteur Institute: From 1886 to 1894, 13,817 persons were bitten, with a mortality of 0.5 per cent. In the New York Pasteur Institute, 313 West Twenty-third Street, under the directorship of Paul Gibier, of 1367 cases treated during the decade ending Jan. 1. 1900, 19 died — a mortality of 0.66 per cent. The patients should be sent to the Pasteur Institute at once, since delay diminishes the protective power of the inoculation. The established affection defies all known methods of treatment. Our aim should be to diminish the intensity of the painful spasms and the psychic disturbances. The patient should be isolated from sounds, light, and excitement of every sort. Food, as a rule, must consist of nutrient enemata, though by the local application of cocain the sensi- tiveness of the throat may be diminished sufiiciently to enable the patient to take liquid nourishment (Osier). For controlling the spasms chloroform by inhalation is most eflfective ; chloral internally and mor- phin hypodermically may be of advantage. The patient's anxiety is best relieved by a cheerful demeanor on the part of the attendants'. TETANUS. {Trismus; Lockjaw.) Definition. — An acute, infectious disease caused by the tetanus bacillus. It is characterized by painful spasms, affecting first and chiefly the muscles of the jaw and neck {trismus), and secondly those of the trunk, especially the extensors of the spine and limbs {opisthotonos). Two varieties are recognized : (a) idiopathic C.^) ; {h) traumatic. In certain institutions and certain localities it occurs endemically, and among new- born children and the colored race it may prevail epidemically {trismvi< neonatorum). The incidence of the disease, however, is decreasing. Pathology. — No constant post-mortem lesions have been found. The virus acts principally upon the nervous centers of the medulla TETANUS. 313 and the cord, produciiif^ inflarnmntion ("and somotiTnes softenin^r) of the gray substance of the cord. According to lirown-SCiquard, the charac- teristic lesions are consecjuent upon an ascendiny neuritis starting from the wound, and it is true that the nerves often present traumatic lesions with redness and swelling of the neurilemma. Tetanus neonatorum often shows inflammation of the umbilicus. l^tiology. — Bacteriology. — In 1884, Nicolaier discovered the bacil- lus of tetanus, and in 1886, Rosenbach first found it in man. It is a long, slender rod, at one end of which appears a swelling due to the forma- tion of a spore in that locality, thus giving the organism an appearance like that of a pin or drumstick. The bacilli are easily stained by Abbott's method, and are purely anaerobic. Pure cultures can be made, but with difficulty, since they will not grow in the presence of the smallest amount of oxygen. If pure cultures are injected into animals, typical tetanus follows. Brieger has obtained two poisons from sterilized cult- ures of the bacillus in the pure state, and termed them " tetanin " and " tetano-toxin " — both most virulent poisons in the minutest quantity. These alkaloidal substances produce the tonic convulsions ; hence tetanus is purely toxic in nature — an intoxication. The bacilli are most proba- bly limited to the point of infection, and here develop the toxin, which "is carried mostly along the nerves to the spinal cord " (Stintzing). Tiberti Avhose experiments corroborate those of Meyer and Ransom, found that the toxin is transported to the nerve-centres through the plasma of the nerve-fibers, but that the normal integrity of the axis cylinders to effect the conduction is preserved. Modes of Infection. — In the outer world tetanus bacilli are found to be both numerous and widely distributed. They abound in the earth (garden-soil in particular), putrefying liquids, manure, in rubbish, and dust of streets and houses, etc. The fact that the bacillus of tetanus is anaerobic explains why it is most apt to follow punctured and contused wounds. An analysis of 1201 cases by the writer and A. C. Morgan ^ affords convincing proof that every case is the result of the introduction of the tetanus bacillus through a lesion of the skin, however minute it may be, and that so-called idiopathic or "rheumatic" tetanus does not exist. The presence of the bacillus in vaccine has apparently been the cause of some recent cases. The locality/ of the injury is most commonly on the extremities, particularly on the hands and the feet, although the figures of Anders and Morgan (previously cited) indicate the great susceptibility of all portions of the body to the poison. Certain Prediposiyig Causes. — 1. Males are more susceptible than females [e. g., out of 981 cases the former sex made up 79.3 per cent.), although males are more exposed to infection. 2. The robust are more receptive than the weak, and the nervous than the lymphatic. 3. Sea- son. In 687 cases the seasonal occurrence was recorded by Morgan and myself and indicated that tetanus is more prevalent in the hotter as com- pared with the colder months of the year. The maximum number of cases occurred in July (4th of July tetanus). 4. Age. An analysis of 583 cases, with reference to liability according to age, gave 229 cases, or 39,3 per cent, from the fifth to the fifteenth years of life, 145 cases, or 24.9 per cent, from the fifteenth to the twenty-fifth years, while there were 86 cases, or 14.8 per cent, between twenty-five and thirty-five years. After the fiftieth year only 14 cases occurred, ^Journal of the Amer. Med. Assoc. ^ July 29, 1905. 314 IXFECTIOUS DISEASES. Immunity. — Behring and Kitasato have rendered animals immune by the injection of cultures of the bacillus after the addition of iodin trichlorid to diminish their strength, and this serum has been success- fully used to protect others against tetanus. Clinical History. — The duration of incubation depends upon whether the given case pursues an acute or a chronic course. In acute tetanus it lasts from one to two weeks, while in chronic the first symp- toms usually appear after the second week. In so-called idiopathic tetanus tlie symptoms ap]iear shortly after exposure to the special causes. Symptoms of Acute Tetanus. — (1) Mild prodromal symptoms (languor, headache, etc.) may precede the more intense characteristic phenomena,' which develop gradually. At first the patient complains of stiffness and tension in the muscles of mastication and back of the neck, and soon tonic spasm of the masseters renders the facial muscles more or less immobile and locks the jaws {trismus or lockjaw). The rigidity of the cervical muscles is shown by the retraction of, and by attempts at raising, the head. The physiognomy is distinctive ; it is immobile, the forehead being often wrinkled and the corners of the mouth retracted, producing a peculiar smile {sardonic grin). Next the muscles of the body become rigid, first the trunk {orthotonos), and then the spine is bent or bowed and the convexity presents anteriorly {opisthotonos). Lateral arching of the body also occurs, though rarely {pleurosthotonos). The belly-muscles are hard and board-like, and their contractions may throw the body forward {emprosthotonos). The arms generally remain movable, but the legs may be rigidly extended. The position of the body is one of constant rigidity, but from time to time convulsive seizures of variable duration occur, causing most agonizing suffering, thoracic oppression, dyspnea, and more or less cyanosis, due to interference with the respira- tory function (especially spasm of the glottis). Sharp, lancinating pains occur at the base of the chest. " Convulsive dysphagia " (as in hydro- phobia) is rarely observed. These spasms are usually reflex. The reflexes are increased. Rostowzew thinks that Kernigs symptom is an early and constant one in tetanus. The intellect remains clear. Pro- fuse perspiration is a significant symptom. Fever of a moderate degree is generally present. The temperature, however, may suddenly leap to 110° or 11*2° F. (43.3°-44.4° C), form- ing an ominous symptom, these extreme elevations of temperature being probably due to paralysis of the centers that regulate bodily heat. Con- versely, fever may be absent throughout the attack, and a brief post- mortem rise of temperature be seen. The pulse is quickened, and in the worst cases may become very rapid (140 to 160 beats per minute), small, and irregular. The urine may be suppressed or its passage im- peded bv the muscular contractions. The bowels are constipated. (2) Chronic Tetanus. — The same symptoms are manifested as are seen in the acute form, but the condition does not progress so rapidly. In some instances the symptoms soon become aggravated, to be followed, however, by periods of decided relief from the painful spasms, so that during the latter the patient's strength can be maintained by means of stimulating food, and intervals of partial freedom from the excruciating pains grow longer in favorable cases, until finally the period of convales- cence may be reached. Relapses, hoAvever, are common. (3) Cephalic tetanus (first described by Rose) usually follows injuries to the head (face). Its most characteristic symptoms are rigidity of the TETANUS. 315 masseter muscles, spasm of tlie pharyngeal muscles, causing dysphagia, chronic contraction of the muscles of the neck and ahdomen (rare), and paralysis of the facial nerve on the same side as the injury. The latter symptom is due to local infection by a toxin. Recovery takes place in about 25 per cent, of the instances, according to Willard's statistics. Diagfnosis. — In view of the usual history, the predominating feat- ure — trismus — together with the early appearance of rigidity at the back of the neck, will, as a rule, render the diagnosis a simple one. Strychnin-poisoning must be eliminated, in which the following table will assist : Tetanus. Strychnin-poisoning. Reception of a wound, generally followed Ingestion of strychnin, followed immedi- by a period of incubation. ately by the symptoms. Begins with lockjaw; later spreads down- Begins with gastric disturbance or a ward (the arms and hands escaping). tetanic contraction of the extremities. Hyperesthesia of the retina occurs and objects look green. Reflex spasms not present at the outset. Violent convulsions present from the onset. Rigidity is persistent, except in the Intervals of complete relaxation occur. chronic form. The course is prolonged into days or Course is brief, terminating in death or weeks. recovery. Cultures made from the discharges of Examination of the gastric contents shows the wound show the bacillus tetani. strychnin. Tetany gives rise to a prolonged spasm affecting the extremities (hands in particular) and the larynx, with intermissions ; it is also char- acterized by a peculiar posture, and occurs chiefly in the young. Mydi'ophohia is discriminated from tetanus by the history of a bite from an animal, by the predominance of the reflex spasm of the respir- atory apparatus, by the intensity of the psychic disturbance, and by the absence of lockjaw and opisthotonos. Course and Prog"nosiS. — " Acute tetanus or that which developed within ten days gave a total of 568 cases and a mortality of 74 per cent. On the other hand, 211 cases lasted over fifteen days, with only 18 deaths, or 8.5 per cent, mortality " (Anders and Morgan). Death results from asthenia, heart-failure, or asphyxia (during the paroxysm). Accord- ing to Richter's statistics, 88 per cent, of military cases are fatal. In the so-called idiopathic cases the mortality-rate is under 50 per cent. Chronic tetanus gives a less grave prognosis than does acute. There is a direct relation between the duration of the incubation period and the mortality-rate.^ In the newborn recovery is so rare that when it occurs the diagnosis may be called into question. Treatment. — In traumatic cases the wound must be disinfected and thoroughly cauterized. The agents employed must be brought in con- tact with every portion of the wound, so that punctured wounds must first be laid open. Excision of the wound, and even amputation, may be ad- visable in some cases. The fact that the deadly poison is developed at the site of infection gives to the local measures supreme importance in the treatment. The application of lipoid substances {e. g.. Peruvian balsam salve) is found to delay the incubation period (Brockenheimer). The patient should occupy a secluded room with little light and a ^ Journal of the Amer. Med. Assoc, July 29, 1905. 316 INFECTIOUS DISEASES. carefully regulated temperature. A single nurse will suffice, and all sources of external irritation should be avoided. A nourishing diet is demanded, and rectal feeding must be instituted as soon as it is found that food cannot be administered per oram, or the food may be intro- duced by means of a small stomach-tube or catheter passed through the nostril. Stimulants hypodermically should not be spared when the heart's action becomes quick and feeble. The spasms are best con- trolleil by chloroform-inhalations, and during the intervals the patient should be kept under the influence of morphin, administered sub- cutaneously. Kintzing ^ reports excellent results from a solution of pure phenol (10 per cent, strength) in sterile water. Of this solution, the adult dose employed was 10 drops diluted, by hypodermic injection deep into the muscles, and repeated every three hours in the beginning, in- creasing the interval as improvement manifested itself. Among other capital remedies are chloral hydrate and Calabar bean. The former may be exhibited by rectal injection (gr. xl — 2.59 at a dose), to be repeated at intervals of six or eight hours until the spasm is overcome. The heart, however, must be carefully guarded. Rarely, chloretone, potassium bromid, curare, nitrite of amyl. belladonna, and cannabis indica are useful. Tetanus-antitoxin has been recommended for the cure of the disease, and is prepared in both fluid (antitoxin serum) and dry form. A dried preparation (which does not deteriorate) is also obtainable from Merck and his agents in the form of tubes containing from 4 to 5 grams each ; at the time used it may be dissolved in water or in glycerin. Of Tiz- zoni's dried antitoxin 2.25 grams are to be given at the first dose, and 0.6 gram at subsequent doses. As shoAvn by recent experimentation, antitetanic serum may prevent further invasion, but it cannot cure infec- tion that has already reached the spinal cord and brain. The dose, as recommended by Copley,^ should be large (30 c.c. at once, to be repeated at least every six hours until improvement is seen). Behring insists upon giving the serum not later than twenty-six hours after the commencement of the attack. Hoffmann^ records recovery in 14 out of 16 cases in- jected with the serum, intradurally. Torres recommends the injection of 120 c.c. of tetanus antitoxin intravenously, to be repeated twice in the twenty-four hours, a third injection of 100 c.c. on the second day and this repeated on the following days, if symptoms be still present. Mag- nesium sulphate (2 c.c. of a 25 per cent, solution) may be injected into the spinal canal after the removal of an equal quantity of cerebrospinal fluid. Propfiylatic injections of 500 antitoxic units should be used at once after disinfection of the primary focus. Baccelli advises subcutaneous injections of carbolic acid. The dejecta should also be thoroughly destroyed as the tetanus bacillus has been found in the intestinal tract. BERI-BERI. {Endemic Multiple Neuritis ; Kakkc ; " Weak legs.'') Definition. — Beri-beri is a specific disease characterized clinically by fever, muscular weakness followed by muscular atrophy, pain, tender- ness, paresthesia, gastro-intestinal disturbance, tachycardia, and often general anasarca. It is not certainly contagious. i^Yetu York Med. Jour., Dec. 23, 1911. ..^^'■''- ^ted.Jour., Feb. 11, 1899. ^International Clinics, vol. ii., S. 20, p. 17. Plat;.; 11. Beei-beei (Herzog, in Philippine Journal of Science). BERLBERI. 317 Historical. — Beri-beri, first icco*5ni/e(l by Strabo among the soldiers in the Roman armies wiiile occupying- Arabia (24 B. C), was strangely enough not grouped with the infections until the beginning of the nine- teenth century. At this period the subject began to receive the serious attention of Dutch and (a little later) of Anglo-Indian writers, and in- vestigators. As stated by Osier, however, we may date the modern study of the disease from Malcolmson's monograph, published in Madras in 1835. It remained for Sheube and Baelz to point out that the prin- cipal morbid lesions are those of a multiple peripheral neuritis. Distribution. — The disease is endemic in tropical and subtropical countries, but may occur epidemically on shipboard, in prisons, and in armies. Instances of epidemic prevalence in armies are numerous, e. g., in Arabia, India, and the Philippines. Birge has reported an outbreak in which 11 out of 13 of a ship's crew were attacked, and Bondurant de- scribed the epidemic that occurred at the State Hospital for the Insane at Tuscaloosa, Ala., while J. J. Putnam observed cases among the New England fishermen. The principal habitats, however, are certain parts of Asia, namely, Japan, China, India, the Malayan Archipelago, the Dutch Colonies, and the Philippines. In all of these countries the cases may multiply under favorable conditions into extensive and devastating epidemics. In England and along the Pacific Coast, among the Jap- anese and Chinese, it is not uncommon at the seaports. Pathology. — The essential feature is the changes in the nerves ; these are inflammatory and degenerative, involving the medullary sheaths and axis-cylinders. In addition to the peripheral nerves, the pneumo- gastric and phrenic may be affected. Degeneration in the muscles also occurs, and, not uncommonly, serous effusions. !^tiology. — Although beri-beri is most probably an infectious dis- ease, the specific cause still remains in doubt. Both the bacillus of Hamilton Wright and the coccus of Okata and Kokubo have been shown to bear no causative relation to the disease. Beri-beri is the result of a protozoan infection (Hewlett and de Korte ^). Davis, of Shanghai, showed a direct relation between the presence of bed-bugs and beri-beri among Chinese prisoners. A second leading theory ascribes the disease to polished rice and fresh fish. Eraser and Stanton's^ experiments on chickens and human beings indicate that polishing rice removes something (pericarp ?) necessary to maintain health on a strict rice diet. Chamberlain and Vedder^ have induced a disease somewhat resembling beri-beri in children nursing from mothers suffering with beri-beri by the administration of rice-polishing extract. The striking diminution in the number of cases in Japan fol- lowing the introduction of an improved dietary would seem to support the food theory, but the number of cases of beri-beri that developed during the Russo-Japanese War (in the Japanese army) did not exceed 75.000 to 80,000.* Predisposing Causes. — {a) The principal disposing condition is over- crowding, more particularly when combined with antihygienic surround- ings. This fact explains the localized outbreaks in armies, asylums, ships, and the like, {h) Certain climatic factors {vide Distribution, supra), ^Journal of Tropical Medicine and Hygiene, October, 1907. ^ Philippine Jour, of Science, 1910, v., 55 to 64. s Editorial, Jour, of the Amer. Med. Assoc, June 15, 1912. *M. Herzog, Philippine Journal of Science, Feb., 1908. 318 IXFECTIOUS DISKASES. as heat and humidity, favoring the development of beri-beri ; hence natives of tropical countries and imported coolies sufter most. (<•) Age and sex. More cases occur amoiiii: males than females, and the decade from 15 to 25 \ears furnishes a large proportion of the cases. Symptoms. — The period of incubation is not definitely known, but is probably from ten days to one month, or even longer. Prodromata are commonly present : they are thoracic oppression, epigastric pains, anor- exia, ]icadac]u\ and a slight febrile movement. Rigors rarely occur. Four clinical varieties are recognized : 1. Atrophic Form. — This is characterized by muscnlar weakness, slowly developing, leading to paralysis of the lower limbs and trunk, rarely extending to the arms, head, and neck. Atrophy of the affected muscles quickly ensues, with loss of the deep reflexes. The extensors are more profoundly involved than the flexors. There are pain and tenderness in the muscles and over the nerve-trunks. The electrical re- action of degeneration is present. Sensory phenomena are constant, such as zones of anesthesia and paresthesia over the aifected parts. Slight dropsy may arise. In cases of the paralytic form that recover, convalescence is protracted. 2. The Wet or Dropsical Form. — The earlier or later development of general anasarca with eff"usion into the serous sacs, characterizes the wet form. The swelling may be enormous and obscure the wasting, which, however, is less marked than in the atrophic variety. The urine contains no albumin and the edema is firmer than that of nephritis. Dyspnea, car- diac palpitation, and tachycardia are commonly present. 3. The Acute, Cardiac (Pernicious) Form. — This serious type may de- velop acutely either as a primary affection or secondary to a mild form of the complaint. The predominating features are cardiac p)alpitation, marked dyspnea, and indications of progressive cardiac failure. A mod- erate leukocytosis is usually present ; this was true of my cases. The urine may be scanty or suppressed, while the presence of indican in large amounts may be noted. The duration may be brief, not exceeding twenty-four hours, but oftener, perhaps, extending over several Aveeks.^ 4. The Mild or Rudimentary Form. — The initial symptoms may be catarrhal in nature, to which are soon added the characteristic features — pain, u'eakness iyi the legs, paresthesia, cardiac jialpitation, and possibly malleolar edana. Mild cases may be the forerunners of the types pre- viously described, including acute pernicious beri-beri. The disease is often associated Avith malaria, the result of a blood examination in 4 cases in my care having shown the plasmodium in 3. or 75 per cent. Diagnosis. — This offers no practical difficulty except in sporadic cases, in whicii the circumstances under which they arise {e. g., the country or region from which the patient may have come), are unknown. The epidemic form is easily recognized. The grouping of the symptoms of peripheral neuritis with edema, absence of deep reflexes, and threat- ening cardiac dilatation, leave little room for doubt in any case. Differential Diagnosis. — Other forms of infectious polyneuritis are dis- tinguished by the absence of the peculiar endemic or epidemic status, the visceral symptoms, the edema, and of the transudation in the serous sacs. In alcoholic neuritis the peculiar history and such characteristics as the 1" Beriberi, with Report of Cases," The Medical Bulletin, by the writer.' MALTA FEVER. 319 prevalence of painful features and trembling are noted ; in diphtheritic multiple neuritin the velum palati is involved. Course and Prognosis. — The course is interrupted by periods of aggravation and apparent pauses, and on leaving the bcri-beric centres, all symptoms may disappear. The prognoHia is mainly dependent on the intensity of the infection, the presence or absence of associated diseases and the circumstances of the individual patient. The particular variety present in the case i'n hand influences greatly the outlook, e. g., the cardiac or pernicious form being highly threatening to life. Again, the anatomic seat of the nerves implicated decidedly aff'ects the prognosis. The mortality diflFers with the seasons, locality and individual epi- demics. In Japan the death-rate is only 12.5 per cent., while among the Chinese and Brazilians it is much higher. Treatment. — 1. Prophylaxis. — It is most probably a fact that under certain compulsory conditions — individual susceptibility, overcrowding, and a warm, moist climate — the usual hygienic measures will not pre- vent the outbreak and spreading of this disease. Under these circum- stances, removal to a non-contaminated locality alone suffices. The fore- going facts were strikingly confirmed during the recent Russo-Japanese War, when the rigid execution of ordinary sanitary means succeeded in limiting serious outbreaks of typhoid, typhus, scorbutus, and dysentery in the Japanese army, while beri-beri proved a veritable scourge {vide supra). Removal of early cases to special hospitals, followed by rigor- ous disinfection of the houses and rooms in which they have been should be systematically carried out during an epidemic season. Certain hygienic measures, such as systematic feeding with easily digestible proteins, exposure to fresh air without undue fatigue, should be advised. A change to a milder and drier climate is usually effica- cious, if practicable. In severe cases rest must be enjoined. 2. Medicinal Treatment. — Various methods have been advised, such as the early free use of the salicylates (Baelz), venesection, and free purga- tion. While all of these are useful in suitable cases, there is not one that is applicable in every instance. The product known as " oryzanin " is thought to possess specific potency by certain Japanese investigators. In cases in which serious cardiac dilatation supervenes, venesection for its immediate effect is often effective in saving life. Many of the most distress- ing symptoms in acute forms (dyspnea, pain, nausea,) are benefitted by the use of morphin hypodermically. The dropsy of the cardiac cases requires rest and saline laxatives, followed by digitalis (Tltv-x, of the tinct. every third hour). For the so-called cardiac seizures, nitroglycerin or inhala- tions of the nitrite of amyl are recommended. The atrophied muscles should be treated with electricity and massage, and strychnin with tonics is indicated for the same condition. MALTA FEVER. (^Mediterranean f&ver ; Rock Fever ; Undulant Fever. ) Definition. — A protracted infectious disease, caused by the micro- coccus melitensis, and characterized clinically by irregular fever, copious sweats., rheumatoid pains, and frequent relapses. 320 ISFECTIOUS DISEASES. History. — Malta fever Avas described clinically by Burnett in 1816 as a type of remittent malarial fever, but it was first depicted as a specific disease by Marston in 18r)9. It is endemic in Malta, and from time to time is encountered there, and at other Mediterranean ports, in epidemic form. Owing to observations made by Wright on the serum reaction, this disease has been shown to exist in India, Ilong Kong, the United States, the West Indies, and Brazil. Kinyonn first suspected the presence of Malta fever on this side of the Atlantic, along the coast and in the islands of the Gulf of Mexico. Musser and Sailer ^ recognized the afteetion in Philadelphia in a soldier who had come from Porto Rico. No essential pathologic lesions have been identified with the disease. Hughes ^ noted an enlargement of the spleen and of the mesenteric glands, and in grave cases, bronchitis and broncho-pneumonia. Ktiology. — Bacteriology. — The micrococcus melitensis (Bruce) has been found in certain tissues (the spleen in all fatal cases), and is readily recognized morphologically and by culture. Bruce, in 2 cases, and Hughes, in 4, reproduced the disease in monkeys by the inoculation of pure cultures of the organism. Antihygienic conditions increase. mor- bidity. There is no special liability according to age. Goat-herders are markedly predisposed. Modes of Infection. — (a) By the " absorption of urine secreted by cases of Mediterranean fever, and this is one way in which workers in hospitals become infected " (Horrocks). (h) It is extremely probable that human beings are infected by the bites of infected mosquitoes — culex pipie7is, stegomyia fasciata. (c) By the absorption of infected goats' milk from the alimentary canal. Gentry and Ferenbaugh have obtained the posi- tive serum test in 3-4 per cent, of the goats examined. The incubation-period lasts from a few days to twenty or thirty. Symptoms. — The disease is of sloto and gradual development, and the features simulate those of beginning typhoid fever. Headache, bone- ache, anorexia, malaise, and slight fever (often preceded by shiverings) ; the face may be congested, and epistaxis may be present. The bowels are constipated, and the stools may be blood-streaked. The spleen is always enlarged and frequently painful, particularly on pressure. Three classes of cases are recognized : (1) K pernicious type which is rare and generally fatal (Hughes) and needs no further description here ; (2) an undulant type, characterized by exacerbations of temperature at pretty regular intervals ; (3) a continued type, in which a continuous fever persists for weeks and even months. The fever is of a remittent type, with undulating course, and perspirations lasting one, two, or three weeks ; this, after an apyrexial period of two or three days, is followed by a relapse, with rigors, high fever, delirium, and increased prostration. The relapse frequently lasts from five to six Aveeks, and then, after a week or two, a second relapse may ensue ; symptoms somewhat sim- ilar to the first — rigors, intermittent form of fever, extreme prostration, and general rheumatoid symptoms. The latter may be so well marked as to prohibit muscular movements of any kind. The case now either termi- nates in recovery, or, after the lapse of one or even two months, there may be a repetition of the whole symptom-complex. In grave cases the tem- perature is continuous, and death may occur in hyperpyrexia (Hughes). The temperature range is often markedly irregular, hence its comparative 1 Phila. Med. Jour., Dec. 31, 1898. ^ Annates de I'Institut Pasteur. MUSCULAR lillKUMATLSM. 321 uselessness, as claimed by Craig, from a diagnostic point of view. A polynuclear leukocytosis is present in Malta fever. Certain cornpliaatl.onH^ as touches of pleurisy and pneumonia, rarely appear-. Diagnosis. — From the use of pure cultures of tlie special organism in the blood of Malta fever patients gives a typical agglutination. Ac- cording to Negre, this test is only reliable for the micrococcuH meJi- tensis when the serum is heated to 56° C. for half an hour. Thus the affection is with ease and certainty distinguished from typJund fever and erratic forms of malaria. In no other manner can it be discriminated from typhoid fever in the earlier stages. The presence or absence of the Widal reaction will assist in the differentiation. If r)ialaria is suspected, the blood should be examined microscopically. Many cases present hacking cough and physical signs of lung congestion, or even consolida- tion, and, as a consequence, are confounded with incipient tuberculosis. The serum test will remove all doubt. Malta fever not infrequently, in its mode of onset and the symptoms present during the first few days, resembles lobar pneumonia (Craig). The absence of rusty sputum, stab- bing chest pains, and the milder character of the cases, however, are an aid in excluding pneumonia. The polyarthritis with fever has led to con- fusion with acute articular rheumatism. Pyemia must also be excluded. Duration and Prognosis. — Soldiers show an average stay in the hospital of ninety days (Bruce) ;. obstinate cases, however, may last six months. Most cases pursue a chronic course. The death-rate is low — about 2 per cent. Death is generally due to hyperpyrexia. Treatment. — This should be sustentative or supportive, in view of the uncertain, protracted course. Nourishing liquids and, usually, stimu- lants are required. Dalton allows solids, such as eggs, rice, and bread, in addition to 2 to 3 quarts of milk.' The bowels should be moved daily. Fever i^ to be combated by the application of cold (cold bath, wet pack, or sponging). Methylene-blue (gr. f — 0.05, two or three times daily) is considered the best remedy available (Audibert and Rouslacroix). Bas- sett-Smith ^ reports two series of cases treated with vaccine prepared from cultures of Micrococcus melitensis., freshly isolated from the spleen durino^ life, with gratifying results. Tonics, coupled with a change of climate, favor convalescence. Hematinics are especially indicated during this period to overcome the well-marked secondary anemia. PROBABLE INFECTIOUS DISEASES. MUSCULAR RHEUMATISM. {Myalgia.) Definition. — A common, painful disease of the muscles and of the structures to which they are attached (fasciae and periosteum), probably due to an attenuated form of the virus of acute articular rheumatism. Leube contends — and very properly, I think — that muscular rheuma- tism is a general disease with local symptoms. The latter may be seated in different parts of the body, and in this way give rise to a number of leading sub-varieties, and it may either accompany acute and chronic ^ Journal of Tropical Medicine and Hygiene, May 15, 1907. 21 322 INFECTIOUS DISEASES. rheumatism or it may be experienced as an independent disease. I have also met with several instances in which it followed joint-rheumatism, and Leube has seen it precede the latter. Certain authors believe that the afFoctinii is a neuralgia of the sensory nerves of the muscles. Pathologfy. — Tn fatal cases (these are exceedingly rare) the affected muscles show a swelling of the fibers and more or less granular change. In long-standing cases there is an atrophy of the muscles, due to trophic disturbance. Strauss describes circumscribed nodules in the muscles. The changes are essentially those of myositis. In the acute form there is often an extensive round-cell infiltration of the connective tissue, with swelling and partial degeneration of the muscular fibers and the formation in them of vacuoles. In the chronic form there is a prolifera- tion of the interfascicular connective tissue. Htiology. — Among the disposing influences the most important are — (1) The rlieumatic diathesis (appropriate soil); (2) Heredity ; (3) Ex- posure to cold, damp, and strong air-currents, especially after heavy ex- ercise or during free perspiration ; (4) Sex, owing to the more frequent exposure of men while following their occupations ; (5) Age. It is met with at all ages, but acute and subacute forms most frequently occur among children and young adults, while the chronic form generally affects elderly persons; (6) Previous attacks increase the susceptibility to the disease. (7) Lumbago may be reflex in character, due to hemorrhoids, enlarged prostate, iind intestinal irritation. Symptoms. — In the majority of instances the clinical symptoms are local. Out of 200 cases Leube found fei'cr in about one-third, the temperature rarely exceeding 102° F. (38.8° C.) for two days in dura- tion. In one-sixth of Leube's cases there was a cardiac murmur that disappeared under treatment in one-half of this number. Pain., which which is sometimes sharp, lancinating, and pai'oxysmal, while in other cases deeply seated, dull, and constant, is troublesome. It is aggravated at night by contraction of the affected muscles, by Aveather-changes, and by pressure. In long-continued cases pressure with the broad side of the hand usually affords relief. The duration ranges from a few hours to several days or longer. The rheumatic nodules are common in the shoulder- and calf-muscles. The cases in which the symptoms tend to persist or recur with changes in the weather may be termed chronic. Leading Clinical Varieties. — (1) Lumbago [Myalgia LumhaUs). — This is the most common form, and may be taken as the type of the myalgias. The onset is sudden, sometimes intensely so, and the lumbar muscles are exceedingly painful and sensitive. Motion, such as stooping or turning the body or rising from the sitting position, causes intense exacerbations of pain. The affection occurs most frequently in laboring-men, its course being brief, as a rule, and recurrences frequent. Erben, from a study of 200 cases of lumbago, finds that the trouble is principally an affection of the lumbar vertebroe, or a neuralgia of the cutaneous nerves. (2) Pleurodynia. — This term implies involvement of the intercostal muscles, and less frequently of the pectorals and the serratus magnus. It is unilateral, and oftener affects the left than the right side, and causes untold suffering, since it is constantly aggravated by the normal respiratory excursions. The pain is also intensified by pressure, reach- ing, etc., and by movement of the trunk, sneezing, and coughing. Similar symptoms may be occasioned by traumatism in Avhich the fibers muscuJjAr rheumatism. ,323 of the thoracic muscles are lacerated, and there is also great danger of confounding pleurodynia with costal periostitis and with pleurisy. (3) Torticollis (^Myalcpla Cervicalis). — Here the nnuscles, some or all, on one side of the neck, and at times the throat, are implicated. The head is held toward the affected side, so as to relax the group of muscles involved, and on attempting to turn it the patient rotates his entire body in a pivot-like manner. The coinplaint is fre<}uent in young persons. (4) Cephalodynia. — By this term is meant rheumatism of the head- muscles of the scalp and fasciae. It may be either general or local., being sometimes limited to the frontal, temporal, or occipital muscles. The pain is severe and greatly increased on motion of the scalp. (5) Other terms descriptive of localized forms of muscular rheuma- tism are employed : (a) Omodynia (myalgia of the deltoid) ; {b) Dorso- dynia (involvement of the muscles of the upper part of the back, etc.) ; (e) Abdominal rheumatism (myalgia of the muscles of the abdomen) ; (d) Rheumatic myositis of the extremities. Diagnosis. — This is assured by the etiologic influences and the presence of pain, which is greatly increased by muscular contraction. The presence of fever does not exclude the affection. It differs from neuralgia in that there are no painful points, and in that firm pressure with the broad hand often affords relief. On the other hand, in gonor- rheal rheumatism the plantar fascias are commonly involved and the patient complains of pain in the head. Dermato-myositis must not be confounded with muscular rheumatism. Unverricht first distinguished the former from the latter, showing that there are present pain and swell- ing of the muscles, as in muscular rheumatism, but additionally redness (erythema) and hyperesthesia of the skin, while the joints usually escape. Of general symptoms, the chief are fever and physical prostration. The spleen is enlarged, and angina and hemorrhages have been noted. The disease is obviously infectious, probably septic in nature, and may rarely prove fatal. Dermatomyositis, unlike muscular rheumatism, is more common among women, especially servants, than men. Abdominal rheumatism has been mistaken for appendicitis. The prognosis is good, the disease never endangering life, though a person may be incapacitated for work by muscular rheumatism. Treatment. — Severe and acute forms demand the use of opiates internally and anodyne and hot applications externally. When cases are seen early, morphin, administered hypodermically, may serve to relieve the pain and cut short the disease. In acute cases the salicylates and other antirheumatic remedies are to be employed. Hot fomentations give comfort, and the Turkish bath may end the attack if it can be used sufficiently early. The hot-Avater bag, sponging with water as hot as can be borne, or dry heat in the form of bags filled Avith heated salt or heated hops, will all do good service. For the dull pain which is so dis- tressing in some cases of torticollis the affected muscles may be covered with flannel, over which a warmed flatiron may be passed for a few minutes. This is an efficient expedient. For lumbago acupuncture is highly commended. Needles of from three to four inches (7.5-10 cm.) in length (ordinary bonnet-needles, sterilized, Avill do) are thrust into the lumbar muscles at the seat of the pain and withdrawn after five or ten minutes (Osier). Schmidt recommends local injection of 5 or 10 c.c. 324 INFECTIOUS DISEASES. of physiologic salt solution for the relief of pain. Blisters have been recommended, but I have tried them -without beneficial effects. In sub- acute and obstinate cases I have recently obtained good results from the use of a 20 per cent, ointment of salicylic acid freely rubbed into the skin. Active friction with anodyne and stimulating liniments (the latter when pain is not great) is worthy of trial. Massage and electricity (con- stant current) are sometimes efficient, and in chronic cases potassium icdid, guaiacum, and arsenic (the latter in small doses) should be tried. The same measures of prophylaxis are to be adopted as in chronic rheu- matism. The general health must also be looked to, every endeavor being made to nuiintain the proper quality of blood and perfect nutrition. CHRONIC ARTICULAR RHEUMATISM. Definition. — An affection of the articular structures which develops slowly and gradully and may have the same etiology as the preceding forms. Rarely it is a sequence of acute or subacute attacks. Pathology. — The joints, as a rule, do not show pronounced gross lesions, there being some degree of synovial injection and also some, though not much, effusion. Inflammatory thickening of the articular and periarticular structures (capsule, ligaments, sheaths of the tendons, etc.) with contraction, is noted, and is a change which deforms and stif- fens some joints to a certain extent. Superficial erosions of the carti- lages may also be witnessed, and muscular atrophy supervenes. The probable causes of these important changes have been pointed out in con- nection with the latter disease. When the shoulder-joint is the seat of chronic inflammation, this muscular atrophy (affecting chiefly the deltoid) reaches its highest degree of development. Ktiology. — (a) Age predisposes to the affection. Though it may ap- pear at any age, the greatest number of cases is furnished by the years from forty to sixty. (6) Sex exerts a slight influence, the disease being observed most frequently among females, {c) External agencies, as pov- erty and occupations which entail exposure to cold and dampness, {d) Hei-edity may operate to favor its development. Symptoms. — The involved joints may not present any visible evi- dences of disease, and perhaps the most prominent local symptom is pain, increased often at night as well as by approaching cold or damp weather. Both the larger and smaller joints are involved, though the former to a greater degree, and yet, though usually multiple, the disease may be limited to one joint (knee, hip. shoulder, etc.). The joints are somewhat swollen, as a rule, at times slightly reddened, tender upon pressure, and their mobility is generally restricted. Pain and stiffness are most marked in the morning hours (after rest), and often largely disappear with each returning evening (after use). All the local symp- toms are subject to exacerbations and remissions. A peculiar crepi- tation may be elicited on applying the hand over the affected joints dur- ing motion, and eventually ankylosis, with some degree (usually slight) of distortion of the joints, may occur. The general features are usually conspicuous by their absence. No fever is present, and, in most instances, there is no serious impairment of the general health. On the other hand, as the result of constant suffering, a wretched general condition with marked anemia and debility MUSCULAR lUlEUMATISM. 325 may finally be reached, such patients often passinff sleepless nif.^hts ;irirl suffering severely from dyspepsia. Chronic endocarditis may develop along with the claronic articular changes — a not uncommon association, though frequently the history of a previous attack of acute rheumatism is also obtainable, to which the endocarditis may be attributed (for the differential diagnosis of this disease vide Arthritis Deformans). Prognosis.^ — Full recovery is, with but few exceptions, out of the question. A cure may rarely be effected if the case come under appro- priate treatment in the incipient stage. The disease, however, rarely shortens the duration of life, though it may do so by interfering with the nutritive processes, the latter effect resulting from loss of sleep (due to pain) and inability to take active exercise. Treatment. — (a) The local measures hold first place. The affected joints should be enveloped in flannel at all times, and underneath the latter may be applied cold cloths, and the whole covered with oiled silk. On the other hand, sponging the joints frequently with hot water relieves the pain and stiffness. • Bier, Reed, and others, employed a hot-air treat- ment with good effects. Blisters are efficacious in removing effusions. In the absence of synovial effusion the thermo-cautery is to be preferred to blisters, and for the swelling and stiffness massage with passive move- ment affords excellent results. Massage is also valuable when atrophy of the adjacent muscles exists ; and in these so-called " rheumatic paral- yses " electricity is an important help. lodin and stimulating liniments are more or less serviceable. [h) Hygienic Measures. — The diet should be abundant and nourish- ing; it may embrace milk, eggs, the lighter forms of meat, fats, fari- naceous articles, and cruciferous vegetables ; wines and alcohol may be permitted. Dietetic abuses, however, tend to aggravate the arthritic condition. The patient should adopt and continue moderately active exercise until compelled to omit it on account of the advancing joint- lesions. Cold spongings of the skin-surface, followed by active friction, have a good effect in that they lessen cutaneous sensitiveness. (c) Internal remedies do not control the morbid process directly, although arsenic, iodin, potassium iodid, guaiacol, and other agents are much used for this purpose, but their effects are usually limited, and never brilliant. It should be our aim to maintain the general health at a maximum level by the employment not only of the sanitary means before alluded to, but also by tonics (iron, quinin, strychnin, etc.). A course of cod-liver oil is the most serviceable form of internal medication. {d) Hydrotherapy is an important adjuvant to the treatment. The thermal springs whose waters are alkaline or contain sulphur, and of which the hot springs of Arkansas and Virginia, and the Rich- field Springs, New York, furnish good examples, have been strongly advocated, and sometimes prove curative in their effects. I have seen excellent results from the methodic use of hot-water baths at a constant temperature (100° to 105° F.— 37.7° to 40.5° C). combined with passive motion and careful manipulation of the affected parts. Every pre- caution must be used to avoid exposure to cold or draft during and after the baths, which should not be prolonged beyond ten minutes. 326 lyFECTIOUS DISEASES. Mountain Fever. (Moiiniai/i Sicknejis). The terra "mountain fever" sliould be regarded aB applicable only to a condition produced by the action of a rarefied air upon the organic functions. There is no definite pafhohhiy. Aron's investigations show that the intake of oxygen is diniinished at high altitude. The Sjrmptoms are a mneh-quickened pulse, urgent dyspnea, head- ache, vertigo, and at times nausea and vomiting. There is a subfebrile movement, the temperature touching 100'^ F. (37.7° C) or even 101° F. (38.3° C). Thirst is present and the appetite is lost. Malaise and a sense of exhaustion on attempting exertion are experienced. Hemop- tysis has been noted, but rarely. The effect upon the human economy of hiffh altitude varies with the extent of the differences in individual reserve nerve-force. Rest and acclimatization Avill almost invariably restore healthy function. Oxygen inhalations are advised (Ai'on). The "mountain fever" of the older writers is 9,lmost universally con- ceded at the present day to be typhoid fever modified by the effects of extreme altitude. Rocky Mountain Spotted Fever. Historic Note. — This disease has been known in the valley of the Bitter Root River, in Western Montana, during the past twenty years. Rock Creek and Bonito, nearly twenty miles disrant from Bitter Root Valley, have furnished a limited number of cases. Mountain spotted fever has also appeared in the valleys of streams situated in the mountainous sections of Northwestern Nevada, Southern and Western Idaho, and in Northern Wyoming. Predisposing Causes. — Climate. — Mountain spotted fever has not been observed south of 40° or north of 47° N. lat., and epidemics are most prevalent at elevations ranging from 3000 to 4000 feet. Season. — The disease prevails exclusively during spring and early summer months. Ocaqjatioii, Age, and Sex. — Persons who are compelled to be in the open air and among the woodlands and farming districts are most likely to become infected. In Anderson's ^ analysis of 121 reported cases, 76 were males and 45 females. Most of the cases occurred between the fifteenth and fiftieth years of age. Parasitic Origin. — A series of investigations, conducted by Ander- son, showed that the Pyroplasma hominis, a parasite closely allied to the Pyrosoma bigeminum (known to cause Texas fever in cattle) and found within the body of the red blood-corpuscles, is the infecting parasite. He further believes that the disease is transmitted to man through the bite of ticks (Dermacentor reticulatus) common to infected districts. Incuhafion. — The period of incubation varies from three to ten days, seven days being the rule. During three or four days of this period the patient experiences slight chilly sensations, malaise, and nausea. Clinical History. — The disease is ushered in by a distinct chill, which is followed by a rapid and continuous elevation in the temperature, * Hyqifivir, lAihorntory Bulletin, No. 14. "Public Health and Marine-Hospital Service of the United States," p. 8. ROCKY MOUNTAIN SPOTTED FEVER. 827 with slight morning remissions, until the tentli to the twelfth day, and in fatal cases it reaches 104° to 106° F. In favorable cases the tempera- ture reaches the maximum from the eighth to the tenth day, after which there is a gradual decline to the normal by the fourteenth day. Following the chill the patient experiences pain in the back and loins, soreness of the muscles, the limbs are moved with difliculty, and there is always slight, and at times severe, nose-bleed after the fiist week of fever; the tongue is heavily coated at the center and base, Avliile its edges and tip are red; nausea and vomiting are common, and persistent constipa- tion is the rule. The conjunctivae are at first congested and later assume a yellowish tinge; the urine is febrile in character, being diminislied in quantity and containing a moderate amount of albumin and also renal casts; the respirations range from 25 to 60 per minute, and it is not uncommon for the patient to develop bronchitis from the third to the sixth day of the fever; the liver and spleen are enlarged. The pulse is weak and rapid, being out of proportion to the temperature. The mind is, as a rule, clear even in the severer forms. Eruption.— ^he eruption is rather characteristic ; it appears on the third to the fourth day, on the wrists and ankles, from which points it spreads to the arms, legs, forehead, back, chest, and, lastly, to the abdomen. The spots are at first bright-red maculge, varying from the size of a pin's point to that of a pea. In the severer forms of the disease these maculse become dark and later assume a purplish tinge. They begin to fade at about the sixth day, and lose their petechial character with the decline of the fever at or about the fourteenth day. Blood. — During the course of the disease the red blood-cells show evidence of destruction, and the white cells may be slightly increased in number. The hemoglobin may gradually fall to 50 per cent. Diagnosis. — Mountain spotted fever is to be differentiated from cerebrospinal meningitis., peliosis rheumatica, malaria, typJioid fever, mountain fever, and purpura hemorrhagica. The eruption is similar to that of typhus fever, but the spleen is less habitually enlarged, and it runs a shorter course with a more abrupt onset and termination of the fever. Prognosis. — Of 121 cases occurring in the Bitter Root Valley dis- trict, 84 were fatal (Anderson). In other districts the rate of mortality may reach 90 per cent. Death usually occurs betAveen the fourteenth and eighteenth days of the disease, and may result from complications, among which pneumonia deserves special mention. Treatment. — The treatment is ordered to meet the indications pre- sented by each individul case. L. B. Wilson and Anderson have sug- gested the use of quinin hypodermically. Morphin, in the form of Dover's powders, is usually required to relieve the intense pain and soreness. Hot sponge-baths are of value in relieving the temperature. The diet should consist of milk, broths, soft-boiled eggs, and soft toast. H. T. Ricketts recommends the eradication of the tick in infected areas as a prophylactic measure. Heinemann and Moore found that serum from horses recovered from spotted fever has a protective value; it can be concentrated as in the case of diphtheritic antitoxin. 328 INFECTIOUS DISEASES. WEIL'S DISEASE. {Acute Febrile Jaundice : FHedler's Disease.) Definition. — An acute febrile disease, probably specific in origin, and characterized by jaundice, remittent fever, and muscular pains. It usually runs a definite course and terminates by lysis. Pathology. — During the comparatively recent studies of the post- mortem lesions occurring in this disease very little has been noted. The liver and spleen are sometimes the seat of an active hyperemia, and occasionally some gastro-intestinal irritation is present. The cortical substance of the kidneys is swollen and mottled, and the epithelium of the tuliules and glomeruli shows cloudy swelling. !^tiology. — The special organism of the disease is unknown ; indeed, it may be an acute febrile jaundice of varied etiology. Jaeger claims that it is due to infection by the bacillus proteus jiuorescens. Cockayne believes that it may be due to some biting insect. Certain French authori- ties consider the disease a ptomain poisoning. Predisposing Causes. — Among these may be mentioned the following : (a) Age. — The age of the patient usually varies from twenty to forty years. A. Holz records a case in a woman fifty-one years old. (h) Occupation. — Butchers are most commonly aifected. Workers in ditches and sewers or those exposed to foul water are particularly prone to infection. (c) Sex and Season. — Most of the recorded cases occurred in males asnd during the summer months. {d) Locality. — The cases have appeared in groups, in both rural and urban localities. Symptoms. — The disease is usually ushered in by a chill., followed by fever, headache, and pain in the muscles, joints, and epigastrium. Jaundice usually appears on the second day, and may either be slight or very intense ; if it be due to obstruction, the stools are gray-colored, showing the absence of bile. The fever is of the remittent type, run- ning from ten to fourteen days and terminating by lysis. Nausea, vomiting, and diarrhea may rarely occur. The liver and spleen are often enlarged, the latter being tender on pressure. The urine is febrile, high-colored, and often shows the presence of albumin, with tube-casts, and sometimes blood (hemoglobinuria). In grave (but rare) cases cere- bral symptoms, such as delirium, convulsions, and coma, may occur and prove fatal. The diagnosis rests on the acute onset, fever, pains in the muscles, joints, and epigastrium, nephritis, and icterus. Schlarnmfieber, which prevailed mainly among young persons who had worked in the recently flooded districts near Breslau during the summer of 1891, and assumed epidemic proportions, has not been satisfactorily classified. Miiller shows its resemblance in many respects to Weil's disease, which may occur at times without jaundice (?). Prognosis. — The prognosis, both as to life and recovery, is good. W. E. Hughes, notwithstanding, records two cases that proved fatal within forty-eight hours of the onset. FEBRWULA. 329 The treatment is purely symptomatic. The diet shouhl be fluid, such as milk, broths, and the like. Hydrotherapy is indicated in the more toxic cases. The muscular pains may be relieved by warm stupes and fomentations. FEBRICULA. {Simple Continued Fever ; Ephemeral Fever.) Definition. — A brief febrile attack, unattended with definite local lesions, and of varied, often indeterminate etiology. A true ephemeral fever is one that lasts about twenty-four hours, while the term simple continued fever or febricula is given to cases lasting a longer period. The cases are diversified with reference to their etiology and clinical relations, but may be roughly grouped under several heads : (a) A large group of cases in which a g astro-intestinal disturbance is the only assignable cause. The latter may be due to cold or more often to errors in diet (particularly the use of tainted food-stuffs), accompanied by absorption of ptomaines, or it may assume the form of gastro-intes- tinal catarrh met with in young children. (b) Undeveloped or abortive forms of the infectious diseases (typhoid, influenza, rheumatism). These affections, particularly during times of epidemic prevalence, may run a brief course without manifesting any of their distinctive characters. This is particularly true of the abortive types of typhoid, and other acute infections. Again, diseases that ordinarily manifest a characteristic eruption {e. g., scarlet fever, measles, erysipelas) may run their course without doing so, or the eruption may escape observation. (c) It may follow exposure to the summer sun or excessive heat (?), or exhaustion of the 7iervous system. (d) It is not infrequently the result of a slight and unnoticed local- ized inflammation (tonsillitis, bronchitis, lymphadenitis, etc.). (e) The inhalation of sewer-gas or other noxious vapors (such as em- anations from decomposing organic matter) may produce an aberrant form of the fever (vide Septicemia). Symptoms.— It is to be remembered at the outset that a single symptom, peculiar to all cases, is the fever. The onset is generally sudden, and especially in ephemeral fever, but it may be gradual ; if sudden, there is rarely either a chill or vomiting, while in neurotic chil- dren a convulsion may occur. The temperature ascends quickly to 102°-103° F. (39.4° C.) or over, pursues the continued type, and at the end of one, two, or more days subsides abruptly by crisis. There are accompanying symptoms, many of which are due to the fever, such as headache, hebetude, mild delirium, flushed countenance, a full, rapid pulse, anorexia, constipation, scanty, high-colored urine, and, not rarely, herpes labialis. Defervescence may be attended with critical sweats, diarrhea, or a copious flow of urine. Special types {e. g., cerebral, gas- tric, gastro-intestinal) may be observed, due to the predominance of the symptoms presented by individual organs or systems. In another class of cases the access of simple fever may be less sud- den, the maximum level attained being somewhat low^er and the attend- ing phenomena less acute and pronounced. Da Costa ^ has described cases belonging to this category. The course is more protracted, though 1 Transactions of the Associatioi of American Physicians, vol. xi., 1896. 330 INFECTIOUS DISEASES. rarely exceeding a week or ten days, and the defervescence is not so abrupt. So-called thermic fever is at the present "writing believed by Guit^ras, who first described it, to be due to a special, though as yet unknown, oriranism. The diagnosis necessitates the exclusion of other acute fevers. The affections from which it is most difficult to distinguish febricula are typhoid fever ^ remittent fever, scarlet fever, incipient tuhercxdosis, larval pneumonia, and vieninf/itis (in children). In febricula, however, there is an absence of local manifestations and of physical signs pointing to consolidation of the lungs ; characteristic skin-eruptions are also absent. Tyson points out that in cases in which there is splenic enlargement (rare) the resemblance to typhoid is close, and the diagnosis may have to remain in doubt until settled by the Widal test or by time. The cases must also be discriminated from the fever which sometimes attends chlorosis and certain nervous disorders. The prognosis is good. Treatment. — Few cases require treatment other than rest in bed and liquid nourishment for several days. Cooling drafts internally, and mild forms of hydrotherapy (spongings, ice-caps) externally, are indi- cated. If traceable to gastro-intestinal disturbance, a laxative usually proves beneficial and eifective. It should be followed by intestinal antiseptics. Unless it is clear that the given case is non-infectious and non-contagious, isolation of the patient should be ensured. MILK-SICKNESS. Definition. — A peculiar infectious disease, occurring both in man and in the loAver animals, when it is known as " trembles." The dis- ease is unknown east of the Alleghany Mountains, but throughout many of the Western and South-western States it formerly prevailed very ex- tensively, with fatal effect. It has, however, been almost exterminated as the result of denudation of the forests and the advancing cultivation of the virgin soil. It still prevails in parts of North Carolina (Osier), and until very recent times has been seen in certain parts of Illinois. No peculiar pathologic lesions have been described. Ktiology. — It is believed to be due to a special poison derived from the earth, but as yet we are ignorant of its exact nature. Phillips claims to have found a spirillum in the blood. Modes of Infection. — The disease attacks cattle most frequently (espe- cially unweaned calves), horses, sheep, goats, and less often many undo- mesticated animals ; wherever trembles prevails among cattle, milk-sick- ness is met Avith in man. It is thought that the poison is communicated to man in the milk, butter, and cheese, or in the flesh of infected animals. Among disposing factors are the seasons, the disease being most fre- quent in the late summer and autumn. It is most common in adult life. Symptoms. — The period of incubation may be short or long in duration, and prodromata, such as headache, anorexia, languor, and oncoming fatigue, may be noted. These symj)toms increase in severity, and are soon eclipsed by the more characteristic features — nausea and vomiting, a hot pain in the stomach, and a peculiar fetor of the breath. There is an unquenchable thirst, a swollen, tremulous tongue, and abso- MILIARY FEVKIi. 331 lute constipation. Fever is present, but it is sliglit, and the surface- temperature is often below the normal. The nervous symptoms include restlessness, merging into mental dulness witli marked indifference, and the latter condition passing in grave cases into a stupor that may deepen into actual coma. Convulsions may arise or the patient may drop into a fatal typhoid state. The diagnosis rests chiefly upon the history (particularly upon the coexistence of " trembles " in cattle) and the exclusion of other acute intoxications. The prognosis is generally favorable, though a fatal termination due to asthenia may occur within a few days of the time of the onset. Treatment. — Prophylaxis consists in the avoidance of those foods that act as bearers of the disease. Apart from the use of supporting measures (appropriate diet and stimulants), we can attend only to the symptomatic indications. Medicated enemata should not be omitted. MILIARY FEVER. (^Sweating Sickness.) Definition. — An infectious disease, characterized by copious sweats and a vesicular (miliary) eruption. In certain countries it has prevailed epidemically (France, England, Italy, Germany), and in 1887 a severe epidemic occurred in France. Schaffer ^ reports the occurrence of a re- cent epidemic in an Austrian province in the spring of 1893, lasting for nearly three months. Out of 5079 persons (the total population of the district), 159 suifered, as follows : 17 men, 14 women, and 128 children. At the present day it seems to be met with only in Picardy, in a few other French provinces, and throughout a limited area in Italy. Neither have definite pathologic lesions nor the specific exciting cause been found. Among predisposing infi,uences the following have been noted : (a) Most epidemics occur in spring and summer ; (6) It is more common among women than men, and most frequent during the middle period of life. A large percentage of the entire population of an in- vaded district (usually limited in area) is attacked. The SjTtnptoms that characterize miliary fever are fever with its usual accompaniments, irritation of the skin, epigastric oppression, copious and persistent sweating, followed, on the third or fourth d-av of the disease, by an eruption (due to profuse sweatings) of miliary vesicles. A. Weischelbaum ^ has shown by serial sections through sudaminse that the fluid in the latter is not due to retained secretions In the sweat glands, but is always of an inflammatory nature. The vesicles burst, and within forty-eight hours scaly desquamation is generally completed. In severe types the nervous phenomena (delir- ium, etc.) are grave in character ; hemorrhages may occur, and at times fatal collapse may follow. Relapses are not uncommon. The prognosis is aff"ected largely by the character of the epidemic, the average death-rate being 8 or 9 per cent. Quinin has met with almost universal favor as a remedy, but the expectant plan of treatment is the most appropriate, the indications being fulfilled as they arise. The sweating may demand atropin. 1 Wiener med. Bldtler, 1893, No. 32, ^ Zeit. f. Klin. Med., 1907, Ixii., 21. 332 IXFECTIOUS DISEASES. FOOT-AND-MOUTH DISEASE. (Epidemic Stoinatiiis : Aphihous Feva:) Definition. — An acute infection of certain lower animals (cattle, sheep, pigs, goats), caused by a micro-organism as yet undiscovered, although Klein has described a micrococcus. It is characterized by fever, by the appearance of vesicles and ulcers in the mucosa of the mouth, in the furrows about the feet and on the udder, and by the rapid develop- ment of asthenia and marked emaciation. Though a disease of mild character, its territorial range is so vast as to entail untold loss to Euro- pean countries. Young animals or sucklings perish in great numbers on account of the deteriorated quality of the milk, which assumes a yellowish- white appearance and has a bitter, nauseating taste. During epidemics of foot-and-mouth disease the poison may be trans- ferred to man, in whom the disease is known as epidemic stomatitis, the poison generally being transferred by means of milk. Boiling the latter destroys the virus, but rarely the infection may be transmitted through butter and cheese made from the milk of infected cattle. Com- munication by inoculation (while milking) may also occur. The disease does not seem to be transmissible through the meat of diseased animals.^ In America a few instances only of transference from animals to man are recorded. Symptoms. — The incubation-period lasts from three to five days, A rigor may mark the onset or merely slight shiverings, followed by fever and malaise, and soon vesicles, such as are described under Aph- thous Stomatitis, appear upon the tongue and inner surface of the lips. The mouth is hot, the mucosa reddened and swollen, and salivation is present. A form of miliary eruption that may become pustular may also appear on the skin-surface, and particularly on the fingers and hands. Hemorrhages have been observed in severe epidemics. The diagnosis is made with ease if the disease be prevailing at the same time among lower animals. The peculiar coincidence of the erup- tion in the mouth and extremities, sparing the rest of the body, has not been noticed in any other eruptive disease (Whittaker). Course and Prognosis. — The course is mild and ends in about one week, the disease being very rarely fatal. Treatment. — Prophylaxis requires the use of milk from healthy animals (cows or goats), together with measures looking to the care of the stables and isolation of diseased cattle. A reliable method of immu- nization against foot-and-mouth disease has not as yet been discovered.* For treatment the reader is referred to the article on Aphthous Stoma- titis. GLANDULAR FEVER. Definition. — By this term is meant an acute infectious disease of children, characterized by adenitis affecting the lymph-glands of the_ neck, especially the anterior cervical. ' Zuell's translation of Friedberger and Frohner's Pathology and Therapeutics of the Donwjilic AnimaU. _ _ . , -r, • i. t>- j c i .. ' Sie^el, "Experiments in Immunization against the Foison oi Jiites and bcratcnes. Quoted fn the Fhiladelph-ia Med. Jour., January 28, 1899. GLANDULAR FEVER. 833 History. — A detailed description of ^liindidar fever was first given by E. Pfeiffer, in 1889, under the name of Drasenfieber, but it had jjrob- ably been previously described by Filatow, of Moscow. Donkin, Fischer and Dawson Williams, in England, and J. l^ark West have given excel- lent descriptions of the disease. Pathology. — The anterior cervical lymphatic glands are involved first, and it is " probable that the infection finds its point of entrance through either the tonsils or the pharyngeal mucous membrane " (Wil- liams). The adenitis may also aflect the inguinal and axillary glands. etiology. — The special micro-organism of the disease is unknown, although Burns has isolated the staphylococcus aureus. The complaint occurs usually in the form of house-epidemics. West, of Ohio, however, has described the most widespread epidemic hitherto recorded. There were 96 cases in 43 families, and rarely did a child exposed to the infec- tion escape. The disease usually occurs during childhood ; the ages of West's cases ranging from seven months to thirteen years. A. E. Rous- sell has reported four cases, one occurring in an adult. Most cases occur between the months of October and May, inclusive. According to Hand, the weight of clinical evidence tends to variation in the etiology in differ- ent cases (e. g., it is often one of the protean manifestations of influenza). The incubation-period lasts usually from five to eight days. Sytaptoms. — The onset is sudden. The child holds the neck stiffly, since movement causes pain ; there are anorexia, nausea, and less com- monly vomiting, the bowels are constipated, and often there is abdominal pain. The child may complain of pain and swelling ; an examination of the pharynx may show some chronic enlargement of the tonsils, and in some cases injection of the pharyngeal mucosa, actual pharyngitis being rare. The temperature oscillates from 101° to 108° F. (88.3°- 89.4° C). Nervous symptoms (delirium, hebetude) are rarely observed. The glandular enlargement becomes obvious on the second or third day, and in most cases is observed first on the left side, then, after a few days, on the other side of the neck also. The glands vary in size from a bean to a hen's egg, and are painful on palpation. They rarely suppu- rate. Other groups of glands (axillary, inguinal) may be successively involved. Cough and dyspnea may point to involvement of the bron- chial and tracheal glands. The mesenteric glands were enlarged in 38.5 per cent, of West's cases. Splenic enlargement occurs in 50 per cent. of the cases, while the liver is increased in size in almost all cases. There is a leukocytosis varying from 18,000 to 25,000. The average duration is sixteen days (West). Among complications may be mentioned hem- orrhagic nephritis, bronchitis, and otitis media. Diagnosis. — The recognition of glandular fever embraces the exclu- sion of such affections as tonsillitis, pharyngitis., and influenza, in the course of which adenitis might arise. Griffith^ has reported cases resembling glandular fever in which influenza was probably the sole dis- ease present. Prognosis. — Recovery is the rule. Treatment. — The course of the disease is probably uninfluenced by treatment. Locally, cold compresses and fomentations are useful. Inter- nally, West advises castor-oil in the early stage, followed by minute doses of calomel (gr. -jL to -jlg-) twice or thrice a day. * Univ. Med. Magazine, October, 1900. PART II. ANIMAL PARASITIC DISEASES. PARASITES OF MAN. The human species furnishes a habitat for many varieties of parasites. Protozoa, including the Amebas and Infusoria, Plathelminthes, Nema- todes, Leeches, Arachnoids, and Insects. Some infest the body surface, while others find their locus in the intestines, bone marrow, vascular sys- tem, muscles, brain, genital apparatus, or solid viscera. AMEBIC DYSENTERY. (Amebiasis.) Definition. — A colitis, usually chronic, though it may be acute, caused by the Entamoeba di/ sentence, often leading to abscesses of the liver. Etiology. — This disease is caused by the amceba dysenterice (Council- man and Latieur) or the entamoeba hystolytica. The amoeba dysenteriae is a unicellular, motile organism, in size 3 to 7 times the diameter of a red blood-corpuscle (15 to 30 micromillimeters). Its protoplasm con- sists of two zones — an outer colorless (ectosarc) and an inner granular zone (endosarc), with a visible nucleus and one or more vacuoles. This micro-organism was first described by Lambl (1859), but it remained for Losch, and especially Kartulis, to show its close association with dysen- tery. The amoeba dysenteriae is occasionally found in healthy individuals, and also in other bowel affections than dysentery (mucous enteritis, simple diarrhea, proctitis due to engorgement), and two species are recognized — a virulent entamoeba hystolytica and a benign form, entamoeba coli. Walker's studies, however, indicate not less than ten species. The ameba is found not only in the discharges, but also in the pus from the secondary liver-abscesses. Flexner^ affirms that bacterial association probably has much influence on the pathogenic powers of the amebas. The principal causative role in the production of this form of dysentery has been ascribed to the pyogenic cocci by Tancarol, Ascher, and others. The disease is much more prevalent in adult males. The mode of transference of the ameba is not definitely known, though the principal source of the dysenteric germs is most probably the drink- ing-water. The disease is feebly communicable by contact. ^ Jour. Amer. Med. Assoc, Jan. -5, 1901. 334 AMEBIC DYSENTERY. ?j?,o Pathology. — The lesions are almost always situated in the large intestine, although rarely the ileum is also invaded. The first visible change is a hyperemia of the mucosa, most marked in the descending colon and rectum ; but the changes which produce the characteristic dysenteric ulcer begin with infiltration and swelling of the submucosa, followed by necrosis, which involves the overlying mucosa with its epi- thelium (Kruse and Pasquale). How the amebse reach the submucosa has not yet been observed. The infiltrated circumscribed areas are oval or hemispheric in shape, and project above the level of the surrounding mucosa. The submucosa presents a grayish-yellow appearance, and is soon thrown off in the form of a slough. The ulcers take various shapes — chiefly irregular, and less frequently round or oval. Their edges are ragged and undermined, and the floor, which is more or less covered with pultaceous material, is rough or crater-like, and formed by the musculature or the outer serous coat of the intestine. From the manner in which the ulcers are formed it is obvious that cellular infiltration (followed by necrosis) may occupy the sub- mucosa for a greater or less distance beyond the borders of the ulcers. In this way fistulous channels may be produced beneath the mucosa and connect two or more ulcers. Usually this ulcerative process affects only certain portions of the large gut, especially the flexures — hepatic and sigmoid — and the rectum ; but it may be general, and I have seen an instance of this kind. Cases are not uncommon in which the ulcers are so numerous as to include almost the entire mucosa of the colon. Healing is attended with the development of fibrous tissue along the edges and in the base of the ulcer, and secondary contraction of this new connective tissue is often productive of colonic stricture, which is usually either partial or irregular. The cases that come to autopsy often show diphtheritic inflammation as a secondary or terminal condition. The microscope reveals proliferation of the fixed connective-tissue cells (rarely pus), and the presence of amebas in the walls and the base of the ulcers, in the lymph-spaces, and rarely in the blood-vessels. The liver may be the seat of prominent lesions. These are (a) ab- scesses, which may be single or multiple. The single or large solitary abscess is usually situated near either the upper convex or the lower concave surface, while the abscess-cavity is formed in a manner similar to the intestinal ulcers. The area affected is at first infiltrated ; it then becomes necrotic, and finally more or less liquefied. Upon the full de- velopment of the first stage the part invaded is a grayish-yellow pulta- ceous mass, but in the second or necrotic stage the abscess contains a yellowish or greenish-yellow, spongy material with beginning liquefac- tion. The contents of the mature abscess consist of a greenish- or reddish-yellow purulent material and of remnants of liver-tissue. The walls of the recent abscess are irregular and ragged, those of an old abscess being dense and fibrous, and a section of the abscess-wall shows an inner necrotic zone, a middle zone (in which there is great proliferation of the connective-tissue cells, compression and atrophy of the liver-cells), and an outer zone of intense hyperemia (Osier). The contents of the abscess show either few or many amebge, and onlv rarely pus. When pus is present it is due to a secondary infectioa'by the 336 ANTMAL PARASITW DISEASES. pyogenic germs. The amebfe probably gain access to the liver by met- astasis from the intestinal foci. Cultures are generally sterile. (b) The parenchyma of the liver may be the seat of circumscribed necrotic spots, due to the action of the toxins formed by the amebae. The lungs sometimes show changes similar to those in the liver ; they are the result of direct extension of the hepatic abscess through the dia- phragm into the lower lobe of the right lung. The kidneys often present the lesions of acute parenchymatous nephritis (Craig). Clinical History. — The mode of onset is gradual except in a small proportion of the cases, in which it is sudden with Avell-marked symp- toms. When, as generally happens, it is insidious, the initial symptom is often a trivial diarrhea. The affection is then characterized prin- cipally by intermissions and an exacerbating diarrhea, the liquid stools containing necrotic tissue of a grayish-brown and sometimes yellowish-gray color. The latter are often bloody and mucoid, later be- coming fluid. I:\xenumher of discharges per day is exceedingly variable, although in most instances they range from six to eight or ten daily. Microscopic examination of the feces during the exacerbations dis- closes amebse that are almost invariably endowed with motion, though usually not Avhen the stools have become formed. Tenesmus is not a prominent feature in most cases, and may be entirely absent. Colicky abdominal pains, nausea, and vomiting are rare. General Symptoms. — Fever is usually present, but it is slight and exhibits marked variations. In certain instances, however, the tempera- ture is below the normal. From the time of onset there is gradual, pro- gressive loss of flesh and strength, and anemia becomes well marked. Complications. — The most common is hepatic abscess, and as the result of perforation of the diaphragm may arise secondary abscess of the right lung. Authors are not agreed as to the frequency of occurrence of liver-abscess (see p. 922) in amebic dysentery, but it is certainly com- paratively rare in this country, not exceeding, perhaps, 3 per cent, of the cases. In the tropics it occurs in 20-25 per cent, of the cases. Peri- tonitis may result from perforation of a dysenteric ulcer, causing death. The point of perforation may, however, be in the rectum, when peri- proctitis is the result ; or it may be in the cecum, when perityphlitis is the sequel. In tropical or subtropical countries the disease is often complicated with malaria. The presence of an intermittent fever is not, however, sufficient to warrant the assumption that malaria complicates dysentery ; we must be able to demonstrate the presence in the blood of the Plasmodium malarice. In pyemia and in suppurative processes gen- erally — conditions sometimes met with in dysentery — the temperature- curve is often distinctly intermittent. Typhoid fever is a rare compli- cation. The typhoid state is met with, and pyemia and septico-pyemia may appear late. Pylephlebitis, pericarditis, endocarditis, pleuritis, nephritis (common), and rheumatoid pains in the joints are observed. Diagnosis. — The slow course, marked by intermissions and exacer- bations of the bloody, fluid stools, the mild general symptoms, apart from emaciation and debility, are salient features, but an assured recog- nition of the aflfection demands a microscopic examination of the stools. Cases have been recorded by Councilman and Lafleur in which the diagnosis rested upon amebte being found in the sputa ; this was ex- plained by the existence of an hepato-pulmonary abscess, which had AMEBIC DYSENTERY. 337 discharged through a bronchus; the intestinal symptoms were negative. Simihir cases have been reported by L. Napoleon Boston ^ and others. Prognosis. — The mortality-rate in certain epidemics has been fright- ful, particularly among soldiers in the field (amounting to 70 per cent.). In sporadic cases the danger to life is less, the mortality-rate in temper- ate climates being not over 5 or 6 per cent. The complications which render the prognosis unfavorable are, — peritonitis, hepatic and pulmonary abscess, pyemia, broncho-pneumonia, malaria ; death may be due to hemorrhage or peritonitis, but in a preponderating proportion of the cases to asthenia. A dangerous degree of debility is indicated by great ner- vous depression ; a cool, clammy skin ; a sunken, pinched facies ; a dry tongue; a feeble, rapid pulse; and by Ioav muttering delirium. Course and Duration. — The average duration ranges from eight to ten weeks in uncomplicated cases; the disease can, however, be cut short by appropriate treatment. It manifests an innate tendency to pursue a chronic course, interrupted by frequent exacerbations or true relapses, and convalescence occupies a long period of time in conse- quence of the profound anemia and debility that supervene. Treatment. — The diet should consist of easily digestible and nutri- tious solids, as raw oysters, eggs, rice, fowl, fish, and the like, in small quantities. Milk should also be freely allowed. It may be necessary to restrict the diet to fluids if diarrhea be well marked. During convales- cence a return to a mixed dietary is to be adopted in a gradual manner. A judicious hygienic regimen calculated to maintain assimilation is especially valuable. Kest in bed, combined with gentle, systematic massage, may be necessary in severe cases ; in other and lighter cases graduated exercise in the open air and rest are serviceable. The medi- cal treatment is by ipecacuanha, in the form of salol-coated pills. Not less than 30 grains at a single dose are to be given on the first day. " Subsequently the amount is to be diminished by 5 grains per diem, so that by the sixth day only 5 grains of the drug are administered. During the next week or ten days a nightly dose of five grains must be allowed."^ Rogers^ recommends the subcutaneous injection of J-grain doses of emetin hydrochlorid. Beck advises the treatment of dysentery with ipecac through the Einhorn duodenal tube, especially in acute cases, as much as 1 to 2 drams being introduced at one sitting. Colonic injections of warm solutions of quinin hydrochlorid (strength 1 : 1000 to 1 : 5000) have proved effective in the hands of most clinicians. Leroy, of Memphis, has used formalin similarly (1 : 1000), with almost specific effects. Copper arsenite internally (gr. j^^ ^- 0.00067) and hot instilla- tions of copper sulphate solution (1 : 10,000 to 1 : 6000) have been found valuable (Storck *). Musgrave^ prefers thymol, which he gives by enema. A small class of cases do not yield to either the ipecacuanha treatment or rectal lavage ; they demand " appendicostomy and systematic, thorough irrigations through the appendix." Recurrences will yield to the same means, and they can sometimes be prevented by promoting the repair of the blood and tissues during the intervals. ^ Jour. Amer. Med. Assoc, April 26, 1902. 2 " The Treatment of Amebic Dysentery, Especially bv Appendicostomv," bv J. M. Anders and W. L. Eodman, Jour. Amer. Med. Assoc, February 12, 1910. 3 Brit. Med. Jour., 1912, 2695, 405. *Jour. Amer. Med. Assoc, Jan. 6, 1912. ^ New Orleans Med. and Surg. Jour., May, 1911. 22 338 ANIMAL PARASITIC DISEASES. FLAGELLATA. MASTIGOPHORA. During the motile period of their existence these organisms possess one or more flagella attached to either or both ends in the various forms, and some of them also possess an undulating membrane, the trypan- osomee being the best exemplars of this latter group. The body of these parasites is very small, many with rounded anterior portion, pointed pos- teriorly ; others, spindle-shaped. They are nucleated, often have vacu- oles, and some contain chlorophyl. Trichomonas var/inalis lives in an acid medium. It is not found in normal vaginal secretion, but in vaginal catarrh with acid secretion ; it may occur at any age from childhood to advanced life. It is a specific parasite of the female generative tract, though, rarely, it has been found in the urine of men, probably introduced through coitus. It is not known how they gain entrance to a woman. Alkaline solutions destroy them, as does cold. Trichomonas i7itestinalis and jmlmonaUs are met Avith in stools, urine, sputum, secretions from mouth ; but these forms are not pathogenic. Lamhlia (Oercomonas) i)itestinalis — a monad commonly met with in intestinal discharges ; not believed to be pathogenic. Cercomonads have been found ((7. hominis) in discharges of cholera patients and {Bodo urinarius) in urine. Balantidium coli {Paramoecium call) is found in discharges from obsti- nate cases of colitis ; also in mucosa, and even submucosa, of rectum and colon. Stokvis has found it in the sputum of a case of pulmonary abscess. The pig is believed to be the source from which man is infected. Trypanosomiasis. sleeping sickness. The trypanosoma is a flagellated hematozoon common to the lower animals, and has been found in man. Trypanosoma hominis is a minute, colorless, translucent, active protozobn, tapering toward its extremities, the anterior of which displays a long flagellum. The body of the organ- ism is finely granular. It is found free in the plasma. Trypanosomes have been known for over sixty years, but their pathologic import was first pointed out by Evans in surra, a disease of horses and cattle in India, trypanosoma Evansii. In May, 1901, Forde found the organism in the blood of an Englishman suffering from an irregular chronic fever, at first thought to be malaria. Six months later Dutton found and recognized the nature of the organism in the blood of this same patient, though about ten years before, Nepven, a French observer, had seen the same or a similar parasite in man, this being the first time that man was found to be subject to infection from trypanosomes. Dutton suggested the name trypanosoma gamhiense for the parasite, and trypanosomiasis for the disease. Trypanosomiasis is engrossing a large proportion of the professional attention at the present day of Europe, Asia, Africa, Australia, and even America. Castellani ^ found the trypanosoma in ' Lancet, June 20, 1903. SLEEPING SICKNESS. 339 the spinal fluid, obtained by lumbar puncture, in 20 out of 34 cases of sleeping sickness, but Bruce first showed the pat}iohj;^ic relationshi)) between sleeping sickness and trypanosonia, and that the agent of trans- mission is the tsetse fly of the genus Glosnina paljjaltH. This fly is not found in America. Trypanosoraes have been found associated with many diseases of man and animals, and Manson believes that three of these — i. iim(li(m Fertr, Kala-azur, Piroplasvioxia.) Definition. — It is a chronic disease, characterized by anemia, irreg- ular fever, emaciation, pigmentation of the skin, enlarged spleen, and by a {)rotozoon organism, whicli is found in the spleen, liver, bone-niar- row, lymph-glands, adrenals, testicles, intestinal and cutaneous ulcers, and intlammatory exudates, and only very rarely in the blood. Tropical splenomegaly, known also by its native Indian name, kala-azar (black fever), from the pigmentation of the skin, has also been termed Dum- dum fever in Indian medical circles, after Dumdum, a military station near Calcutta. The disease is met Avith in India, Assam. China, Egypt, and Af- rica. Epidemics move forward very slowly — about 14 miles a year — the disease clinging to a place for almost five years and then disa})pearing. Ktiology. — In 1885 Cunningham, and in 1901, Firth, called atten- tion to certain minute bodies to be found in the protoplasm of the cell exudate of the base of the Oriental sore or Delhi boil. In November, 1900, Leishman found these bodies in smears from the spleen of a case of Dumdum fever in a soldier invalided home from India. In the winter of 1902—3 Major Leishman noted these same organisms in smears of blood and internal organs from a trypanosome-infected rat. In May, 1903, he published these observations, and suggested that the organisms were try- pan oeomes. Soon after Donovan found them in fluid obtained by splenic puncture from an Indian, hence the name, Leishman-Donovan body. Low. Manson, Rogers, Bentley, and others have since found them. They are minute, oat-shaped, oval, or round bodies, with faintly staining protoplasm, but deeply staining chromatin masses, usually placed at opposite poles of the cell. Rogers succeeded in cultivating these bodies in citrate of soda solution, typical flagellated organisms resulting — the proof of their nature. Unlike the usual type of trypanosomes, the flagellum is attached to the end of the body at Avhich the micronuclous is situated, and it does not pos- sess an undulating membrane. It probably escapes from the body of the infected individual in the discharges from cutaneous or intestinal ulcera- tion, and in all likelihood the intermediate host is some biting insect. Predisposing" Causes. — One-third of the cases occur under twenty years of age, and the Hindus were more fre(iuently afl'ected by the disease than the Mohammedans, the proportion being about 4 to 1 (Brahmachari). The Oriental sore — Delhi or Bagdad boil, a local infection, without constitutional symptoms — is apparently due. to the same trypanosome as tropical splenomegaly, but it is not fatal, and one attack, as a rule, gives immunity. Manson says it has been noted that Oriental sore is peculiar to camel-usino- countiies, and if this really be due to the same Leishman- Donovan body as kala-azar, that a reduction in virulence of the organ- ism has been attained by j^assage through the camel, as is the case with small-pox in its passage through the cow. The inference is, therefore, that the virus of Oriental sore should be employed in an attempt to protect against kala-azar. The disease prevails at all ages, in both sexes, and shows a predilection for the natives and old residents. ►. Symptoms. — There is fever, irregular in type, generally remittent, often comparatively long intermittent periods, the whole extending over some months. The fever may occur in ague-like attacks. A dirt}-, sal- low, anemic appearance of the cutaneous surface is noted, and occa- sionally areas of pigmentation. Enlargement of the spleen and liver PSOROSPERMIASrS. .'Ml occur early, the former being an invariable accompaniment, wliile the latter is less constant. Dyspnea, emaciation, progressive and, finally, extreme weakness, and more or less edema are present. Leucopenia, in which the proportion of white or red corpuscles may be less than one to one thousand with relative low polymorphonuclear counts, is almost diag- nostic of the disease. Cutaneous and intestinal ulceration devehjp various hemorrhages or purpura, and these, in an extremely emaciated individual with a large protuberant belly, make a picture fairly characteristic. Death often results from some intercurrent affection, Amon^ the cora- moner complications are pneumonia, pulmonary tuberculosis, abscesses, and splenalgia due to infarcts in the spleen. Prognosis. — Manson regards the disease as absolutely hopeless ; he has never seen a case recover. Rogers places the mortality at 96 per cent. Donovan gives an equally gloomy prognosis. Treatment. — Tonic and hygienic. Quinin is of no special value, but may be employed with iron and arsenic. When possible, segregate infected cases, since no other known method of prevention exists, and, as we have seen, once developed, it proceeds to a fatal issue. PSOROSPERMIASIS. Psorosperms belong to the lowest form of pjrotozoa. They are also known as sporozoa, and, because of their parasitic relation to cells, as cytozoa. A common form occurs in the muscles of the pig {sareocystis Miescheri). The amoeba coli of amebic dysentery belongs to the protozoa. Various coccidia may occur in man (e. g., sarcocystis hominis) to produce the disease indicated by this heading. {a) Internal J*so7-ospermiasis. — In man, hepatic disease similar to that found in the rabbit is produced by the coccidium oviforme. The tumors formed by the coccidia may be palpable, and the liver may be quite tender. Some chilliness and fever, malaise, and stupor passing into coma have been observed. Death was caused on the fourteenth day in a case admitted to St. Thomas's Hospital (Osier). The necropsy showed whitish neoplasms in the peritoneum, omentum, kidneys, pericardium, liver, and spleen. In the intestinal variety of internal psorospermiasis nausea and vom- iting, diarrhea, and the typhoid state may be manifested. Involvement of the kidneys has caused hematuria and frequency of urination. {h) External Psorospermiasis. — Cutaneous psorospermiasis, one form of which was formerly called keratosis follioiclaris, is characterized by lesions at first of a hard, crusty, papular type, later becoming confluent, and situated on the fiice, lumbo-abdominal, and inguinal regions. These papillomatous growths contain either parasitic sporozoa, or, as suggested by Montgomery and others, parasites that belong to the blastomyces. In carcinoma, epithelioma, and Paget's disease of the nipple coc- eidia are readily found in and between the pathologic epithelial cells, but whether they have an etiologic bearing upon these malignant affec- tions is still a matter of uncertainty. Prophylaxis consists in cleanliness and care in preparing such food veg- etables as spinach, lettuce, cabbage, and other greens that may possibly be contaminated by the excreta of the lower animals liable to psoroform-in- fection. The treatment of psorospermiasis is symptomatic, though rectal injections of a solution of quinin (1 : 5000 to 1 : 1000) may be tried. 342 ANIMAL PARASITIC DISEASES. MALARIAL FEVER. {■Chills and Fever; Fever and Ague; Swamp Fever.) Definition. — An infectious, non-contagious disease caused by the liematozoon of Laveran. It is characterized by splenic enlargement, brief febrile attacks which recur periodically, melanemia, and a ten- dency in protracted cases to irregular fever and extreme anemia. The following sub-varieties will be discussed : (I.) Intermittent fever ; (II.) Pernicious intermittent ; (III.) llemittent fever ; (IV.) Malarial ca- chexia ; (V.) Masked inter niittents ; and (VI.) Malarial hematuria. Historic Note. — There are few diseases with which the profes- sion has been acquainted longer than with malaria, and chief among the earliest known hotbeds of this disease were the city of Rome, the Pontine marshes about the latter, and the swamps along the lower Danube. It is pretty generally believed that the prevalence of the disease long has been, and still is, diminishing. This view is fully corroborated by my own observations upon the cases from four leading hospitals of Philadelphia. The drying of marshy districts of a malarious character, thereby rendering them unsuited to the development of the mosquito, is the cause of this decreased prevalence. New England, once a region in which the disease was very preva- lent, now aftbrds few cases. Again, in the southern portion of the United States, where the severer forms of malaria prevailed extensively in the past, a marked tendency to progressive reduction in the number of cases has also been observed. In foreign lands (England and Continental Europe) the constantly decreasing prevalence and virulence of this dis- ease have been noted by numerous careful observers. The relation be- tween malaria and the mosquito is suggested in the wn-itings of such ancient authors as Columella and Varro. The peasants say " in such a place there is much fever because it is full of mosquitoes." Shep- herds returning from the European mountains to their cabins smoked them to drive out the mosquitoes. The sheep occupied the cabins at periods Avhen the famished mosquitoes inflicted their bites upon these animals, after which they showed little tendency to bite man (an ancient prophylaxis). Mbu is the term used in Eastern Africa for both malaria and the mosquito. In 1848 Noth, of America, maintained that both yellow fever and malaria were transported by the mosquito, and King, in 1883, showed that malaria was transmitted in this manner. In 1891 Laveran recognized the mosquito as an intermediary host of this parasite. Similar views were held by Pfeiffer and Koch in 1892 and Bignami in 1894. Pathology. — The chief and most constant morbid lesions are attributable to the direct effect of the malarial parasites upon the blood. The symptomatic anemia (often quite pronounced) results from the de- struction of red corpuscles by the parasites. There is a marked ten- dency to an accumulation of pigment in the blood and in certain of the internal organs, particularly the spleen and liver. To account for this anomlooqg mpii ab'm -■i-Ni-i'l .haeiJ 8BY/ ,1 bioul inairi ■ufiini lio) i.\' yvii . 'i ' -Id tizoH /I' iii-l ^»rhJ J! fflf ■' ' ,91081/1)10 1 Ifirrno'H— .1 /— .t .}; .'J ■ iff'wlo IflTOVsa .airno'i iliiiiiB fiJiw Jam 79V'irf i .KJii9ina'J8 Ifluhi ■' (iboci ibIi! uuiJissiiuu^iU'/ — .ti ,«. .aava'i nATaAup lo aTi3AHj.4. aiil -lyiTsdJ nl sidfafv eTom on &i sloaoqioo ba-i »ii3 Yi ax/. laari edJ li gniwode ,olo8i/qioa j : f>'jl«-.iif'(ft Jiir-J-pJilt ^'d• -'osri'l-T^''^ hoT rnrmoV- ."C- iH liilfi •] r/iiii I '. -fii ■/(( •)f^>(J-ifi ii. 'ui.mi.vjLi. .-.uii^.ilV -uAi.V. jA'V .li HO.? DESCRIPTION OF PLATES III. and IV.» The drawings were made with the assistan of the camera lucida from specimens of fresh blood. A Winckel microscoiw, objective '^ (oil immersion), ocular 1. was used. Figures 4, 13, 23, 24, and 4'2 of I'late III. were drawn from fresh blood, without the camera lucida. PLATE III. The Parasite of Tertian Fever. 1. — Normal red corpuscle. 2, 3, 4.— Youni; hyaline forms. In I. a corpuscle contains three distinct parasites. 5, L'l. — 13eginnini:'(if nisnientation. The parasite was observed to form a true ring by the con- fluence of two iistudoiMKlia. During observation the body burst from tlie corpuscle, which became decolorized and ilisaiijieared from view. The parasite became, almost immediately, deformed and motionless, as shown in Fig. 21. 6, 7, 8.— Partly developed pigmented forms. 9.— Full-grown body. 10-14. — Segmenting bodies. 15. — Form simulating a segmenting body. The significance of these forms, several of which have been observed, was not clear to Drs. Thayer and Hewetson, who had never met with similar bodies in stained specimens so as to be able to study the structure of the individual segments. 16, 17. — Precocious segmentation. 18, 1'.), 20.— Large swollen and fragmenting extracellular bodies. 22.— Flagellate Dody. 23, 24.— Vacuolization. The Parasite of Quartan Fever. 25.— Normal red corpuscle. 26.— Young hyalinL- form. 27-34.— Gradual development of the intracorpuscular bodies. 35.— Full-grown b(jdy. The substance of the red corpuscle is no more visible in the fresh specimen. 36-39.— Segmenting bodies. 40.— Large swollen extracellular form. 41.— Flagellate body. 42. — Vacuolization. PLATE ]V. The Parasite of ^stivo- autumnal Fever. 1, 2. — Small refractive ring-like bodies. 3-6. — Larger disk-like and ameboid forms. . , 7.— Ring-like body with a few pigment-granules in a brassy, shrunken corpuscle. 8, 9, 10, 12.— Similar pigmented tjodies. 11.— Ameboid body with pigment. 13.- Bodywith a central clump of pigment in a corpuscle, showing a retraction of the hemo- globin-containing substance about the parasite. 14-20. — larger bodies with central pigment clumps or blocks. 21-24.— Segmenting bodies from the spleen. Figs. 21-23 represent one body where the entire process of segmentation was observed. The segments, eighteen in number, were accurately counted before separation, as in Fig. 23. The sudden separation of the segments, occurring as though some retaining; membrane were ruptured, was observed. 2V33.— Crescents and ovoid bodies. Figs. 30 and 31 represent one body, which was seen to extrr.de slowly, and later to withdraw, two rounded protrusions. 34, 35.— Round bodies. 36. — " Gemmation," fragmentation. 37.— Vacuolization of a crescent. 38-40.— Flagellation. The figures represent one organism. The blood was taken from the ear at 4.15 p. m. : at 4.17 the body was as represented in Fig. 38. At 4.27 the flagella ap])eared ; at 4.:i3 two of the flagella had already broken away from the mother body. 41-15. — Phagocytosis. Traced with the camera lucida. ' These illustrations are reproduced by permission from the article by Drs. Thayer and Hewet- son in The Johns Hopkinit Hoxpital Reports, vol. v., 1895. The Parasite of Tertian Fever. I'LATK III. rfpafe. -^ '■ »■ ■ ■ :., -' , • ■', 1,5; : , ^-^* . ■ '%^ t i'\., t* The Parasite of Quartan Fever. r*^ .tj^ ^ • 1'i.aTk IV. The Parasite of Aestivo Autumnal Feven 2 • 3 4 5 • iE-*p 22 26 '.iVi^ ^^ o ^u. w 37 Jf 39 4-0 •C# 44- ^wv^ «4Z> iri;?:-- MALARIAL FKVKR. 343 is the fact mentioned in the description of the amebic (infra) that the hemoglobin of the blood is converted into melanin (pigment) by the organisms. The phenomena of the disease are, at least in part, referable to the toxic action of this pigment. The malarial parasite also engenders a toxin which may be in part responsible for the morbid lesions of the disease. The spleen is engorged with blood, and at first is swollen (chiefly during the febrile paroxysm), but it soon becomes permanently enlarged (" ague-cake "). A rare accident in intermittent fever is rupture of the spleen. Hemorrhagic infarcts are occasionally presented by this organ. The liver is also engorged, but not to the same extent as the spleen. The heart-chambers may be found to be acutely dilated. Neuritis has been observed by Gowers, Bamstark, Ewald, and V. P. Gibney. W. G. Spiller^ reported a case that showed partial sclerosis of the motor tracts, and recent hemorrhages within the left internal capsule {vide Pernicious Malarial Intermittent, also Remittent Malarial Fever). !^tiologfy. — Parasitology. — Our knowledge of the malarial parasite may be discussed under five heads : (1) Discovery of the Plasmodium malarise in the blood of persons suffering from the disease. (2) Its developmental cycle in man (sporulation), as shown by Golgi, in 1885. (3) The discovery, by MacCallum, of its method of sexual fertiliza- tion. (4) Its fertilization and development in an intermediate host (the mosquito), as first pointed out by Surgeon-Major Ross. (5) The obser- vations of the Italian school, showing its method of re-entering the tissues of man. (1) In 1880 Laveran discovered the malarial parasite, but it was not until 1883, Avhen Marchiafava, Colli, and Golgi published their confirma- tory investigations, that the parasitic origin of the disease was accepteil. (2) Laveran and Golgi observed that certain parasites, especially those found in estivo-autumnal fever, developed into peculiar crescentic bodies (gametocytes). Other more rounded, ring-like bodies were seen to display abnormal agitation in from ten to fifteen minutes after being withdrawn from the body, followed by the discharge from the protoplasm of several filamentous bodies or flagella (microgametocytes). The latter wei'e seen to separate from the parent-cell, after which they were observed swimming independently in the blood. (3) The significance of both the crescentic and flagellated bodies was first described by W. G. MacCallum, of the United States, in 1897. While studying the life-history of the " halteridium," it was noted that a limited number of ellipsoid bodies were produced, corresponding to the crescentic bodies seen in human malaria. Certain of these bodies were hyaline, others granular, and it was the former variety only that de- veloped flagella. A flagellum, on swimming away from the mother-cell, was seen to display peculiar agitation on approaching one of the granular bodies (crescentic). One of the flagella was seen to enter the granular body and effect a symbiosis with it {sexual fertilization). Fertilization was followed by a short rest, after which the granular body assumed a worm-like form, and then swam slowly away, its pointed end directed foremost and trailing behind it pigment particles, which had been situ- ' Amer. Jowr. Med. Sci., Dec, 1900. 344 ANIMAL PARASITIC DISEASES. ated within its protoplasm. Later MacCallum was able to confirm these investigations by a microscopic study of the blood from a case of malaiia (eativo-autumnal) in man, the flagella being formed after exposure to the air. In human malaria sexual fertilization takes place in the mosquito's stomach or middle intestine within the first twelve hours. (4) Manson correctly supposed that the mosquito sucked blood from malarial subjects. Surgeon-Major Ross,^ of Liverpool, began his investi- gations in India, in 1895, by endeavoring to determine what became of the parasite after fertilization in the mosquito's stomach. During August and September, 1897, two members of the species Anopheles maculipennis, bred from the larvje, were fed on the blood of patients containing cres- cents, and he found that peculiar spheroidal cells developed on the walls of their stomachs, which convinced him that ''these cells constituted the long-sought mosquito stage of the parasite" {zytjote). In 1898 Ross studied the " zygotes of protozoma " of birds. He found that they attached themselves to the outer coats of the mosquito's stomach. The zygote grows rapidly, without movement or change in form, protruding into the insects body-cavity. Later its capsule be- comes easily perceptible and the cell-substance is seen to divide into from ten to twelve ''meres. " In from one to three weeks, depending on the external temperature, the zygote matures, when each mere contains a number of delicate, "thread-like" blasts. The next step in the development of the parasite is the rupture of its capsule, setting free these "thread-like" blasts within the insect's body; they are then carried by the blood's currents to all its tissues, more par- ticularly into the insect's salivary gland. The common duct of the sal- ivary gland of the mosquito (genus Anopheles) passes along the middle stylet of the proboscis, opening at its extremity, and a portion of the secretion of this gland is poured into the Avound caused by the insect's bite. In the human body the blasts return to the amebulae, with which the life-history of this parasite began. (5) In 1898 Grassi found three chief species of the mosquito in mala- rious localities, the Anopheles claviger being constantly present. Manson gives 32 members of the family Anophelinfe, which have been shown, with more or less precision, to be hosts of the malarial parasites. Banks has shown conclusively that Myzomyia ludhwi should be added to the list. In Nov., 1898, Bastianelli, Bignami,^ and Grassi conducted a series of experiments, by feeding mosquitoes the blood from persons suffering from estivo-autumnal fever, confirming the findings described by Ross, in Aug., 1897. These investigations showed the mode of infection ; that healthy mosquitoes become infected by sucking blood from malarial pa- tients, and that in from eight to twenty-one days such insects may infect healthy men by their bites. One mosquito may infect many persons, and may possess this power for an indefinite period, " since not all of the germinal threads escape from the venomosalivary gland." ^ Neither the common house mosquito (genus Culex) nor the Anopheles nigripinee takes part as an intermediary host for this parasite. The fact that mos- ' Brii. Mfid. Jour., Dec. 18, 1897. ^ "Malaria and Mosquitoes," Lancet, Jan. 13, 1900. ^ Jour. Amer. Med. Assoc., Feb. 3, 1900, A.Woldert. MALARIAL FEVER. 345 quitoes (Anopheles claviger) are known to occupy non-malarious districts proves the innocence of the uninfected insects. A single case of malaria transported to such territory often results in an epidemic. The malarial parasite of Laveran belongs to a subclass of the pro- tozoa known as hematozoa {hoemameha). Of the latter, three varieties, corresponding with the three leading clinical forms of the affection, have been distinguished in man, and the evolution of two of these parasites at least takes place within the red blood-corpuscles. Manson describes five species which he classifies as follows : Benign { ^ . )> do not form crescents. '&' r Quotidian — pigmented ^ Malignant < Quotidian — unpigmented Vform crescents. ( Tertian J They enter the red cells in the form of small, non-pigmented plasmodia, exhibiting ameboid motion, and then feed upon their host, transforming, at the same time, the hemoglobin of the latter into dark pigment-granules as they develop. The special varieties of the malarial parasite as ob- served in microscopic studies of the blood of human beings will be described separately. (1) The Hcemameha Causing Tertian Intermittent Fever. — This begins its asexual cycle of evolution in the red blood-corpuscles as a small hyaline ameba. Its development is attended with the appearance in its inte- rior of fine, brown, motile granules in the form of pigment, and when matured it about equals the size of a normal red corpuscle. It now assumes a spheric form, the pigment collecting centrally, and sporulation into fifteen to twenty or more segments follows. The tertian parasites are exceedingly numerous in the blood, and pass through the various stages of their life-cycle almost simultaneously, the sporulation of an entire generation occurring Avithin the space of a few hours (Golgi). The occurrence of the malarial paroxysm follows the process of sporulation, which is attended, most probably, with the development of a toxin, and the symptoms of the disease may be attributable chiefly to the effects of the latter. The red corpuscle that includes the parasite becomes enlarged and decolorized as the latter develops. The parasite of tertian intermittent runs its cycle in about forty-eight hours. Hence infection by a single generation would result in sporulation every second day, followed by the malarial paroxysm. Quite commonly, infection bv two groups of parasites occurs on successive days, and, since each has a definite period of evolution, a daily malarial paroxysm is the result (quotidian intermittent). Multiple infection with this parasite may occur, but Avith great rarity. (2) The Hoemameba Causing Quartan Fever. — This cannot be distin- guished from the tertian parasite at the beginning of its asexual career, but later differences are clearly perceptible. Its ameboid movements are more deliberate, and its pigment-granules are coarser, darker, and also less motile than those of the tertian organisms. Unlike the latter, it does not attain the size of the red corpuscles, and during sporulation the seg- ments (five to ten in number) encircle in an orderly way the central pigment-mass or clump, "rosettes" of great beauty thus being formed. 346 ANIMAL PARASITIC DISEASES. The red blood-corpuscle that harbors the quartan parasite contracts upon its destioyer, appears shrivelled, and its color changes at the same time from the normal to a deep greenish or bronzed tint. It sporulates about seventy-two hours after it enters the red corpuscle ; hence, if only one group of parasites be present, febrile attacks occur every fourth day — quartan intermittent. On the other hand, double quartan infection results in paroxysms on two successive days, followed by an intermission lasting one day, while trijde infection, or the presence of three groups, causes daily paro.xysms — the quotidian intermittent. Infection by more than three groups of the quartan parasite may occur, but is very rare. (3) The Rcemameha Causing Estivo-autumnal Fevers. — The endogen- ous cycle of this variety is evolved, chiefly, in certain of the internal vis- cera, and the microscopic examination of the blood in the various stages of the disease does not always give a positive result, as in benign tertian and quartan. The organism invades the red blood-corpuscle, but to what extent is questionable. It is a quite small hyaline body, its size at maturity scarcely equalling one-half the dimensions of the red corpuscle, and it accumulates a few fine pigment-granules. The parasite may be found in the later stages in the blood from certain internal viscera, as the spleen. After the condition has lasted a time characteristic oval and crescentic bodies, which are more or less refractive, may be observed in the fresh blood. These so-called ''sickle-form bodies" show central rods and clumps of coarse pigment, and are connected "with the malignant type of malarial fevers. Kino;-form bodies, and, at times, the sigJiet-ring forms, are observed. The red corpuscle, at whose expense the parasite develops, assumes a brassy-green hue, becoming shrivelled and crenated. It would appear from the studies of Manson, Marchiafava, Big- nami, and Surgeon Craig ^ that two varieties of parasite are concerned — quotidian and tertian forms of autumnal fevers {vide table, p. 345). The parasites of tertian estivo-autumnal fever are larger than the quotidian parsisite, and during the hyaline stage the signet-ring form, slugcrish ameboid movement, clear-cut refractive outline, and the occur- rence of one organism in a blood-cell which is not wrinkled are observed; during the pigmented stage, the ameboid movement and fine granular motile pigment. Segmentation takes place outside the corpuscle. Cres- cents are large, slender, and deeply pigmented (see Plate IV., p. 346), The quotidian parasite is smaller, at times actively ameboid, and more than one parasite may occupy a single red cell, which is usually wrinkled. Their pigment is motionless, and usually in the form of short rods. Unpigmented parasites also occur (Manson). Crescents are small, plump, and often present a double outline. Segmentation occurs within the red corpuscle. Development of Flagella. — Some of the crescents become ovoid with scattered pigment ; this in turn becomes more or less spherical, the pig- ment forming a central ring ; '' this finally approaches the periphery, the whole parasite becomes violently agitated, throwing out flagella, which have a wave-like motion, many of which break away " (Wright). Predisposing Causes. — (1) Soil. — Fresh- water marshes favor the de- velopment of malaria, and are most fruitful in influencing its growth 1 New York Med. Jour., Dec. 23, 1899. MALARIAL FEVER. ?A1 when located near the coast and tainted with salt water. Again, marshy districts affording luxuriant vegetation are notorious as malarial foci. Keeping in remembrance the foregoing facts, we can readily see why malaria is unusually prevalent in certain countries (chielly tropicalj, and why it is chiefly confined to the low-lying estuaries and the deltas of rivers. The same facts explain satisfactorily why certain districts which were very liable to the affection should have become, as the result of denudation of the virgin soil and its subsequent drainage and culti- vation, entirely free from the complaint. Epidemics following the upturning or the removal of the surface of the virgin soil are probably due to importation of the disease (or infected mosquitoes), and are com- mon on the frontier of the South and West. (2) Climate. — Malaria is more prevalent in tropical and subtropical than in temperate climates, and more common in the latter than in the polar zones. Hence it occurs more frequently in the southern than in the northern States of our own country. (3) Rapidly growing trees dry the soil by absorbing enormous quan- tities of water. In the Roman Campagna extensive experiments have been made with the eucalyptus tree, and districts protected in this manner becoming almost entirely free from malaria in a few years, the environment being unsuited to the mosquito. (4) Seasons. — In temperate latitudes most cases are developed in the autumn, the maximal period corresponding with the month of Septem- ber. This dictum is based upon 4841 cases of malaria gathered by the author from the records of the leading Philadelphia hospitals.^ Cases that develop before the "Anopheles claviger " makes its appearance (in June) are possibly relapses. In the tropics the case seems to be different, and two maximum periods — spring and autumn — obtain. Statistics from the hospitals of Rome, collected from 1864 to 1898, show the maximum number of cases to occur in August, September, October, November, and July, respectively, and in June the minimum number. (5) Persons occupying the upper stories of a house or living on elevations are affected with relative infrequency, for the reason that mos- quitoes are always found near the earth's surface, where the air-currents are feeble. This fact also explains nocturnal infection. (6) Race exerts little influence, but in the United States negroes are slightly less susceptible than are the whites. (7) Sex is without effect when men and women are equally exposed. Cases are, however, vastly more frequent among males because of their increased liability to mosquito bites while following certain occupations (agriculture, marsh-draining). The 5J44 cases collected by me gave the numerical proportion of 6 to 1 in favor of males. (8) Age. — Children are more susceptible than adults. (9) The disease may flare up after either an accident or surgical operation. Immimity. — There are individuals immune from malaria and experi- mental malaria. An individual may present this property after a mild fever has been cured by quinin. Maurel has shown that when living in a malarious district whites may in time show marked immunity. By the use of methylene-blue and euchinin an immunity may be established against the inoculation of from 1 to 2 grams of estivo-autumnal blood. 1 Univ. Med. Mag., May, 1897. 348 ANIMAL PARASITIC DISEASES. Incubation. — According to Bignami and Bastianelli, the period of incubation for experimental malaria is : Quartan, 15 days ; spring tertian, 12 days ; estivo-autumnal tertian, 5 days. The administration of potassium bromid, potassium iodid, arsenic, carbolic acid, antipyrin, and phenocoll may result in a longer period. Angelo Celli has seen spring tertian show incubation of 22, and the estivo-autumnal tertian 17 days. Hpidemiology. — Estivo-autumnal fevers are rare in their recur- rence, while mild tertian and quartan prevail with each new spring, and the first cases of tertian are noted to occur in the same houses in which the last recurrences of these fevers appeared. After the first cases there is a lapse of from seventeen to eighteen days, after which the epidemic spreads. The life and habits of the Anopheles have a direct bearing upon epidemics — '' either the first cases of these fevers in July are recur- rences of a previous infection, or the very first cases of tliese fevers in July are primary" (Celli). "Both hypotheses are possible. In both we have to deal with a contagion circulating, so to speak, between the temporary host (man) and the definitive host (mosquito), a contagion which, by means of the blood of the relapsing cases of the preceding year, is transmitted by the agency of mosquitoes, and starts the epi- demic of the following year." There are many interesting (juestions not yet explained. (I.) Intermittent Fever. — Symptoms. — The clinical history pre- sents itself under two heads : (a) the paroxysms, and {b) the manner in which the paroxysms recur. (fl) The Paroxysms. — There may be premonitions lasting from one to several days, and most significant, yet not distinctive, are headache, pain in the nape of the neck, yawning, a yellowish complexion, and a slight splenic enlargement. In a large proportion of the cases, how- ever, the onset is abrupt. Typical paroxysms present three stages — chill, fever, and sweating. The chill is intense, causing shivering, and often chattering of the teeth. Malaise is marked, the skin is cool and pale, face slightly cyanotic, and limbs painful. This stage usually occurs in the morning houi^s, but the time of onset is not constant ; its duration, also, varies greatly, generally lasting from one to two hours. The internal temperature rises rapidly ; the pulse is small, rapid, and of high tension. The hot stage succeeds the chill, and, in striking contrast with the first stage, the face wears a decided flush and the skin is burning hot to the touch. The temperature continues to rige, but not so rapidly as in the first stage. Its maximum level, usually from 104° to 106° F. (40° to 41° C), is soon reached, and may either be maintained uniformly for several hours, or the curve may show two small summits if the tempera- ture be recorded frequently (Fig. 26). The pulse is full and bounding, except in the rare instances in wliich acute dilatation of the heart en- sues, when it is quite feeble and sometimes irregular. The length of the second stage is from three to six hours. The temperature generally begins to decline before the close of the febrile stage. When sweating, which soon becomes profuse, sets in, the symptoms of the hot stage are promptly relieved. The temperature falls by crisis, touching the normal level in a few hours ; the decline, however, is less MA LARFA L FE VKR. 349 rapid than the rise at the bo_o;inning of tlie paroxysm, 'ilie fall may be unbroken by any fresh elevations of temperature, though more often the latter occur. Less frequently defervescence occurs by stops, the temper- ature falling one or more degrees, and remaining at the new level for a short period ; then dropping again about an equal distance, and so on until the normal is reached. Usually, following the paroxysm, the tem- perature becomes subnormal (about 97° F. — 36° C). The length cf *he typical malarial paroxysm ranges from eight to twelve hours. M E M E M E W E M E M E M E M E M E M E M E M E M E M E M E M E M TT ul E UOWKAS twireme'at') Vrine Usily Amfi F ' " ' "f ;^ s" y\ V V ^ ,>^ ^ \^ 1^ - i>i r^ -* -\^ f\ vV "^ ^ 1^ '*»;' ^ ^ l.\ ^ ^ - ^ - - r"^ vt*. - r ^a j ' N < ^sS SEi ^ V ^ ^ ^ \ R inQO U^ ■ ■ Vi K 1^ k 1 ■ ' -Oj ^ j{ ' I ^ S2 1 « k 1 4 '.y w "d ^\ *. 1^ ^ - ^ - , ■■ . I ^ ^ I V I I ..f^ J 1 ^ ^ V, ^ ^ . i fv V y \ ^^ . ij *■ 4l ^ ■ _ ■' s \^ f !y T^ \ w r ,/ "^ OTO t v .2 97° \/ v ■2 — t- q Dui/(^IHs Puis*. ,,; ^'^f, ^. %/ %. 5^- '^fi^ H ^f^ W6 '-i, %. m 'ho ^P ^ ^4.^ ^^' Besp. ,^ ^^ ^i^^ ^M ^^/f %i 'ks 'kc ^M % 'M '^ff ^ff k -^- .4/- . ^¥ I>ate. ,g r ■' ^^ •• ■2/ - ■■ J^f ' •41 = 3«« -33« ■37« -86" Lae" Fis. 26.— Temperature-curve in a case of double tertian fever. C. F. C, aged forty-one years. (5) The Manner in which the Paroxysms Recur. — The special cha- racteristic of this form of intermittent is the regularity with which the paroxysms recur in cases that are not under treatment. The intermis- sion, or time between two successive paroxysms, is most frequently twenty-four hours (quotidian intermittent fever) ; almost as often it is forty-eight hours (tertian intermittent) ; and less frequently it is sev- enty-two hours (quartan intermittent). If there be two paroxysms on 350 AyiMAL PARASITIC DISEASES. one (iav — a rare occurrence — the term '' double quotidian" is used to designate the case. Of the above types, as stated in the life-history of the parasite, three only — the quotid/an (malignant), the tertian, and the quart(7n — have been clearly distinguished. The cjuotidian ague (the most frequent clinical variety) is generally due either to double infection by the tertian parasite or the (juotidian parasite (single infection), and rarely is it to be attributed to the presence of three groups of the quartan para- site, resulting in daily sporulation. It sometimes happens that the par- oxysms recur a couple of hours later each successive day, when it is called a '■'■ retardhui " intermittent fever, or they may recur a little earlier, when the term "-anticipating'' is employed. Other More or Less Characteristie Symptoms. — Apart from the par- oxysms and the regularity with which they recur, splenic enlargement is almost always present, and hence is of considerable clinical import. After the first paroxysm or two the swelling is usually marked and demonstrable, especially by palpation. The organ can be shown to in- crease in size with each succeeding paroxysm. Tenderness is elicited on pressure, and commonly outlasts the course of the aftection for a con- siderable length of time. Moderate enlargement of the liver may be present, but this is not so constant as enlargement of the spleen. Connected with the skin are two symptoms of considerable diagnostic value: (1) a yellotoish-hroivn discoloration, the so-called "malarial com- plexion," due to the deposition of pigment; and (2) herpes. The latter occurs usually on the prolabia or on the nose, though rarely elsewhere. Other skin-eruptions, as urticaria and purpura, have been described by authors, but they have no real clinical worth. As stated under Pathology, acute dilatation of the heart may develop, attended with the usual physical signs of this condition, but it rarely lasts longer than the brief febrile paroxysm. Murmurs of functional origin may also be heard in the heart during the attack, and the lungs upon auscultation sometimes present the signs of a dry bronchitis. The urine may contain a small amount of albumin, and rarely there is acuce nephritis — a rather common sequel in the negro. There is a temporary increase in the amount of urea eliminated, and this may be observed from two to six or eight hours before the chill (Jaccoud). Gastro-intestinal syniptoms may be present, as diarrhea, which is sometimes considerable, catarrhal Jaundice, and paroxysmal vomiting, but these are limited to the graver forms of intermittent. There is a rapid diminution in the number of both red and white cor- puscle^, proportionate " to the severity and the number of the attacks " (W. W. Johnston). The leukopenia is associated with an increase of large mononuclear leukocytes. Thomson emphasizes leukocytic variation at different times of day, correlating these with the stage of development of the parasites ; he also found that the more numerous the parasites, the greater the leukopenia, whereas a small number on sporulating cause a leukocytosis. The hemoglobin is reduced and granules of pigment are found in the plasma. Clinical Varieties. — Besides the typical attacks, mild or rudimentary forms are met witii, these either being due to slight infection or appear- ing as the remnant of cases of usual severity after active treatment. The separate stages of the febrile attacks are not well marked, and one or more may be missing ; thus the chill may be absent (dumb ague). MALARIAL FEVER. 351 In children there is no rigor noticcctblc. "^I^licy grow pale, tlie mucous membranes often being slightly livid during the chill, and the paroxysmn may be initiated by a convulsion or other nervous phenomena. Acute nephritis is a ratlier fref|uent sequel in white children. (II,) Pernicious Malarial Intermittent. — This truly serious form occurs chiefly in highly malarial districts, and rarely also in the wide- spread regions in which the simple variety prevails. In the United States it is encountered most frequently in the Southern and Southwest- ern States. In this form of malaria the parasites of estivo-autumnal fever are constantly associated. The paroxysms do not recur with strict regularity, and the primary paroxysms are rarely pernicious in character. Pathology. — This type of malaria may arise (1) as a fresh infection, and (2) as a reinfection. (1) Infection. — The blood is more or less hydremic, and the blood- disks are in all stages of disintegration. The spleen is considerably swollen, soft, and its parenchyma is turbid and lake-colored, all its tissue elements being more than naturally pigmented. Upon microscopic ex- amination pigment-granules and red corpuscles containing parasites and phagocytes are observed, particularly in the pulp adjacent to the arte- rioles. The liver is enlarged, soft, and turbid, and pigmentation occurs, but it is also microscopic. In the minute vessels phagocytes and para- sites containing pigment are perceptible within the red corpuscles, and numerous small necrotic areas have been observed. The kidneys show microscopic pigmentation, most marked in the vicinity of its blood-sup- ply. Minute areas of cell-death are sometimes seen. The brain may be abnormally colored, assuming in severe cases a chocolate tint, and in mild types a lighter hue. The brain-tissue is often anemic, and more rarely edematous. Occasionally there is congestion. The capilla- ries are literally blocked with phagocytes and blood-disks more or less disintegrated (containing parasites), and perivascular infiltration and minute hemorrhages may rarely occur, producing a focal lesion. (2) Reinfection. — The blood is often extremely hydremic. The spleen may or may not be much enlarged, and is usually quite firm, with a well-marked pigmentation that is obvious to the naked eye. The liver is, as a rule, moderately increased in size, and is somewhat indurated, while macroscopically it is seen to be deeply pigmented. The changes presented by the kidneys diifer in no essential manner from those of the liver. The microscopic appearances of the liver, spleen, and kidneys, apart from the fact that the amount of pigment present is relatively greater, are entirely analogous to those met with when a fresh infection occurs. Pigmentation of the lung is also common. Clinical Varieties. — Three varieties merit description : (a) Congestive Chills (Algid Form). — These are accompanied by raging gastro-intestinal symptoms (vomiting, purging, etc.), inducing systemic collapse, which simulates to a nicety the algid stage of cholera. The temperature of the interior of the body is much elevated. True dysenteric symptoms may arise, and sometimes jaundice, followed by grave nervous symptoms, may be a secondary development. The intel- lect is unclouded, as a rule. This condition is to be discriminated from yellow fever, with which it has frequently been confounded. The para- sites in this affection center in a special manner in the gastro-intestinal 352 A^'I^IAL parasitic diseases. mucosa, in the vessels of ■which they may be seen in unusual numbers, sometimee forming distinct thrombi. In the United States this is the most common among the pernicious forms. (b) Hemorrhagic Peryiicinus Malarvt. — In this form the chill is severe and prolonged, and during the hot stage the urine is bloody and scanty, containing considerable albumin, with bloody, epithelial and granular casts. Hemorrhages from other outlets of the body (mouth, rectum, vagina, nares, stomach) may also occur, together with larger and smaller cutaneous ecchymoses, and the yellowish-brown malarial complexion is intensified. The mind may renuiin clear, although the patient is restless and anxious. Urinary suppression may ensue, and uremic toxemia be superadded ; the greatest dangers being cardiac failure, uremia, and de- lirium (or coma independently of the latter). Death is rarely the direct consciiuence of hemorrhage. Brem believes this form to be due to an hemolysin produced by the malarial parasite. ((?) Comatose Form. — The chill may be absent. Grave cerebral symptoms, as acute delirium or sudden coma, seize the patient violently. The hot stage is attended with high fever, and if the patient survives the paroxysm, the violent nervous symptoms either disappear suddenly with the appearance of the sweating stage, or may outlast the latter by several hours. Primary paroxysms rarely prove fatal, but recurrences bring im- minent danger. This variety is due to an inordinate localization of the malarial parasites in the brain, where they form complete thrombi, and induce pathologic lesions in the adjacent structures. (III.) Remittent or Continued Malarial Fevers (Kstivo- antuninal Fever). — On account of the intensity of the gastro-intes- tinal symptoms this variety is also termed bilious remittent fever. Its severity exceeds that of intermittent malarial fever. It prevails for the great part in warm and truly tropical climates, though it is also seen in its milder forms in temperate climates. The estivo-autumnal parasites previously described are the specific cause of the disease. Pathology. — Melanosis of the spleen, liver, and brain is generally observed; on the other hand, in rare instances in which the specific parasite had even been demonstrated during life, the internal organs were found to be non-pigmented on autopsy. The degree of th« pig- mentation depends upon the length of time that the patient has been infected, as well as upon the frequency of reinfection. The spleen, if it be a fresh infection, becomes swollen, but is soft ; in protracted cases it becomes permanently enlarged and firm. Microscopically the pigment is seen to be most abundant in the splenic pulp and within and around the splenic veins. The liver is enlarged in like manner. The pigment that is found in the form of granular masses in all tiie hepatic tissue- elements (especially Kupffer's cells, vessels, vessel-walls, and perivascular tissue) gives to the organ a bronzed appearance (" bronze liver"). As in pernicious malaria, so in this affection, the brain, and particu- larly the gray matter, is in long-standing cases of a dark brown or almost black color. The arterioles are often found stuffed with phagocytes and blood-disks which contain pigmented parasites. Punctate hemorrhages may occur in the brain. The kidneys are pigmented and may show " a severe acute degeneration of the cortical tubule cells " (Ewing). Mass- ing of the parasites in the renal capillaries may occur. Other organs and tissues of the body, including the lymphatic glands and the skin, MALAUrAL FEVER. 353 become more or less deeply pigmented. The hlood sliows mai-ketl hydre- mia, Avith partly or wholly degenerated red blood-disks in abundance. Symptoms. — There may be prodromal symptoms, such as headache, anorexia, and epigastric oppression, lasting a day or two, but these signs are variable. There may be daily or bi-daily paroxysms of fever which resemble the ordinary quotidian and tertian intermittent forms, with this difference, however, that the febrile paroxysms are of longer duration (twenty hours or more). Both the rise at the onset and the decline at the end of the paroxysm are more gradual than in true intermittent malarial fever, and the initial chill may even be wholly absent. The febrile attacks are often "anticipating," the succeeding paroxysm be- ginning before the elevated temperature of the preceding touches the normal level, giving rise to a remittent type of fever which often exhibits considerable irregularity. The remissions may become shorter, producing finally a continued type of curve — continued malarial fever. In typical cases of remittent fever a chill generally occurs at the on- set, but is less severe than in malarial intermittents. Shortly after the chill the temperature rises rapidly, so that in ten or twelve hours it may reach 104° or 105° F. (40.5° C). The pulse is full and accelerated to 100 or 120, and there is rending headache. Nausea and vomiting are common ; oppression in the epigastrium is intense, and there is well- marked tenderness in the latter region. The spleen is found to be en- larged on palpation. Nervous symptoms (delirium, coma, etc.) may develop speedily, and rarely a mild bronchitis may also arise. About midnight the remission in the temperature and sweating begin, in consequence of which the headache and gastric symptoms largely disappear. The temperature usually drops to 100° F. (37.7° C) by the next morning, to be followed by a new exacerbation of fever, which commences about noon of the second day. The same symptoms now repeat themselves. The affection has usually, by this time, reached its acme, and the temperature may have risen to 106° F. (41.1° C). Grave nervous symptoms may also have appeared. The urine is dimin- ished in amount, often slightly albuminous, and acute nephritis is ob- served in 4.7 per cent, of the cases (Thayer) ; while either a slight or marked hepatogenous jaundice may appear. Urriola^ states that the presence of malarial pigment in the urine is a pathognomonic sign. A. C. Smith ^ reports instances of bubo (inguinal) as a complication. Herpes lahialis is quite common. The nocturnal remission again ensues, and in the mild types or in those brought promptly under suitable treatment the febrile paroxysms grow briefer, resulting in an intermittent form of fever. The course of light cases is run, usually, within two weeks. In severe types or in neglected cases the separate febrile paroxysms grow longer until the remissions become slight and simulate continued fevers. These are the cases that are distinguished by the same symp- toms as those that mark typhoid fever, save only the eruption and the Widal reaction. The course of the attack, if not properly treated, pro- longs itself to three, four, or more weeks, and the salient features of pernicious intermittent may suddenly appear and the disease mav ter- minate life. On the other hand, mild forms of the continued type also occur, and these yield promptly to the specific — quinin. 1 Interstate Med. Jour., Jan., 1912. ^ New York Med. Jour., June 22, 1901. 23 35-4 ANIMAL PARASITIC DISEASES. (IV.) Malarial Cachexia. — This is an exceedingly chronic condi- tion, and is usually a remnant of one of the acute forms. AVhen the latter are not properly treated, they are apt to drag on, and assume the characteristic features of chronic malarial cachexia. The condition may, however, be chronic from the start in truly malarial localities. The symptoms are varied both in character and in intensity. There is fever at intervals, but chills do not occur, and the temperature-curve is typical neither of remittent nor intermittent fever, although it may approx- imate either the one or the other. Again, the fever is sometimes wholly irregular, though its range is not high, and it seldom exceeds 103° F. (39.4° C). The skin often presents the dirty yellowish-brown com- plexion to a marked degree. The spleen is enormously enlarged and indurated, and hypertrophy with hardening of the liver may also be pronounced. The blood is profoundly anemic, the count in one of my cases showing but 1,300,000 red corpuscles per cubic millimeter. Many of the local and general symptoms are dependent upon the well- marked anemia. Among general features may be mentioned debility, frequent sweatings, and dropsy. Nervous symptoms may also be notice- able, and chief among these are tremors, neuralgia, palsies, vertigo, wakefulness, and nervous palpitation of the heart. Among the rarest concomitants of this condition is paraplegia. Malarial neuntis is met with and presents most of the features common to other toxic forms of neuritis. Slight cough and dyspnea evidence the presence of mild hro7i- chitis ; and anorexia, nausea, diarrhea, and other symptoms of chronic gastro-intestinal catarrh are observed. The joints and voluntary mus- cles may be painful. Hemorrhages from the various mucous surfaces and into the retina are common ; and I have seen one case in which spongy, bleeding gums, with numerous petechias, pointed to the existence of associated scorbutus. Tuberculosis finally developed and carried ofiF the patient. Chronic dysentery, fatty degeneration of the heart, and chronic nephritis may develop and prove serious sequelae. These cases do well, generally, if the patient can be removed permanently from the malarial district. In long-standing cases the spleen does not return to its natural dimensions. Complete recovery, however, may be expected. (V.) Masked Intermittent. — This presents itself in much the same forms as chronic malarial cachexia, but with the important diflference that there is no fever. This type comprises a long list of conditions, at the head of Avhich stands neuralgia, most frequently involving the supraor- bital branch of the trigeminus. Often a striking periodicity is observed, the painful paroxysms usually beginning in the morning and terminating in the late afternoon hours, the patient's sufferings increasing steadily in intensity until just before the close of the attack, when they sud- denly abate. Among other nerves implicated with relative frequency are the occipital, the intercostal, and the sciatic. Except the blood- appearances be characteristic or unless the attacks yield promptly to quinin, a certain diagnosis of malarial neuralgia should not be ventured. Craig,'^ out of 395 cases of latent and masked malaria, found the estivo- autumnal parasite in 275 ; they appeared as a small hyaline disc or ring- form within the red blood-corpuscle. The parasites, however, have been observed in all stages of growth, even undergoing segmentation. Craig » Amer. Med., Oct. 29, 1904. MALARIAL FEVER. 355 believes that the latency can be accounted for by the fact that the few organisms present do not generate sufficient toxin to provoke character- istic symptoms. Masked intermittents may assume the forms of pares- thesia, anesthesia, convulsions, or paralysis; tliey may also appear under the guise of edema, hcmorrliages from the various mucous outlets of the body or into the skin, diarrhea, dysentery, dyspepsia, bronchitis, pneu- monia, appendicitis, etc. But, since these affections may all obey th(; law of periodicity, we should not pronounce in favor of malarial infection unless they yield readily to the therapeutic specific, or the parasite is found. (VI.) Malarial Hematuria and Hemoglobinuria. — I have pre- viously described a hemorrhagic form of pernicious intermittent in many cases of which hematuria is a prominent symptom. Boisson,^ in 3 cases of hemoglobinuric fever, occurring in soldiers attacked with malaria in Madagascar, found great reduction in the erythrocytes, while 7 out of 10 red cells contained parasites. I have observed several instances of malarial hematuria in the Kensington district of Philadelphia, where the milder forms of malaria prevail. Hematuria in its severest form is seen with the approach of cold weather (Jones). It is rare in the negro. Young in both sexes and males over puberty are .most apt to suffer. The blood shows pigmented parasites (forming rosettes), and sometimes cres- cents and pigmented leukocytes. The symptoms consist of a mild cold stage, a subfebrile temperature to which is added hematuria, or more often hemoglobinuria. The par- oxysms may recur daily, bi-daily, or at longer intervals, and in severe forms the hemoglobinuria may be continuous, with aggravations at definite intervals. Suppression of urine may appear early, accompanied by ui-emic features, e. g., coma, nausea, vomiting, diarrhea. The lumen of the renal tubules may be occluded by plugs of granular material de- rived from the hemoglobin. The diagnosis demands the demonstration of the malarial parasites in the blood, and of the hemoglobin in the urine. Tyson recommends Teichmann's (hemin crystals) test to show the pres- ence of hemoglobin. The earthy phosphates are precipitated, filtered out, and a small portion placed on a glass slide and carefully dried. A minute granule of common salt is carried on the point of a knife to the dried mass and thoroughly mixed with it. Any excess of salt is then re- moved, the mixture is covered with a thin glass cover, a hair interposed, and a drop or two of glacial acetic acid allowed to pass under. The slide is then carefully warmed until bubbles begin to make their appearance. After cooling, hemin crystals can be seen by the aid of the microscope, and are easily recognizable by an amplification of 800 diameters. Chemi- cally they are hydrochlorate of hematin. The so-called blackwater fever is an intoxication due to repeated at- tacks of malaria, in which " some exciting cause produces a sudden hemolysis " (Prout), and quick spontaneous disappearance of the malarial parasites (Plehn). Other observers (Sambon, Macay) regard hemoglobin- uria as a specific disease. Bass and Johns found that calcium salts added to culture-mediums caused hemolysis of the infected as well as the non- infected cells of the blood of the sufferer. The leading- characteristics are irregular paroxysms of fever wuth rigor, bilious vomiting, jaundice, hemoglobinuria, and nephritis. This form occurs in the Philippines, in Germany, and other countries. 1 Rev. de Med., May 10, 1896. 356 ANHfAL PARASITIC DISEASES. According to Frank A. Jones, obesity occurs among persons coming from a climate free from malaria to the Mississippi's delta. They neither have chills nor manifestations of chronic malaria. '' The obesity sub- sides rapiilly by changing from a malarious to a non-malarious climate." Complications. — The author's analysis of 178U cases of malaria (intermittents and remittents) showed complications in about 10 per cent. The more common among these were: Enteritis (16), nephritis (14), rheumatism (10), typhoid fever (S), lobar pneumonia (5), jaundice (5), and dysentery (4). The opinion of the ])r()fession is divided upon the question: "lias pneumonia any special connection with malaria?" According to the results of my collective investigations, pneumonia is rarely associated. Craig affirms that malaria may present typical symp- toms of pneumonia, prol)ably owing to a localization of the malarial para- site in the capillaries of the lungs. Thayer's studies show that the fre- quency of albuminuria and nephritis in malarial fever is somewhat below that observed in the more severe acute infections. Typhoid fever is a complication of malaria, according to these re- searches, but the relationship between these afiections cannot be close. Diagnosis. — (1) Of Intermittents. — This is difficult, unless the brief febrile paroxysms, with their characteristic stages and other diagnostic features (enlarged spleen, malarial complexion, herpes), together with the rigid periodicity of the paroxysms, be present. Eesidence in a mala- rial district is confirmatory. The only unquestionable method of diag- nosis is provided by a microscopic examination of the fresh blood. If this cannot be made an early diagnosis is rarely possible until the peculiar manner of recurrence of the paroxysms is established. Differential Diagnosis. — Xon-malarial affections, exhibiting an inter- mittent form of fever, are often mistaken for malarial intermittents. Of these, (a) pyeviia is very apt to be thus confounded. It will be observed, however, that the chills occur at more irregular intervals, and that pros- tration is more profoun sufferers, 38 were farmers (Stiles). Symptoms, — In the usual form (lung infection), cough, is common but not constant; the sputa are similar to those of lobar pneumonia, although they may be absent from time to time. Free hlood-sjntting often occurs at intervals. Jacksonian epilepsy may supervene from metastasis to the brain. Diagnosis. — This rests upon the detection of the eggs in the sputum. Place a drop of the bloody sputum on a slide, and upon it a cover- glass. On microscopic examination the red color will be found due to both red blood-cells and large dark-broAvn, thick-shelled, operculated ova. which vary from 80 to 100 jj. in length, and from 40 to 60 a in breadth. The prognosis depends upon the number of the parasites present, the age of the patient (the young and the old bearing the disease badly) and the presence or absence of complications. Pulmonary tuberculosis is an unfavorable complication. Treatment. — Prophvlaxis embraces care reo;ardinor the drinkino;- water, and the collection and disinfection of the sputum as in pulmonary tuberculosis. The patient should be sent to healthy non-infected areas. There is no special medical treatment. Distoma Hematobium (Bilharzia hematohia ; Blood-fiukes). — This hematode is a narrow worm with anterior abdominal sucking-disks. The male is shorter and thicker than the female ; the former being 4—15 mm. (|— f in.) long ; the latter, about 20 mm. (i in.). It prevails mostly in Egypt, Cape Colony, and other parts of Africa, and its en- trance into the human body is now believed to be through the skin of those who bathe frequently in the African rivers, in many of which it abounds. It is not unlikely that, as formerly held, infection may also occur in many cases from drinking the impure water of the rivers. The parasites or their ova are found in the bladder, the pelvis of the kidney, and the veins (portal, mesenteric), most rarely the pulmonary. The symptoms are hematuria, with some pain during urination. The last few drops of urine voided only contain blood, although rarely hemorrhage is more extensive and then the entire bulk is blood-tinged. Cystitis often occurs, with resultant thickening of the bladder wall. The ova become nuclei for vesical stone-formation. Proctitis may result when the parasites lodge in the rectum, in which case mucous and bloody stools wath tenesmus result. Ova of the para- sites are found in the urine. No serious systemic disturbances occur in bilharziosis except, rarely, profound anemia from loss of blood. There is slight leukocytosis with increase in the eosinophile and large mononuclear cells. Prophylaxis as regards drinking and bathing in African waters should be exercised. Fouquet affirms the value of the extract of male fern internally in this form of distomiasis. ECIHNOCOOOUS DISEASE. 363 OESTODES. ECHINOCOCCUS DISEASE. (Hydatid or Bladder-vwrm Disease.) The taenia echinococcus is the smallest tape-worm of our domestic animals, and lives between the villi in the small intestine, especially in the larger breeds of dogs. It has a length of from 4 to 9 mm. (|- to 1 in.), and consists of only three or four sections, the last one of which is mature. The rostellum projecting from the small head has thirty or forty booklets arranged in a double row and a quadruple sucking appa- ratus. Thousands of eggs are contained in the mature segment. The intermediary hosts for the larvae are rarely man, the horse, and the sheep, but more often the hog and ox. I/ife History. — The ova, embryos, or the proglottides even, of the adult tenia are voided by the dog, and in various ways, later, are ingested by man. The dog first becomes infected by eating the echinococcus cysts of some animal that harbors the larval form of the tenia, and the matured teniae appear in from eight to ten weeks. The liberated six- hooked embryos burrow through the intestinal wall or enter the portal vein ; they pass into the solid viscera and muscles. There they develop into the larval form and cause the formation of echinococcus cysts. In the development of echinococcus cysts, about four weeks after the ingestion of the bladder-worm eggs, small nodules appear, about 1 mm. (^ in.) in size. In about five months the cyst-walls consist of two layers, an external layer and an inner, granular, parenchymatous layer (or endocyst), containing a clear liquid. As the reaction to the irritation caused by the parasite and its cyst increases, a fibrous investment forms around them. At this time, also, small daughter-cysts, or vesicular buds, form the minor granular layer of the mother-cyst, and contain the heads of the larvae. They are soon set free, and may themselves give rise to other or granddaughter-cysts in a similar way. These really become the breeding capsules of little cellular outgrowths that form the scolices or heads of future teniae. They show the four sucking disks and a circle of booklets. Each scolex, when taken into the intestine of the dog, de- velops into an adult bladder-worm or taenia echinococcus. This endogenous mode of cystic growth is common in man (^. hydatidosus). In animals the so-called exogenous cyst development is the more common in which the primary cyst-buds push out between the cyst wall and then develop externally. A third variety is the multilocuiar echinococcus {E. alve- olaris. Buhl), affecting principally the liver. A large, hard tumor is seen that on section shows a firm connective-tissue framework surround- ing alveoli that average a small pea in size. These alveoli contain small echinococcus cysts with thick, laminated walls. They may contain scol- ices or booklets, and sometimes they are sterile. The echinococci may be situated in the lymph-channels and bile-ducts (Zenker). The pure hydatid fluid is colorless, limpid, neutral in reaction, and has a specific gravity of 1005 to 1012. About 96 to 98 per cent, is water, and sodium chlorid, carbonate, and sulphate : traces of sugar (dextrose) ; cholesterin and uric acid are found among the constituents. Among the changes that an echinococcus cyst may undergo the com- monest is that of the death of the echinococci, as from diminished nour- ishment due to intense proliferation of daughter- and granddaughter- 564 ANLVAL PARASITIC DISEASES. cysts. The contents become thickened, putty-like, or granuhir, and even calcified. Remnants of these obsolete cysts, such as the chitinous sub- stance of the old and outer wall-layer and booklets, may be found. Sometimes rupture of the cyst occurs, with serious consequences to the patient ; or the peritoneum daughter-cysts or free scolices may be dis- seminated and grow. Or perforation into the respiratory, digestive, or urinary tracts and discharge of daughter-cysts and hydatid fluid may take place. Lastly, suppuration and the formation of large hepatic abscesses may ensue, either spontaneously or on account of septic instru- ment? used for tapping the cysts. Ktiology. — Carelessness in the feeding and the keeping of dogs is the primary source of hydatid disease, and the preparing of food where dogs are allowed ro roam about, and so on, accounts for the majority of cases. Females are more often aftected than males, and childi-en and young adults seem to be oftener aftected than those older in years. As regards the geographic distribution, echinococcus disease prevails most extensively in Iceland, where man and dog live closely together. In Australia, also, many persons are affected. It is not so common in Europe, Asia, or Africa, and in America it is rare. Organs Affected. — The tenia echinococcus has an undoubted predi- lection for the liver. "' Of 1806 organ-infections, the following organs were the most frequently aff"ected: liver (1011), lung (147), and kid- ney (126) " (Stiles). The brain and spinal cord, spleen, bones, muscles, the heart, and blood-vessels are involved with uncertain frequenc3^ Symptoms. — Hydatids of the Liver. — Unless the cystic tumors com- press the portal area or the biliary passages, or invade the neighboring viscera, subjective symptoms may be entirely wanting. Not infrequently echinococcus sacs, partly calcified, have been found postmortem, not having produced any symptoms during life. Grradual but progressive loss of flesh and strength with the presence of a fluctuating tumor may be the only symptoms present until late in the disease. If the cysts attain a large size, a sensation of dragging, and of pain even, is often present ; as a rule, however, pain is absent throughout the course of the disease. If the tumor displaces the diaphragm upward and compresses the lung, cough and dyspnea result. In some cases the sac has ruptured into the bronchi, and given rise to cough and to expectoration of the fluid and vesicles. If the portal veins and bile-duct are compressed, splenic enlargement from passive congestion, ascites, and jaundice will occur, these symptoms being more common when the cysts are multilocular. Rupture may occur into the intestines (colon), into the pleura or pericardium, causing pyothorax or pyo-pericardium, or into the inferior vena cava, causing fatal pulmonary embolism. Fever is usually absent throughout, unless the contents of the sac become converted into an abscess; then rigors or chills, fever (hectic in type), and sweatings occur, with jaundice (more or less intense) and rapid emaciation. Not infrequently the cyst-wall becomes partly calcified and the con- tents are reabsorbed. When rupture occurs, unless the contents be evacuated through the respiratory, alimentary, or urinary tracts or externallv, svmptoms of collapse develop and are followed by death. Toxic erythema or urticaria may follow rupture of cyst. The physical signs give on inspection fulness or bulging in the right ECHINOGOOOUS DISEASE. 365 hypochondriac region, especially if the cyst be single, of large size, and Bituated anteriorly. Palpation confirms inspection and shows a fluctuating mass or masses. A trembling impulse is felt sometimes on deep palpation, aided by light percussion over the opposite side of the cyst, constituting the so-called " hydatid thrill." This sign cannot always be elicited, but when present is pathognomonic of the disease. The remainder of the liver shows uni- form enlargement. The spleen is often palpably increased in size from passive congestion. Percussion reveals, in addition to the hydatid fremitus, an increased area of dulness to the left or posteriorly, depending on the location and extent of the growths. If the left lobe be involved, the line of flatness may extend across the sternum to the left hypochondriac region. If the cysts are multiple and on the antero-inferior surface, the stomach may be displaced toward the left and dulness may extend across the epigastrium; if posteriorly, the pleural cavity may be encroached upon, causing an increased area of flatness upward in the postero-axillary line. Frerichs claims the line of dulness posteriorly in hydatid disease to be a curved one, whose convexity is upward. Auscultation gives, according to Santoni and others, a short sharp booming sound when the tumor is percussed, that may be likened to one produced by striking a membrane stretched over a metallic frame. Diagnosis. — In the entire absence of subjective symptoms and of characteristic physical signs, the diagnosis is impossible. If the cyst be of sufficient size to give fluctuation and the liver be irregularly en- larged, with an absence of fever, pain, and marked emaciation, the dis- ease may be strongly suspected. The only certain demonstration of the condition is the discovery of the characteristic booklets or heads in the aspirated or discharging contents of the cyst. Among the conditions that may be misdiagnosed for hydatid disease are — {a) Dilatation of the gall- bladder, {h) hydronephrosis, (c) right-sided pleurisy with eifusion, (cZ) syphilis of the liver, (e) carcinoma, (/) abscess, and {g) cirrhosis. Hydatid Cyst. Dilatation of the Gall-bladder. Previous history negative, except the com- A previous history of having passed panionship of dogs. biliary calculi is often present. Pain and jaundice usually absent. Attacks of biliary colic followed by jaun- dice either are present or enter into the previous history. Enlargement in any direction, depending Enlargement is always in one direction — upon the location of the cysts. downward and posteriorly. Hydatid thrill may be present. "Hydatid fremitus" never present. Less so. The tumor is somewhat movable. Hydatid Cyst. Hydronephrosis. The history is negative {vide supra). There is a history of renal calculi or of vesical inflammation. Urinalysis is negative. Urinalysis reveals evidences of renal disease. The tumor is most prominent over the The tumor is most prominent in the hepatic area, and is associated with flank and iliac fossa. If extending to enlargement of the liver. . the right hypochondriac region, it does not move with the liver. The duration is indefinite and uremia The duration is short; a termination in rare. uremia is common. 366 ANIMAL PARASITIC DISEASES. Hydatid Cyst. Pleurisy with Effusion. The onset is slow ; pain and fever are The onset is sudden, and violent pain is absent. present, with fever and dyspnea. The presence of a fluctuating mass in the The presence of eflusion, beginning at hepatic area, 7ioi changing with the po- the base of the chest and gradually sit ion of the patient. Hydatid fremitus extending upward — changing with the is present, but no bulging of the inter- po.'^ition of the patient and accompanied costal spaces. by bulging of the intercostal spaces. Aspiration reveals a clear yellow liquid Aspiration gives a cloudy, turbid liquid, of low spocifio gravity witliout albuiiiiii, containing albumin and flakes of lymph but chlorids, sugar, and hooklots. with high specific gravity. The disease invariably runs a chronic The disease generally runs an acute coui'se. course. For a differential diagnosis from (d), (c), (/), and [g) I would refer the reader to the discussion of the several diseases (_vide Diseases of the Liver). Echinococcus of the Respiratory Organs. — The lung has been the seat of the larvne quite frequently, and instances have been noted especially in North Germany and Australia. The right lower lobe has been the seat of predilection, though sometimes the pleura is the primary source of trouble. There are pain in the chest, cough, dypsnea, perhaps arching of the overhanging thoracic region, signs of a pleural effusion, a tym- panitic note above the prominence, hemoptysis, and the pathognomonic expectoration of Iiydatid disease. The general condition may or may not be seriously affected. Perforation into the pleural sac by pulmonary eehinococci may be followed by empyema, and, later, by perforation of the chest wall. The heart may be dislocated. Compression of the lung may produce gangrene. The diagnosis, in the absence of the characteristic sputum, is to be made from phthisis and a pleural effusion. Their location at the base of the chest may serve to differentiate hydatid cysts from phthisis, as well as the absence of marked emaciation. The characteristic curved upper boundary of dulness in pleural effusion and the change of the boundary upon changing the patient's position will serve to distinguish this affec- tion. Pleural eehinococci sometimes cause great compression of the lung and a barrelling of the chest on one or both sides. The pain may be quite sharp, and the respiratory murmur either distant or altogether absent. EcMnococcus of the Mediastinum. — Hare has collected 6 cases of hydatid disease among 520 cases of mediastinal tumors. Echinococcus of the Heart. — Most of the cases have shown involvement principally of the right side of the heart. Echinococcus of the brain and spinal cord should not be confounded with cystic degeneration of the choroid plexuses. J. H. Lloyd found 19 distinct cysts in the lateral ventricles and one occupying the fourth ven- tricle. The symptoms of cerebral hydatids are those of tumor, persistent and intense cephalalgia, vomiting, psychical disturbances, convulsions, amblyopia, and "choked disk," and sometimes paralysis. Hydatid dis- ease may develop inside the dura mater, or it may penetrate from with- out and destroy the vertebrae before they compress the cord to a great degree. The symptoms are those of a compression myelitis. Echinococcus of the Spleen. — About 40 cases of involvement of the spleen have been described. The organ may become greatly enlarged and be mistaken for that due to malaria, leukemia, etc. The hydatid thrill may be detected. TAPE-WOBMS. 367 Echinococcus of the Kidneys. — More than 100 casew have been ob- served, mostly in Germany and France. The cyst may be as large as in hydronephrosis. Many of the cysts arc of the exogenous form of growth. As a rule, one kidney only is affected, and generally the left one. Ab- dominal and thoracic compression symptoms may be caused, and bulging is often present in the lumbar region in marked cases. This may be punctured as an aid in the diagnosis. Rupture into the pelvis of the kidney and the discharge of the smaller cysts may give rise to renal colic and to the discharge of the cysts with the urine. More rarely, rupture of a suppurating cyst may take place in the loin. Echinococcus of the peritoneum is rare as a primary condition. Echinococci have also been located in the bladder, prostate, testicle, ovary, uterus, great omentum, mesentery, pancreas, arteries, lymphatics, thyroid gland, muscles, bones, joints, parotid gland, orbit, and mamma. A peculiar complication of echinococcus cysts is the occasional development of urticaria. It has been noted especially shortly after the puncture of a cyst, and this is somewhat diagnostic when it appears. The prognosis is generally grave both as to life and cure, although some cases of hydatid disease of the liver have lasted for more than ten y ear<. The character of the changes in the cysts and their mode of termina- tion influence the prognosis. Thus, the occurrence of suppuration is to be dreaded. Spontaneous cures have been noted in a few instances. Treatment. — As in most of the other parasitic diseases, prevention is more or less effectual, and a cure is difficult or impossible. Infection of the dog should be avoided by preventing its gaining access to possible sources of hydatid disease, as the raw flesh of animals, especially in the form of meat-scraps around slaughter-houses. In order that human beings may not be affected, dogs should not be carelessly handled or allowed to be where they may come in contact with food and drink in any way, whether meat or eggs, vegetables, fruits, or cereals. Cleanli- ness in keeping dogs and in the proper preparation of food are essential in regions where hydatid disease is prevalent. Medicines cannot reach the parasites in man, situated as they are in larval form encysted in the various tissues and organs of the body. Whenever the cyst becomes large, accessible, and the cause of trouble- some symptoms, surgical measures may be resorted to. Among these are, simple tapping, tapping with aspiration, and with the subsequent injection of various substances (as iodin and zinc-chlorid electrolysis), and incision with drainage. Excision of the liver cysts has been practised by Raggi, Pozzi, Tansini, and others, but its practical value is still undetermined. Should suppuration occur, treat as an abscess. T^NI^ OB TAPE- WORMS. Natural History. — Tape-worms are found in the intestine of man, and are the matured or completely developed larvae or cysticerci from the muscles and solid viscera of animals. Different varieties of cysticerci develop from the ova of the respective varieties of tenise. These tape- worm eggs, after having passed out of the bowel, may be taken into the systems of various animals by various modes, entering the circulation, it may be, and becoming fixed within the solid tissues, especially the muscles. In about two or three months pea-sized cysts develop, and from the cyst-walls there gradually forms a new tenia-head, called a 368 ANIMAL PARASITIC DISEASES. scolt'.r. or nurse. The ■worm-cysts, popular!)^ termed "measles," con- stitute the cysticerci. Remaining in the tissues, they die and become calcified in from three to six years (Striimpell). But, if taken into the stomach by the eating of raw or partially-cooked meat, a tape--\vorm de- velops from the scolex. The maturation of the segments of the tape- worm commences several months after the fixation of the scolex in the intestine. In the natui-al life-cycle of a tape-worm the usual order of lodgement may be reversed. Thus man instead of a lower animal may become the host of the tenia eggs, which in turn may find their way into the solid viscera and muscles to develop into cysticerci. Again, this same order may be brought about by " auto-infection." The tape-wonr has a ribbon-like form ; although it has a number of segments and joints, giving it a link-belt appearance. When matured, these segments, or proglottides^ develop male and female generative organs. Varieties. — Taenia Solium [Pork Tape-worm). — This worm is rarer in America and also in Europe than formerly. It develops in the small intestine after the ingestion of raAv or underdone " measly " pork. This worm does not necessarily exist singly, as its name would indicate, although such is usually the case. It ranges from 2 to 4 meters (6 to 13 feet) in length. The head is rounded, pin-head in size, and is succeeded by a thread-like neck and by gradually shortening and widening segments. Four suckers and a projecting circle of twenty-six long and short booklets arm the head of the tenia. The mature ones become detached, and are passed with the feces. They are about 1 centi- meter (|- in.) in length and from 6 to 8 millimeters (5—^ in.) in breadth, and about 1 meter (39.36 in.) from the head they are "approximately quad- rilateral" in shape. These proglottides are bisexual. The female mat- rix occupies the middle of each proglottis, and is provided with from eight to fourteen irregular, tree-like branches on each side. The male generative organs are small vesicles in the anterior portion of the seg- ment. The sexual opening is situated on one side, near the middle. The ovarian or uterine apparatus of a mature segmient contains myriads of thick-shelled eggs, each one of which has an embryo with six booklets. Taenia Mediocanellata {Saginata). — The beef tape-worm is some- times called the ''unarmed tape-worm," since the head possesses suck- ing disks, but no booklets. It is more common in this country and even in some of the European countries, as England. Longer than the tenia solium, being 4 to 10 meters (12 to 80 feet) in length, its segments are also thicker and larger,, measuring from 16 to 88 mm. (|^ in.) long, and from 8 to 10 mm. {^ in.) broad. The head of the worm as well as the ripe ovum is also slightly larger and proportionately thicker. The ova- rian branches are more numerous (eighteen to thirty in number) and di- vide more dichotomously than those of tenia solium. Proglottides are also found in the stools, where they sometimes exhibit a crawling motion that has caused them to be mistaken for individual parasites. Cysti- cercus saginata has never been observed in ma,n. Bothriocephalus latus [Fish tape-worm, Tcenia lata) occurs most com- monly in Russia, Switzerland, Holland, and the German Baltic prov- inces. It is the longest cestode, measuring from 6 to 10 meters (20 to 30 feet). The head is club-shaped, unarmed, and has two lateral longi- tudinal grooves as suckers. The segments may be distinguished from TAPE-WORMS. 369 those of tlie preceding varieties named by their marked breadth and shortness, also by the centrally situated, tortuous ovarian rosette, and the sexual orifice near the center of the abdominal surface of each pro- glottis. The ova are larger than those of the pork and beef tape-worms, though thinner-shelled and with a sort of lid at on(! end. They develop only in fresh water. From them is formed an embryo with vibrating cilia and six booklets. Pike and other fish swallow these embryos, which develop into cysticerci in the muscles, peritoneum, and solid vis- cera. The eating of measly fish, raw or partially cooked, thus favors the development of this tape-worm in the human intestine. Symptoms. — Tape-worms may develop in man at any period of life. D. J. Milton Miller met with one in a child a few months old who had been fed on expressed beef-juice. Contrary to what has been supposed in days gone by, there are no absolutely diagnostic symptoms of the presence of tape-worm that can be relied upon. Indeed, the ex- istence of a tape-worm in the bowel may not be suspected even because of the total absence of indicative, subjective sensations. On the other hand, teniae may cause considerable local distress and impairment of the general health. Because of this fact a knowledge of the existence of tape-worm in certain neurotic subjects leads to an inordinate description of symptoms that exist mainly in the workings of a morbid imagination. Alimentary symptoms of tape-worm may be as follows: anorexia alter- nating with a voracious appetite, constipation alternating with diarrhea, colicky pains in the abdomen, indigestion, nausea, and vomiting. Cer- tain foods (herring, garlic, sour foods) increase the colic-like pains, others decrease them, as milk, eggs, and oils. Greneral symptoms of the teniae may be added, as lassitude, inappe- tence, mental uneasiness, worry and irritability, depression of spirits, some physical prostration, and even emaciation. Various reflex symptoms^ such as pruritus of the nose and anus, vertigo, migrain, tinnitus aurium, palpitation, visual disturbances (even temporary amaurosis), unequally dilated pupils, chorea, and epileptiform convulsions have been attributed to these parasites. But, on careful inquiry, adequate causes for some of these symptoms may be found in other associated morbid conditions. The bothriocephalus, however, may cause anemia, often very grave, even fatal. The blood-picture, in fact, is identical with that of pernicious anemia, as Schaumann's study of 38 cases has shown, and as was the case in three Finnish sailors seen by W. E. Robertson. This, in all likeli- hood, is due to some toxin elaborated by the worm. The blood-findings are otherwise unique among the verminous parasitic diseases in that they are the only class in which eosinophilia does not occur. Diagnosis. — This is always to be made by the discovery of tenia segments or ova in the underclothing or stools. The doubtful presence of suspected tape-worm may be cleared by the administration of a suitable purgative, which will usually suffice to bring away portions of the worm in the dejections. I would here add a special warning lest mucous casts or shreds or vegetable structures (as of onion) be mistaken for tape-worm. The diagnosis of the variety of the tape-worm is made by a careful scrutiny of the segments. Those of the tenia saginata are larger and fatter than, and their generative apparatus is unlike that, of tenia solium. Hypochondriasis can be excluded by repeated examinations of the 24 370 .4.V/.l/-li. PARASITIC DISEASES. Stools, especially after the exhibition of cathartics, and by the uniform failure to detect portions of tape-worm or tenia eggs. Prognosis is favorable. Indeed, teniae saginata may exist at all ages and for years -without any danger to the patient. Tenia solium, however, is at- tended with danger on account of the possibility of its causing cysticercosis. Treatment. — Prophylaxis. — The way to avoid acquiring a tape- worm is to use none but well-cooked meats ; this applies to beef and pork in particular. The use of pure drinking-water is of no little im- portance also. The pi'oglottides of the tenia should always be burned, and not thrown where they may be taken into the bodies of other animals, as the cow or hog, and then be allowed to propagate. Governmental inspection of the meat-supply in abattoirs should be rigidly enforced. Curative. — Before administering the chosen anthelmintic, the patient needs to undergo a "preparatory treatment." This has for its object the starvation of the parasite, so as to weaken its hold upon the intesti- nal mucosa. This is specially necessary in the case of ta?nia solium, in Avhich the cephalic booklets are obstinately and firmly fixed to the membrane, and since a cure cannot be said to have been effected unless the head be dislodged with the dejecta. For about two days prior to giving the remedy the patient should be restricted in diet to milk, light soups, a little white bread, and the like. Meanwhile, the bowels should be purged gently once or twice, after a simple enema. In the evening preceding the day on which the drug is to be exhibited, a saline cathartic should be given to empty the bowel as completely as possible. The following morning no breakfast should be allowed, and before noon the selected anthelmintic should be administered. If the worm does not come away in a few hours, and an intense sense of pressure is felt in the abdomen, a brisk purge is indicated. The worm should be passed into a bowl containing warm water. There are several very efficacious anthelmintic drugs to choose from. Prominent among them is male fern. Given to an adult in doses of \ to 1 dram (2.0-4.0) of the ethereal extract, and followed in several hours by a calomel and a saline purge, it usually succeeds in bringing away the tenia. Schilling gives in the morning, fifteen minutes after a break- fast of coffee with Zweiback, this formula : I^, Fresh ethereal extract of male fern, sij ; Powdered jella, gr viiss ; Simple syrup, q. s. ad 3j. Sisr. Shake well and take at one dose. If evacuation of the bowels be delayed, an enema of warm water is indicated. Another valuable remedy is pelletierin, the active principle of pomegranate ; the tannate may be prescribed, dose 1 to 1.5 gm., in cap- sules ; or, a decoction of the pomegranate bark may be used, in combi- nation with male fern, as in the Leipsic formula (Striimpell): !^. Granati radicis corticis, ^iv-v (128.0-160.0); Aquge, Oij (1 liter). Mix and macerate for twenty-four hours, and boil until reduced to f ^v (148.0). Add : Oleoresinse aspidii, 3j (4.0). Sig. To be taken in three or four doses, at short intervals. TAPJ^-WOJiMS. ;j71 Pepo in eraulsion or in a sugary paste (a?jout two ounces — 04.0 — and deprived of the envelopes) is at once a useful and iiarmless remedy. Another effective vermifuge is kousso (Brayera anthelmintica). An infusion of half an ounce (10. 0) of the flowers to one pint of water and mucilage of acacia is made, a wineglassful of which may be taken every half hour. The Germans recommend sometimes the agreeable, though more expensive, Rosenthal's " kousso tablets." Enough of the.se to make 15 grains (0.972) may be taken within one hour, with cafe noir or lemonade. Koussin (the active principle) in doses of 80 to 40 grains (1.94-2.592) has also been recommended, but should not be given to pregnant women, as abortion may be produced. Among other remedies of value as vermifuges may be mentioned kamala (1 to 3 drams — 4.0- 12.0 — of the powder and hairs, in wine or water), oil of turpentine (^ to 2 ounces — 16.0—64.0 — in emulsion or milk), and thymol. The combined use of such drastics as croton oil renders the action of the anthelmintic drug more certain at times. Although the head of the tenia may not be detected in the stools along with the body of the worm (and such is usually the case), a cure usually follows nevertheless, since, on account of its smallness, it may easily escape notice, and also from the fact that the head often dies and thus loses its hold upon the membrane, being carried away with the feces. On the other hand, if after the lapse of several months from the removal of a tape-worm, segments again appear in the stools, it may be inferred that the head was not dislodged or that another worm has developed. In cases where the tenia seems to redevelop with remarkable frequency and obstinacy it may happen that the head and neck are well protected beneath one of the valvulse conniventes. After the removal of the tape-worm — a weakening procedure, as a rule — the condition calls for supportive measures. The diet should not be too heavy for a time, but nutritious and easily digestible. T^NIA NANA. This is the smallest tape-worm in man (v. Siebold). It varies from 8 to 20 mm. (-g— f in.) in length and from 0.5 to 0.7 mm. [-^^ in.) in width. The head has four suckers, a rostellum, and booklets. The seg- ments are yellowish, short, and broad. It is more common than is sup- posed. It is believed by some observers that, occurring in children, as it commonly does, this parasite is the cause of epileptiform convulsions and enuresis nocturna. Thousands of worms may be found within a cubic centimeter of fecal matter. Hymenolepis nana fraterna, which develops in rats without intermediate host, is regarded as being identical with the T. nana. Persons infected should occupy separate beds until cured. Male fern is the only remedy which has thus far been useful in expelling this worm (Stiles). T^NIA PLAVOPUNCTATA. [Taenia Diminuta ; Tcenia Leptocephalata.) Taenia diminuta is a very small cestode, 20 to 60 mm. (f— 2i in.) in length, with a small club-shaped head and nearly a thousand segments. The cysticerci inhabit such insects as the asopia familiasis (caterpillar and cocoon) ; the anisolabis annuli (belonging to the orthoptera) ; and the coleoptera axis spinosa and scaurus siriatus. Man has been infested a 372 ANIMAL PARASITIC DISEASES. number of times, probably by taking food containing these infested insects. Tcenia MadagadoaHeinsis and Taniia serrata are other forms rarely found in man. NEMATODES. HELMlNTHOLoaiSTS inohide in this chiss the cvlindric worms, certain varieties of which are among the most common entozoa that infest the human body and inhabit the intestines. ASCARIASIS. Ascaris I/Umbricoides (Bound-worm). — Natural History. — This species resembles the common earth-worm, and is the most frequent in occurrence of all the parasites. It usually appears in children be- tween the ages of three and ten years. The round-worm inhabits the upper portion of the small intestine, and occurs singly or in numbers. Its body is round, fusiform, and marked with fine transverse striae. It has a yellowish or reddish-brown color, and measures in the female from 7 to 14 inches in length (17.5—35 cm.), and from 4 to 8 inches in the male (about 20 cm.), its thickness being about that of an ordinary goose-quill. The cephalic extremity of the worm has three oval papillae, furnished with fine teeth ; the caudal extremity is straight in the female and curved in the male. Lumbricoid worms develop from ova, which are about .05 to .06 mm. long, elliptic, dark-reddish in color, and have a thick, resisting envelope ; they occur in the feces. The eggs obtain entrance into the human intes- tine most probably through drinking-water and food. The round-worm sometimes, though rarely, migrates from the small intestine. It has been vomited, and it has also crawled into the pharynx, mouth, and nares, and has been withdrawn thence by the patient's fingers. It has even passed into the larynx and trachea, causing fatal asphyxia or pulmonary gangrene. The Eustachian tube and biliary ducts may be invaded with such serious symptoms as perforation of the mem- branum tympani and hepatic abscess. Symptoms may be absent, and yet the worms be found repeatedly in the stools. Existing symptoms are indefinite, and point simply to an irritative condition of the boAvels. Some writers ascribe them to toxins elaborated by the worms. Serious symptoms may, however, result from the migration of the worm, as into the biliary passages. Eustachian tube, or larynx. Fever is not a necessary concomitant. Lumbricoid worms may give rise to any or all of the following symptoms : colicky pains, nausea, vomiting, indigestion, diarrhea (sometimes), restlessness, irrita- bility, anorexia, itching of and picking at the nose, disturbed sleep with grinding of the teeth, salivation, and nervous twitchings. Very nervous children may manifest epileptiform convulsions, choreic movements, dilated pupils, vertigo, cephalalgia, mental disturbances, and even contractures. Complications. — The development of jaundice will indicate obstruc- tion of the bile-duct, in cases in which the worms have been found in the feces. Intestinal obstruction from coiled -worms has occurred. So also, suffocative symptoms coming on, especially at night, in a child with worms, may be due to a migrating lumbricoid. Perineal abscesses ASCARIASIS. 373 and inflamed herniae that have perforated externally sometimes diseharge the ascaris lumbricoides. Diagnosis. — This is positively determined only by discovering the worms or ova in the stools. The prognosis is good, unless serious complications arise {vide supra), when it should be guarded accordingly. Treatment. — Prophylaxis. — The water used for drinking purposes should be obtained from the purest sources. Before giving an anthelmintic, it should be borne in mind tliat no good result can be certainly obtained unless the gastro-intestinal tract be nearly deprived of food for from twelve to thirty-six hours, so that the toxic action of the drug used may be exerted directly upon the un- protected worm. Santonin is at once the most efficient and the most easily administered remedy. It may be given in doses of gr. ;|^ to 1 (0.0162-0.0648) of the crystals to a child, or from gr. ij to iv (0.1296-0.2592) to an adult, in the form of a troche, before breakfast. A little milk or other light nourishment may be allowed, the troches being continued once or twice daily for two or three days. This treatment is to be followed by a brisk purge, preferably gr. j to iij (0.0648-0.1944) of calomel. I have sometimes combined small doses of calomel with the santonin in a troche, and with good effect. Xanthopsia or yellow vision, spasms, and even convulsions, and saffron-colored urine may follow the use of san- tonin in cases of idiosyncrasy or overdose of the drug. Oil of worm- seed (chenopodium) in doses of five to ten drops, in emulsion, capsules, or on sugar, may also be used with benefit. Another favorite remedy with some is the unofficial fluid extract of spigelia and senna, to be given in from 1- to 3-dram (4.0-12.0) doses. Finally, the fluid extract of spi- gelia alone (1 to 2 drams — 4.0-8.0), followed by a brisk purge, may bring away dead worms. Oxyiiris Vermicularis {Seat-, Fin-, Thread-, or Maw-ivorm). — Natural History. — The ascaris vermicularis, as this worm is also called, inhabits the colon and especially the rectum. It is a small worm, as several of the commonly-used terms signify, and frequently it occurs in great numbers, sometimes agglutinated with mucus into feculent balls. It is most common in children, though found not rarely at any period of life. The female oxyuris is whitish in color and about ten or twelve millimeters (one-half inch) long, the male being about three or four millimeters (about one-sixth of an inch) in length. Oxyures develop from ova in about two weeks after the ingestion of the latter. The eggs are irregularly ovoid, about -^ in. (0.05 mm.) in length, and tena- cious of life. By the time the embryos have reached the cecum, they are sexually mature, and when the female arrives in the rectum, im- mense numbers of eggs are deposited that mature into great numbers of worms, the latter being discharged with the feces. Sometimes the worms crawl out of the anus. Infection with the ova may take place through water and food (green, uncooked vegetables and fruit) that have come in contact with the hands of infected persons. Scratching the anus will permit of the reception of oxyuris eggs under the finger-nails (Zenker and Heller), and in careless, ignorant, and uncleanly persons the possibility of such an auto- or re-in/ection should be recognized and avoided. 374 ANIMAL PARASITIC DISEASES. Symptoms. — Priin'his avi (itchini; of the anus), sometimes burning pain, and tenesmus, with restlessness and disturbed sleep, are the com- monest symptoms of the presence of this parasite. The itching is always woi-se at night, and may be paroxysmal. An herpetic or eczem- atous eruption, around the anus should arouse suspicion, particularly in children, of the presence of the oxyuris in the rectum, and it ac- counts for the intense itching. Anorexia and anemia, rectal irritability, and ''nervousness" may be associated. It is believed that the migra- tion of the worms into the vagina may excite vulvo-vaginitis, pruritis, and leukorrhea, and that habits of masturbation may be induced in both girls and boys by the sexual irritation caused by the Avorm. Inspection of the stools will reveal, in positive cases, the whitish, thread-like parasites. Diagnosis. — The pruritus, indicating rectal trouble, will direct the physicians attention to the anus, where the oxyures may be seen; if not found, their discovery in the feces or the discovery of the eggs by microscopic examination will suffice. The prognosis is good, and proper treatment is always effective, though occasionally exceedingly refractory cases are encountered. Treatment. — The exhibition of anthelmintics and purgatives, such as recommended for destroying and removing the lumbricoid worm, may be effective against seat-worms also, in reaching those lodged in the bowel above the rectum. C. W. Stiles^ states that the adult worm lives in the small intestine and should be driven into the large intestine by an an- thelmintic before local injections are given. Ashford recommends beta- naphtol in 2-dram doses. The larval forms may be killed by methylene- blue in pills — 18 to 24 one-grain pills daily for five days. This treat- ment is to be taken three times, ten days apart. Attacking the oxyures directly, however, by means of enemata is rational treatment. The rectum should be well emptied of feces, so that the worms may be exposed to the action of the medicament injected, and for this purpose enemata of cold water, either simple or with salt or soap, may be resorted to. Injections containing the decoction of quassia (1 or 2 ounces — 32.0 to 64.0 — of the powder or chips to the pint — ^ liter — of water) are nearly always curative. Other useful remedies are carbolic acid, turpentine, tan- nin, vinegar, canijjhor, potassium sulphid, and the oil of eucalyptus. The injections should be repeated once or twice daily for at least ten days. Rectal irritation may be allayed by injections of laudanum and starch-water (gtt. iij-v to the ounce — 32.0). Anal itching is often amenable to carbolized vaselin, at bed-time, or to belladonna ointment. Ascaris Alata. — This is another name for the ascaris vi^stax, a species of worm found in the intestines of the dog and cat, and occa- sionally in man. It is a slender worm, with a closely-rolled spiral tail and a wing-like projection on either side of the head. The female is about 6-7 centimeters (2.7 inches), the male about 4 centimeters (1.75 in.) in length. Scarcely ten instances, however, have been recorded in which this parasite has occurred in man. Trichocephalus Dispar (Ascaris trichiura). — Natural History. — This so-called whip worm measures about four or five centimeters (2 inches) in length, and is characterized by the very slender, hair-like appearance of the anterior two-thirds of its body, in contrast to the 1 " Proceedings of the Araer. Soc. of Tropical Medicine," N. Y. Med. Jour., Apr. 18, 1908. UNCINABIASrS. 375 thick posterior portion, wliicli is more or less straiglit and blunt-pointed in the female, but rolled into a spiral in the male. Its particular habitat seems to be the cecum, though sometimes it is also found in the colon. It may exist in great numbers. Enroponns appear to be infected with the parasite more commonly than Americans. Propagation is effected by the microscopic eggs, which are ovoid, hard, nodular, brownish, and about 0.05 mm. {-^]^ in.) in length. Symptoms. — It is not certain that the parasite causes any symptoms. The diagnosis is made by detecting the microscopic ova in the feces. The prognosis and treatment are not called for. UNCINARIASIS. {.Ankylostomiasis ; Hookworm Disease. ) Ankylostomutti Duodenale (Dochmius Duodenalis). — Natural History. — This parasite belongs to the family of strongylidce of the nematoid worms. It was discovered in Milan, in 1838, by Dubini. The length of the female is from 8 to 18 mm. (^ inch), and of the male from 6 to 10 mm. {^ inch). Its body is thread-like, with a conical- shaped head, and a large, bell-shaped mouth surrounded by a horny capsule, and possessing four hook-like teeth, ventrally situated, and two smaller, vertical teeth on the dorsal side, by which the worm fixes itself to the raucous membrane. A bulbous-like swelling exists at the tail end of the male worm. It inhabits the jejunum and duodenum. The eggs are found in muddy water, or in warm moist earth, and there liberate the embryos. These develop into larvse, which soon enter the dormant state, remaining quiescent for an indefinite period until they are taken into the human stomach through drinking-water, food, dirt (" dirt-eaters "), or, more commonly, dirt that has collected upon the hands and about the nails. Probably direct infection through the skin, as first shown by Loos, is the usual mode of infection, however, and Allen J. Smith and others have regarded the subtropical dermatitis known as "ground itch " as an expression of this mode of infection. Loos has shown that on the com- pletion of the exogenous phase of the embryo, the parasite enters through the skin, generally of the feet and legs, by contact with soil contaminated with the ova of the ankylostoma. Carried by the blood stream to the lungs it passes into the air vesicles, then into a bronchus, to the trachea, esophagus, and stomach, and finally to the small intestine. Here sexual characters develop in the parasites, reproduction ensues, and the ova are deposited in the bowel. They do not multiply within the intestine. Predisposing Causes. — (a) Geographical Distribution. — The par- asite is found in Italy, Egypt, India, Philippines, Germany, Belgium. Switzerland, and in England was found by Haldane in miners in Corn- wall. B. K. Ashford^ (U. S. Army) has shown that a large percentage of all cases of anemia occurring in Porto Rico are induced by this para- site. H. F. Harris has found the ankylostoma prevalent along the Gulf of Mexico and in the southeastern section of the United States. The Rockefeller Sanitary Commission, after a survey made to determine the degree and extent of hookworm infection, show^ed that hookworm disease belts the earth in a zone about 6Q degrees wide, extending from parallel 36 north to parallel 30 south latitude. Not less than 58 per cent, of the earth's estimated population is in the infected area. The importation of 1 New York Medical Jour., April 14, 1900. 376 AXIMAL PARASITIC DISEASES. infected Italian. Hunf the lymjih-channels is caused by the ])arasite. There are several conditions or endemic diseases produced. Elephantiasis arabum is believed by Manson to be the eft'ect of these parasites, in a certain pro- portion of cases at least. In specimens of night-blood from 88 Cochin Chinese he found filarire in 21 ; 14 specimens came from patients with ele- phantiasis, and oidy 1 showed filarite. This latter fact, he explains, is to be expected, since, in order to give rise to elephantiasis (due to an infarction of the lymphatic glands connected with the diseased areas), the adult filariae BRAC'ONTIASIS. .383 must lie on the distal side of the glands, which rnukes it impossible for the young filariae to pass into the general circulation, " '^i'herefore the person least likely, in a filarial district, to have filariye in his hlood is one who is the subject of elephantiasis." ^ Embryos can be demonstrated in the blood as soon as the adult filarite reach maturity and begin to dis- charge them, ^. e., before the usiuil obstructive symptoms appear (Jtivas and Smith ^). Hematochyluria and Chyluria, — The patient passes a white, opaque, milky urine, occasionall}' bloody, with a clotty sediment. This may be intermittent, and normal urine may be passed for many weeks before chyluria or hematochyluria reappears. There may be at the same time a slight degree of polyuria. Under the microscope, fat granules and Avhite and red corpuscles are seen. The lively, wriggling embryo filarise may also be discovered in the urine, as well as in the blood at night. There is a dilatation of the lymph-vessels in the kidneys alongside of the tubules, and in the abdominal lymph-plexuses. Sometimes a little vesical irritation and straining during urination may be caused by the endeavor to pass chylous blood-clots. The thoracic duct above the diaphragm has been found impervious (Stephen Mackenzie). Lymph-scrotum and lymph-vulva have been caused by the filarise. The parts are greatly swollen, thickened, and contain distended lymphatics filled with a turbid and either milk-white, salmon-colored, or blood-red coagulable liquid that is discharged upon puncturing the varices. The filaria is not always found in the exuded lymph. The inguinal and femoral regions are often enlarged. An erysipelatous inflammation of the parts is not infrequent in these cases, and may be ushered in b}' a chill and high fever, lasting a day or two, and ending with a profuse sweat. The filarise have been found in ascites (Winckel), in hemoptysis, and in the feces (Yamane, Japan). Worms killed by blows or other injuries are often absorbed, but may act as an irritant and cause abscesses. Treatment. — Healthy subjects must protect themselves against mosquito bites. Filtering, boiling, and storing the drinking water in mosquito-proof receptacles are important measures. Thymol, in from 1- to 5-grain (0.0648-0.324) doses, given for from two to eight weeks, has caused the disappearance of the larval filarise in several cases. Methylene- blue appears also to have produced a cure in a case of chyluria reported by Flint. Henry, however, states that he has "given this drug in larger doses than were used in the case reported by Flint, and for a much longer period, without the slightest effect upon the parasite."^ The adult filaria seems to be beyond the reach of any known medication that will not prove dangerous. DRACONTIASIS. ( Guinea-worm Disease.) The parasite is the Jilaria or dracunculus medinensis or persarum, common in the tropics of Asia, Africa, and America. It is usually solitary, and measures from 50 to 100 cm. (20 to 40 in.) in length and about 2 mm. [-^ in.) in diameter. It is cylindric, w'hitish, with blunt papillated head, and a sharp, curved tail. The body is nearly filled by the uterus, which contains innumerable embryos, which, after maturation of the worm, ^Bvilish Med. Jou.r., June 2, 1894. ^Southern Med. Jour., October, 1912. 3 Med. News, May 2, 1896. 384: ASIMAL PARASITIC DISEASES. escape shortly after contact with -water in the form of a milky fluid. The process of emptying the uterus takes from two to three weeks. This accomplished, the worm dies. It is then taken into the stomach and in- testines of man through the contaminated drinking-water. The female enters the intestines by way of the mesentery and brings forth its young, which pass into the connective tissue of its human host. The male worm is unknown. The worm has an inexplicable afiinity for the sub- cutaneous and intermuscular tissues of the feet and legs, where it attains full development. Symptoms. — Wherever the parasite is situated, it may often be felt coiled up under the skin, which at that point becomes red and fluctuating like an abscess. When opened, either surgically or naturally by the worm, the head appears through the aperture. The favorite spot for perforation is the dorsum of the foot, though sometimes it extrudes from the legs, rarely the thighs, and very rarely from the thorax and abdomen. Treatm.eiit. — Prophylaxis in regard to the drinking-water and as to bathing where the intermediary host of the dracunculus — the cyclops — has its habitat is essential for safety. The treatment embraces the surgical measures necessary to remove the worm and to promote the healing of the irritated tissues. Roth claims that after incision the application of carbolic acid (1 : 15) causes the worm to be removed in two or three days. Native Indian physicians commend highly the local a.pplication of the leaves of the '" amarpattee " plant. OTHER PILARIS. Among other filarite that have been found in man are the following : The Jilaria immitis, which causes hematuria and has been found in the por- tal vein, whilst the ova were discovered in the ureteral and vesical walls ; jilaria labiaUs, found in a lip pustule ; filaria loitis. found in a cataract ; Jilaria trachealis and bronchialis, seen in the trachea, bronchioles, and lungs ; filaria hominis oris, observed by Leidy in the mouth of a child ; filaria loa, noticed in the tropics among negroes, its habitat being beneath the conjunctiva. Recently L. N. Boston found filaria mermus (ac- cording to Wardell Stiles, to whom he referred them) in a cavity in the centre of an apple. They are believed to be parasites of the apple worm, but whether pathogenic, is not known. OTHER AND UNCOMMON NEMATODES. Eustrongylus Gigas. — This parasite is exceedingly rare in man, but has been found in many of the carnivora and in some herbivora. It is supposed that fish act as the intermediary host for the larvae. The worm is enormous in size, the female being from 25 to 100 cm. (10 to 40 in.) in length. It is a red, cylindric parasite with blunt-pointed ends. Its seat is the kidney, which it may destroy, causing hematuria and the presence of the eustrongylus ova. Dr. John McKenna has recovered an adult eustrongylus from a child whose urine had long contained ova. Anguillula stercoralis or strongyloides intestinalis occurs in the stools of certain tropical endemic diarrheas. It is common along the Gulf of Mexico. The parasites are oviparous, and the eggs may be taken through the drinking-water. They have been found in the biliary and pancreatic ducts, as well as in various parts of the intestines. The ad- ministration of thymol or male-fern is to be recommended. OTHER PARASITIC INSECTS. 385 Echinorhynchus moniliformis occurs in rats, and in one ca?«e, that of a Sicilian, reported by Calandruccio, the ova were found in the feces. PARASITIC ARACHNIDA. Pentastoma Tenioides. — This parasite is an inhabitant of the nasal fossae of the dog or horse, though it may also occur in man both in this and in the larval form. The ova are ejected during sneezing, and are then ingested by man. The larvae are found in the liver, lungs, and kidneys. Sarcoptes (Acarus Scahiei). — This insect produces the skin affection known as " the itch," or scabies, an affection more common in Europe than in America, where it constitutes only about 4 or 5 per cent, of all cases of skin disease. It is most prevalent among the poor and the un- clean. The female is visible to the naked eye, and is about 0.5 mm. (^ in.) in length ; the male is about 0.25 mm. (y^ in.). Both are nearly as broad as they are long. The parasite penetrates the skin and lives in a burrow or cuniculus that it makes for itself. The female lives in the end of the burrow, which may contain a number of ova, and appears as a minute, brownish-black, dotted, sinuous line, situated chiefly in the cutaneous folds, where the skin is mostly delicate, as between the fingers. Secondary skin lesions, due to scratching, are common. Sulphur ointment, well rubbed in after hot bathing, is usually quite efiicacious. Sarcoptes scabiei hominis is a variety of the preceding that infests other animals (cat, dog, cow, horse, wolf, goat, camel, etc.). Occasionally it may gain an entrance into man's skin, but dies simultaneously in the human host, although many invasions may occur. Leptus Autumnalis (Harvest Bug). — The most comjnon of several va- rieties is a mite of a reddish color, having six legs armed with claws and sharp mandibles. It arises among low bushes and thus appears about the ankles and legs. It partially penetrates the skin, boring only far enough with its short, thick head to procure nourishment. Artificial dermatitis may be produced by the irritation of scratching. Mercury, sulphur, and naphthol ointments suffice to destroy the parasite. Demodex Folliculorum (Comedo Mite). — This minute parasite may be expressed from swollen sebaceous follicles of the nose, cheek, and other parts of the face. It has a worm-like body with very short legs, and is only about 0.2 to 0.4 mm. (-^ in.) in length. It is not known to produce acne, as was formerly supposed. OTHER PARASITIC INSECTS. PEDICULOSIS. (Phthiriasis.) Lice or pediciili live on and attack the skin. Three forms are found on man r pediculus capitis, pedieulus corporis, and pediculus pubis. The pediculus capitis is whitish or grayish in color, about 1 mm. {-^ in.) long (male), and has six legs under the front part of the body. The 25 386 ANIMAL PARASITIC DISEASES. oviparous female is nearly twice as long as the male, and lays from fifty to eighty eggs on the hairs within a week. These ova, or "nits," ma- ture in from three to eight days. Itching is the most prominent symp- tom, and an eczematous eruption above and behind the cars and in the neck is often associated. '■ Plica polonica '' was a phrase once used to designate the matted condition of the hair in extremely dirty, crusty, and lung-neglected cases of head-lice. Secondary adenojjathy of the cervical lymphatic glands is a common feature in neglected cases. Pediculus Vestimentorum {Corporis). — This louse inhabits more often the clothing tiian the body itself It is larger than the head louse, and, like the latter, moves slowly. The nits are found with difficulty on the fibers of the underclothing. It sucks blood through a proboscis inserted into the sweat pores, and after withdrawing leaves a minute hemorrhagic speck. Irritation of the skin is produced, and in old cases, as in filthy tramps, the skin becomes scaly and quite pigmented (vagabonds disease). The efforts at scratching are almost frantic, and after a cure is effected parallel white lines, the remains of scratch-marks, followed by atrophic changes, may be visible, as in a case that I reported.^ Pediculus or Phthiriasis Pubis (Crab-louse). — This parasite is not limited to the pubis, but attacks also the hairy region in the axilla, on the chest, and may even reach the beard and eyebrows. It clings firmly to one or two hairs close to the skin. Its six legs with strong claws are placed closely together at the anterior part of the ovoid body. Treatment. — The hair should be cut short where the head-lice and nits are abundant. Saturating the hair and scalp with kerosene oil for twenty-four hours usually kills the parasites. Body-lice may be destroyed by scalding the underclothing and hot-ironing carefully about the seams. A hot soap-and-water bath is sufficient for the body, and sedative and antiseptic ointmerjits may be useful adjuvants. Mercurial and beta- naphthol unguents usually suffice in treating for pediculus pubis. Prof. J. V. Shoemaker affirms that naphtol is a remedy that meets the indica- tions presented by all forms of the disease ; he prepares it as follows : I^. Beta-naphtol, 3J (4.0) ; Cologne water, fgiv-vi (120.0-178.0).— M. Cimex Lectularius or Bed-bug. — This too well-known parasite is flat, brownish-red in color, and from 2 to 5 mm. {-^-\ in.) in length. It in- fests beds and public vehicles, emitting a disagreeable odor. It is a blood-sucker, and causes considerable itching, local irritation, and urti- caria even in some persons, while others are unmindful of their attacks. Sulphur fumigation and mercuric chlorid applications to the harboring places of the bed-bugs are effectual destructive agents. Saturated sodium bicarbonate solution will relieve the burning and itching. Pulex Irritans (Common Flea). — This "ubiquitous" parasite is from 2 to 4 mm. {y^-\ in.) in length, black or (when filled with blood) brown- ish-red in color, having six legs, the hind ones of which are relatively very large and powerful, enabling it to jump many times its own height. A flea's bite causes a sharp sting, and leaves a slightly raised red spot with a dark, pin-point center, the site of penetration of the biting appa- ratus of the insect. Treatment is the same as for the preceding insect. ' International Clinics, vol. iii , third series, p. 769. OTHER PARASITIC INSECTS. 'i87 Pulex Penetrans ['■'■ Ji/ifjer''). — This parasite, also called "sand-flea," is indigenous to the West Indies, South America, and the Southern States. The impregnated female penetrates the skin, and especially that of the feet, for purposes of ovulation. As the distention with tiie eggs occurs, swelling, pain, and even ulceration may appear. The sand-flea is a small, egg-shaped insect, about half the size of an ordinary flea, brownish in color, and exceedingly resistant to crushing force. Prophy- laxis in regard to foot-wear is necessary. Essential and antiseptic oils may also be put on the feet or stockings. Ixodes ( Wood-tick). — There are several varieties of tick- or wood- louse that may attack the human skin, among which ixodes albipictus is supposed to be the most common. Ixodes rieinus and ixodes bovis are found on horses and cattle. They are blood-suckers, adhering to the skin very firmly, and wheals may be produced by them. A drop of tur- pentine, or of some such essential oil as anise or rosemary, will cause them to loosen their hold. Dermanyssus Avium et Gallinse. — These bird- and fowl-insects are small and grayish-white in color, and may attack the human skin and cause eczematous eruptions, owing to the scratching induced by the irritation. Culicidse [Mosquitoes and Gfnats). — The blood-sucking mosquito [culex auxifer), so well known, may also transfer to human beings the filaria sanguinis hominis and the plasmodium malarise. The gnat (culex pipiens) is very troublesome during certain seasons, particularly along water-courses and in wooded districts. Its bite is quick, sharp, and stinging. The hirudo (leech) is a parasite that sometimes attaches itself to bathers. In the tropics it has been known to cause severe bites and inflammation. A remarkable case of hemoptysis is on record in which a leech was found attached to the larynx, below the cords. The bites and stings of bees, wasps, spiders, and ants have been known to cause considerable inflammation, edema, and blood-poisoning. Estridae {Bot-flies). — These may become parasitic in man in the larval form. Species of the hydoxerma and dermatobia, that infest the skin of the horse, ox, goat, etc., have also been observed among the Central and South American Indians. They burrow beneath the skin of the abdomen, scrotum, and other regions. Muscidse (Common Flies). — Common flies affect the skin of man by depositing eggs in wounds. The ova hatch within twenty-four hours sometimes, and the dipterous larvae may swarm to make the so-called *' living " wound or sore (myiasis vulnerum). The larvae or maggots do not penetrate the tissues, however. The principal flies that infest wounds are the flesh-fly (sareophila carnaria), the blow-fly (ealliphora vomitoria), the screw-worm fly (compsomyia maeellaria), and the ordinary house-fly (musca domestica). Internal myiasis may also be caused by swallowing the ova of these flies. The larvae may thus be vomited or defecated. Epidemic urticaria is often caused by the migration of the caterpillar (cnethocampa).' Among other parasites that attack man and inhabit par- ticular regions are the following : The simulium reptans, or creeping gnat of Sweden ; the seroot-fly (zimb)' of Abyssinia ; tne ixodes carapato, a virulent bed-bug in Brazil; the hcematopota pluvialis (Clegg) of the West Highlands. 388 ANIMAL PARASITIC DISEASES. SYPHILIS. Definition. — A chronic infectious disease communicable from per- son to person by direct or indirect contact ■with a specific virus, or by heredity. According to its clinical course, it is characterized by five periods : (1) Period of primary incubation — the time which elapses be- tween contact with the poi:?on and the appearance of the chancre. (2) Period of secondary incubation — the time which elapses between the appearance of the initial lesion of the disease (the chancre) and the de- velopment of its cutaneous manifestations. (3) Period of secondary symptoms (skin eruptions). (4) Intermediary period characterized by the absence of lesions, although evidences of existing dyscrasia can still be found. (5) Period of tertiary symptoms. The hereditary form of the disease is transmitted at the time of procreation by the sperm virile, by the ovum, or by both. Prince Morrow ' points out that the important lesions of the disease are those that occur in the internal organs — visceral syphilis. General Pathology. — {a) Primary Lesion of Chancre. — This ap- pears at the sit-e of inoculation, an