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HARRY R- ABBOTT
MEMOTIIAD
LIIW^TOT
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Digitized by the Internet Archive
in 2011 with funding from
University of Toronto
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This is a rare edition,
I because a few of the first
edition were issued before
the Tii stake in the spelling
of "Gorgas" was noticed.
The "e" vjas corrected in
folio ^Ying copies. / J .
1
Tlll^: l'IJI\(Il'LJ^:S AXD
ri^iACJTICE OF ^nCDICIXE
DKSKiNKI) FOR 'I^IIH USE oF IMJACrriTIONEKS AM) STUDENTS OF MEDICINE
BY
WILLIAM OSLER, M. D.
FKT.I.OW OF THE HOYAL COLLEGE OF PFIYSICIAXS, LOXDOV
rUOFKSSOU OF MEDUnXE IX THE JOHNS HOPKINS INIVERSITY AND
rHYSU"IAN-I\-('HIEF TO THE JOHNS HOPKINS HOSPITAL, I5ALTIMOKE
FOKMERLY PKOFESSOIi OF THE INSTITUTES OF MEDICINE, MC GILL UNIVERSITY, MONTREAL
AND PROFESSOR OF CLINICAL MEDICINE
IN THE UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA
NEW YORK D. APPLETON AND COiMPAXY
1892
Copyright, 1892, By D. APPLETON AND COMPANY.
TO
THK MEMORY OF MY TEACHERS:
wii.iJAM Airnirii joiinsox,
PRIEST OF TllK I'AKISII OF WESTON, ONTARIO.
-TAJIKS BOVKLL,
OF Tin: TORONTO sniooii of medicine,
AND OF THE UNIVERSITY OF TRINITY COLLEGE, TORONTO.
ROBERT PAL:\IER HOWARD,
DEAN OF THE MEDICAL FACULTY AND PROFESSOR OF MEDICINE, M^GILL UNIVERSITY, MONTREAL.
K ( ) T I : .
IVfy tlijuiks iii'c due lo my fni-iiicr first assistant, II. A. Litlcur for nuicli licl]), (linH't and indirect; to iiis suecesKor, W. S. Tliaycr, for assistance in the section on iJlood Diseases and for the pre[)aration of the illustrative charts; to 1). Meredith KeeftC, for the statistics on tuberculosis; to II. M. Thomas, for many 8iii^- gestions in the section on Nervous Diseases, and particularly in the section on Topical Diagnosis; to L. P. Powell, of the J(jhns Hopkins Fniversity Library, for a careful revision of the manu- script; and to INTiss P. (). llunipton, for valuable aid, especially in the preparation of the index.
Johns Hopkins Hospital,
Baltimore, January i, 1S92.
"Experience is fallacious and judgment difficult." Hippocrates : Aphorisms, I.
"And I said of medicine, that this is an art which considers the constitution of the patient, and has principles of action and reasons in each case,"
Plato : Oeorgias.
COiN 'V !•: N 'l^s.
SKCTION I. Sl'KCiriC IM'IKTlorS DISKASKS
1. Typhoid Vvxcv . II. 'ry[)lius FoviT HI. Kolapsinjj Fevi>i* IV. Small-pox
Variola Voi'a llaMnorrliai^ic Small-])ox Varioloid . V. Vaccinia (Cow-jiox) — Vaccination VI. Varicella (Chicken-pox VII. Scarlet Fever VIII. J\Ieasles .
IX. Kubella (Kotheln) . X. Epidemic Parotitis (Mumps) XI. Whooping-cough . XII. Influenza
XIIT. Dengue .... XIV. Cerebro-spinal Meningitis XV. Diphtheria . XVI. Eryeipelas . XVII. Septicaemia and Pya^nia SepticaMuia Pyaemia XVIII. Choiera Asiatica . XIX. Yellow Fever
XX. Dysentery XXI. Malarial Fever .
Intermittent Fever . Continued and Remittent Malarial Pernicious Malarial Fever Malarial Cachexia XXII. Anthrax
XXIII. Rabies .
XXIV. Tetanus XXV. Syphilis.
Acquired .
Congenital
Visceral
Fever
PAnE 1 '.id 43 4« 49 52 .•54
r,o
(;.")
07 77 81
82
84
87
90
92
09
110
114
114
116
lis
125 130 140 147 151 152 153 156 159 162 165 107 109 172
Vlll
CONTENTS.
XX y I. Tuberculosis
1. General Etiology and Morbid Anatomy .
2. Acute Tuberculosis
3. Tuberculosis of the Lymph-glands (Scrofula)
4. Pulmonary Tuberculosis (Phthisis, Consumption)
5. Tuberculosis of the Serous Membranes G. Tuberculosis of the Alimentary Canal
7. Tuberculosis of the Liver ....
8. Tuberculosis of the Brain and Spinal Cord
9. Tuberculosis of the Genito-urinary System
10. Tuberculosis of the Arteries
11. Prognosis in Tuberculosis .
12. Prophylaxis in Tuberculosis
13. Treatment of Tuberculosis . XXVn. Leprosy
XXVIII. Glanders
XXIX. Actinomycosis
XXX. Infectious Diseases of Doubtful Nature
1. Febricula (Ephemeral Fever)
2. Weil's Disease .
3. Milk-sickness
4. Malta Fever
5. Mountain Fever
6. Miliary Fever (Sweating Sickness)
PAGE
184 184 197 204 208 235 239 242 242 243 246 246 247 249 256 259 2G1 2G4 264 2G5 266 266 268 268
SECTION n. CONSTITUTIONAL DISEASES.
I. Rheumatic Fever 270
II. Chronic Rheumatism 278
III. Pseudo-rheumatic Affections 279
IV. Muscular Rheumatism , . , . . 281
V. Arthritis Deformans (Rheumatoid Arthritis) 283
VI. Gout 287
VII. Diabetes Mellitus 295
VIII. Diabetes Insipidus . . . . , 305
IX. Rickets 307
X. Scurvy (Scorbutus) 313
XI. Purpura 316
XII. IIa3mophilia 320
SECTION III. DISEASES OF THE DIGESTIVE SYSTEM.
Diseases of the Mouth 323
Stomatitis 323
Aphthous Stomatitis 323
Ulcerative Stomatitis 324
Parasitic Stomatitis (Thrush) 325
Gangrenous Stomatitis 326
Mercurial Stomatitis 337
ciiNTKNTS.
is
II. Diseases of llir Siiliviirv (iIiukIh
ll\ |»(>r<('crrl ion . . , .. XrroMloiiiiii ..... Inlliiiiiiiml ii)ii of tlii^ Siiliviit'V (ilatnls
III. I )isrHS('S of llir IMllirvilX .
('iiciilalury I >isl iirliiiiicfs
Aciilo l'liiirvii;;it is ....
Clii-oiiic IMiiirvii^Mtis
IMccinl i«'ii of I ho IMmryiix
Aculf Infi'cliouH IMih'^'iiion of llic rimiyn.x
lu'lro-i»liarvti^('iil Abscess
Aii^iiiJi liudovici ....
IV. I)iseiis(>s of t ho Tonsils
l<\)lliciiliir or Ijaeimar 'roiisillitis Siippiirativo 'ronsillilis . (Miroiiie Tonsillitis V. Diseases of the (I'jsopha^us AfUlo (Ksophaj^itis Spasm of (he (l']sopha^us Stricture of the (Ksophji^us . Cancer of the (Kscphai^us Iviipture of the (Ksophau^us . Dilatatiotis and Diverticula .
VI. Diseases of the Stomach .
Methods of IMinical Examination . Acute Gastritis ....
Phle!:!:monous Gastritis
Toxic (lastritis ....
Diphtheritic Gastritis
Mycotic Gastritis Chronic Gastritis (Chronic Dyspepsia) Neuroses of Stomach
Gastralgia
Nervous Dyspepsia
Nervous Vomiting
Peristaltic Unrest
Rumination .... Dilatation of Stomach . Peptic Ulcer (Gastric and Duodenal) Cancer of Stomach. TTicmorrhage from the Stomach .
VII. Diseases of the Intestines .
1. Diseases of the Intestines associated with
Catarrhal Enteritis Diarrhoea .... Enteritis in Children . Diphtheritic or Croupous Enteritis Phlegmonous Enteritis Mucous Colitis Ulcerative Enteritis
2. Miscellaneous Affections of the Bowels
3. Appendicitis (Typhlitis and Perityphliti
Diarrhoea
VAum
;:;;(>
:m
Mil
:{;:2 :m
:v.\2
'Mir)
'S.'M :{:59 :{40 :{41 .">42 ;{4:J 344 .U4 344 348 350 350 351 351 351 359 359 3G0 361 3G3 362 364 368 376 385 388 388 388 388 391 395 396 396 397 403 405
X CONTENTS.
PAGE
Typhlitis 405
A})pen(licitis 406
4. Intestinal Obstruction , . 413
5. Constipation (Costiveness) 420
VIII. Diseases of the Liver 423
1. Jaundice (Icterus) 423
2. Affections of the Blood-vessels of the Liver 427
3. Diseases of the Bile-passages 430
Catarrhal Jaundice 430
Cholelithiasis (Gall-stones) 431
Other Affections of the Bile-ducts 437
4. Cirrhosis 440
5. Abscess of the Liver . 446
6. New Growths in the Liver . 451
7. Fatty Liver 455
8. Amyloid Liver 456
IX. Diseases of the Pancreas 457
1. Hfemorrhage 457
2. Acute Pancreatitis 458
3. Chronic Pancreatitis 4G0
4. Pancreatic Cysts 460
5. Cancer 401
X. Diseases of the Peritonaeum 4G2
1. Acute General Peritonitis 462
2. Peritonitis in Infants , . 4G6
3. Localized Peritonitis 466
4. Chronic Peritonitis 467
5. New Growths in the Peritonajura 468
6. Ascites (Hydro-peritonaeum) 469
SECTION IV. DISEASES OF THE RESPIRATORY SYSTEM.
I. Diseases of the Nose Acute Coryza Chronic Nasal Catarrh Autumnal Catarrh (Hay Fever) E[)istaxis .... II. Diseases of the Larynx .
1. Acute Catarrhal Laryngitis .
2. Chronic Laryngitis .
3. (Edematous Laryngitis .
4. Membranous Laryngitis (Croup)
5. Spasmodic Lary^ngitis (Laryngismus Str
6. Tuberculous Laryngitis .
7. Syphilitic Laryngitis HI. Diseases of the Bronchi .
1. Acute Bronchitis .
2. Chronic Bronchitis .
3. Bronchiectasis.
4. Bronchial Asthma .
5. Fibrinous Bronchitis
idulus)
474 474 475 477
478 480 480 481 481 482 486 487 489 400 490 402 405 407 501
CONTMNTS.
XI
liitis)
I\'. Dist'H^t'S of llir Iiim^«»
1. ('in'iilalnry hi-'MirliMiiri-s in \\n- Lnn
2. I'llrlllllnllitl .....
«t. ( 'lii'oiiir IiiliT^t II ml riD'iiiiioiiia i< III •t. hi-(>iiclii)-|in<'iiiii<iiijii (( 'jipill'Mv I'roin 5. Km|iliys('mii
( 'iHiipcii.Nnlorv Miiipliv.'^riiKi
lly|MTl I'opliic l'!ii)|)liyM'iiiii
Alro|)|ii(' i'linpliysciMii ft. (lunun'iii' (»r 1Im> liiiii;,'
7. Abscess of tlu^ lillli;; .
8. IMuMimoiiokoniosis 1). Ni'w (iiowtlis ill the l,iiiij;s
V. Discasps of tlu« IMi'urn
1. Aciito IMtMirisy .
Fibrinous or IMaslic IMcurisy SiTo-llhriiious IMourisy . INiruliMit IMcurisy (KnipytMiia Tulicrculous IMcuri.sy Oilier N'ariclics of Pleurisy
2. (Mironic IMciu'isy 'S. Hydro! liorax 4. Piunuuot liorax (ily(lro-|)ncuniotliorax and Pyo
Affect ions of the jMediiistiiiuin
pneumothorax
rAOK
rm
MI
.'( ; ' ' '
:.i I
Till 51(1
r,r,<) r,:,2 r,:,:i nrid r)r,H rtrtH
558 558
r,i',r, r,7i 'ill
574 577
SP]CTIOX V. DISEASES OF THE CIRCULATORY SYSTEM.
I. Diseases of the Pericardium
1. Pericarditis ....
2. Other AlTections of the Pericardium II. Diseases of the Heart .
1. Endocarditis
Acute Endocarditis Chronic Endocarditis
2. Chronic Valvular Disease .
Aortic Incompetency Aortic Stenosis IMitral Incompetency I\Iitral Stenosis Tricuspid Valve Disease . Pulmonary Valve Disease Combined Valvular Lesions
3. Hypertrophy and Dilatation
Hypertrophy of the Heart Dilatation of the Heart .
4. Affections of the ^Myocardium
Aneurism of the Heart . Rupture of the Heart Xew Growths and Parasites Wounds and Foreign Bodies
5M1 5!J1 502 592 592 599 G02 G02 608 GIO 014 G18 G20 G20 G28 628 6:^5 640 646 647 647 648
xii CONTENTS.
PAGE
6. Neuroses of the Heart 649
Palpitation 649
Arrhythmia 650
Rapid Heart (Tachycardia) 652
Slow Heart (Bradycardia) 653
Angina Pectoris 655
6. Congenital Affections of the Heart 659
HI. Diseases of the Arteries 663
1. Degenerations 663
2. Arterio-sclerosis (Arterio-capillary Fibrosis) 664
3. Aneurism 670
Aneurism of the Thoracic Aorta 671
Aneurism of the Abdominal Aorta 680
Aneurism of the Branches of the Abdominal Aorta .... 681
Arterio-venous Aneurism 682
Consrenital Aneurism 682
SECTION VI. DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
I. Anaemia 684
Secondary Anaemia 684
Primary or Essential Anaemia 686
II. Leukaemia 696
III. Hodgkin's Disease 704
IV. Addison's Disease 708
V. Diseases of the Thyroid Gland 711
Goitre 711
Tumors of the Thyroid . 712
Exophthalmic Goitre 712
Myxoedema , . 714
SECTION vn.
DISEASES OF THE KIDNEYS.
I. Anomalies in Form and Position o .717
Movable Kidney . .717
II. Circulatory Disturbances o . 721
III. Anomalies of the Urinary Secretion 722
1. I hematuria 722
2. Ilaemoglobiiiuria , . 723
3. Albuminuria . 725
4. Pyuria (Pus in the Urine) 729
5. Chyluria (Non-parasitic) 730
6. Lithuria 730
7. Oxaluria 733
8. Cystinuria 734
9. Phosphaturia 734
10. Indicanuria 735
11. Melanuria 736
12. Other Substances 736
CONTKNTS.
Xlil
IV. V.
VI.
\ II.
VIM.
1\.
X.
XL
XII.
Xlll.
rnnniH
A<Mlll< hli^jlll'N I)iH«'HMO
Cliroiiir Ilii^'lil'.M DihcuHc .
Clirnliic I'lUflirh) limlnlis NrplintM
Cliroiuc liilrr.stiliiil NrpliritiH A my l( •ill hiscaso ....
ry.-iitis
II y(ln>in'|i|ir<»>is .... Nt'plintlilhia^is (Kciml Calculu.s) Tumors of tlu' Kitlncy (\v.sti(^ I>i.s(Mi.s(> of tlir Kidney . IViincphrii! AbMivs.s
|
VAUU 7:{7 |
|
:\\ |
|
740 |
|
717 |
|
liU |
|
7:.H |
|
7^:2 |
|
n\r, |
|
7;o |
|
7:2 |
|
ir.i |
SECTION VIII. DISEASES OF THE NEKVOUS SYSTEM.
1. nisca.^^t'.^ of llu^ NiTvcs ....
1. Nouiitjjs (Inflammation of the Nerve-filjivs)
2. NiMiromata
3. Disoaso.s of till' Cranial N'crvo.s
Olfactory Nrrvc ....
Optic Nerve and Tract Lesions of the lietina Lesions of the Optic Nerve AlTections of the Chiasma and Tract AtTections of the Tract and Centres
Motor Nerves of tiie Eyeball
Fifth Nerve
Facial Nerve ....
Auditory Nerve ....
Glosso-pharyngeal Nerve
Pneumogastric Nerve .
Spinal Accessory Nerve
llypoiilossal Nerve
4. Diseases of the Spinal Nerves
Cervical Plexus .... Brachial Plexus .... Lumbar and Sacral Plexuses
Sciatica
n. Diseases of the Spinal Cord
1. Affections of the Mening:es
Diseases of the Dura Mater . Diseases of the Pia Mater . Ihemorrhaije into the Spinal Membranes
2. Affections of the Blood-vessels
3. Acute Affections of the Spinal Cord
Acute Diffuse Myelitis
Myelitis of the Anterior Horns .
Acute and Subacute Polio-myelitis in Adults
Acute Ascending (Landry's) Paralysis
4. Chronic Affections of the Spinal Cord ,
Spastic Paraplegia ....
I'i'} 7M 7H2 7H2 IK]
>(>
7H7 7^8 700 TU.i
707 bOl 805 805 8(19 812 813 813 814 817 818 8-iO ^20 820 822 824 825 828 828 831 8^!5 835 836 836
xiv CONTENTS.
PAGE
Locomotor Ataxia 840
Hereditary Ataxia (Friedreich's Ataxia) 848
Syringo-inyelia 849
Compression of the Spinal Cord 851
Lesions of the Cauda Itlquina and Conus Medullaris .... 854
Tumors of Spinal Cord and its Membranes 855
Progressive (Spinal) Muscular Atrophy 857
Bulbar Paralysis 860
in. Diseases of the Brain 862
1. Affections of the Meninges 862
Diseases of the Dura Mater (Pachymeningitis) 862
Diseases of the Pia Mater 863
2. Affections of the Blood-vessels 867
Hypera?mia 867
Anaemia 868
QCdema of the Brain 869
Cerebral Haemorrhage 870
Embolism and Thrombosis (Cerebral Softening) 878
Aneurism of the Cerebral Arteries 883
Endarteritis 884
Thrombosis of the Cerebral Sinuses and Veins 885
3. Affections of the Substance 887
Topical Diagnosis 887
Aphasia 898
Inflammation of the Brain 903
4. Hemiplegia and Diplegia in Children 906
Hemiplegia 906
Spastic Diplegia (Birth Palsies) 909
Spastic Paraplegia 910
5. Sclerosis of the Brain 911
Miliary Sclerosis 912
Diffuse Sclerosis 912
Tuberous Sclerosis 913
Insular Sclerosis (Sclerose en Plaques) 913
6. Chronic Diffuse Meningo-encephalitis 914
7. Tumors of the Brain 918
8. Chronic Hydroce})halus 922
IV. General and Functional Diseases 924
1. Acute Delirium (Bell's Mania) 924
2. Paralysis Agitans 926
Other Forms of Tremor 929
3. Acute Chorea (Sydenham's Chorea ; St. Vitus's Dance) .... 929
4. Other Affections described as Chorea 942
Chorea Major; Pandemic Chorea 942
Habit Spasm; Convulsive Tic 942
Saltatoric Spasm 943
Chronic Chorea 944
Rhythmic Chorea 945
5. Infantile Convulsions (Eclampsia) 945
6. Epilepsy 948
Gnnid Mai 950
Petit Mai 053
\
|
CONTENTS. |
XT |
|||||||
|
rAOB |
||||||||
|
.Fiirkmniijiu Kpilj'psy . 053 |
||||||||
|
7. |
Mi^'iiiiiic . . . 057 |
|||||||
|
H. |
Nriinil^'iii O.'JO |
|||||||
|
0. |
Pr«)f«'H.si«)iml SpuHmH; ()c(UipHti<»n NouroM-^ . IHJJI |
|||||||
|
10. |
'r«'(auv ..... |
WVi |
||||||
|
11. |
liyslcriu |
. 0«7 |
||||||
|
(^»nvul.^iv^ l<\)iin |
. |
068 |
||||||
|
Non-coiivulsiv«i l''itrm . |
000 |
|||||||
|
12. |
NtMini.sthcniH .... |
078 |
||||||
|
IM. |
Tiu' 'rnimiialio NiMiroscs. |
081 |
||||||
|
11. |
OtluT l'\>rms ol l''uMcli<»iial I'araly |
sis |
unr, |
|||||
|
IVriodii'al i'aralvsis . |
1»M.', |
|||||||
|
A.stasia — Abasia . |
UHC, |
|||||||
|
V. Vjvso-inolor and 'i'nipliic DKs{)r(U'i*s |
UH7 |
|||||||
|
1. |
Ixayiuiud's Disease . |
UH7 |
||||||
|
2. |
Antjii)-neurotic (Kdetna . |
OHO |
||||||
|
8. |
Facial lleini-atrophy |
900 |
||||||
|
4. |
Acromegalia .... |
im |
||||||
|
5. |
St'l(>r(idenna .... Ainhum .... |
^ |
mi 004 |
SECTION IX.
DISEASES OF THE MUSCLES. I. Myositis OO.5
II. Idiopathic Muscular Atropliy . . . .
1. Psoudo-hypertrophic Muscular Atrophy
2. Prinuiry Atrophic Muscular Paralysis .
III. Thomsen's Disease ; Myotonia Congenita
IV. Paramyoclonus Multiplex .....
006 900 907 008 999
SECTION X. THE INTOXICATIONS; SUN-STROKE; OBESITY.
I. Alcoholism 1001
1. Acute Alcoholism , . 1001
2. Chronic Alcoholism 1001
3. Delirium Tremens 1003
II. Morphia Habit . 1005
III. Lead Poisoning , . 1007
IV. Arsenical Poisoning 1011
V. Ptomaine Poisoning 1012
1. Meat Poisoning 1013
2. Poisoning by Milk Products . lOU
3. Poisoning by Shell-fish and Fish 1014
VI. Grain Poisoning lOlo
1. Ergotism . 1015
2. Lathyrism 1016
3. Pellagra 1016
VII. Sun-stroke 1017
VIII. Obesity 1019
B
xvi CONTENTS.
SECTION XI. DISEASES DUE TO ANIMAL PARASITES.
PAGE
I. Psorospermiasis 1023
1. Internal Psorospermiasis 1022
2. Cutaneous Psorospermiasis 1023
II. Distomiasis 1024
III. Diseases caused by Nematodes 1025
1. Ascariasis 1025
2. Trichiniasis ' . . 1026
3. Ankylostomiasis 1031
4. Filiariasis 1032
5. Dracontiasis «... 1034
6. Other Nematodes 1035
IV. Diseases caused by Cestodes 1036
1. Intestinal Cestodes : Tape-worms 1036
2. Visceral Cestodes „ . .1039
Cysticercus Cellulosee 1039
Echinococcus Disease 1041
Multilocular Echinococcus 1046
V. Parasitic Arachnida . . . 1047
VI. Parasitic Insects 1048
VII. Pseudo-parasites (Myiasis) 1050
UJIAUTS AA'l) II.I.USTJiA'nONR
CIIAIIT
1. 'rv|»li(>i(l I'\v('r will) Ivclnpsc* II. Tvplioid Im-vct— II yprrpN ifxiii — Dciith III. lllustnitin;; (ho lUotnl C-lmn;;i\s in TvpliDJd I'Vvt I\'. Tvpiioiil l'\»vi>r — IIa'in()rrlm«;(! from the Bowels V. lUu.stnitiii^' Inllut'iico of Baths in Typlioid Fovi> VI. Rolnpsiiii^ Fovor (aftor Murchison) \'II. Small-pox (after Strl\nipcll) . VIII. llaMnorrha^ii' Smull-itox .... IX. Scarlet Fover (after Striimpell) X. Measles (after Striimpell) .... XI. Malaria — Tertian Ague .... XII. Illustrating Heredity in Tuberculosis.
XIII. Chronic Tuberculosis, Two-hourly Chart for Three Days
XIV. Blood Chart, illustrating Rapid Production of Ana'mia in
ILrmorrhagica
XV. Temperature, Pulse, and Respiration Chart in Pneumonia XVI. Blood Chart, illustrating AnaMnia in Purpura Ihrmorrhagica
XVII. Blood Chart, illustrating Chlorosis
XVIII. Blood Chart, illustrating Pernicious Ana^nia XIX. Blood Chart, illustrating Leukaemia
f*AOB 12
M 18 21 35
50 53
. 70 . '78 148 and 149 . 188 . 224 Purpura
319 518 G85
693 701
I. Optic and Visual Tracts (after Starr) 788
II. Motor Area of the Cerebral Cortex (after Mills) 890
III. Motor Tract (after Starr) 892
IV. Degeneration of Pyramidal Tract in Hemisphere, Crus, Pons, and Me-
dulla (after Gowers) 893
V. Lichtheim's Schema in Aphasia 899
* The red shows the two-hourly, the black the morning and evening temperature.
THE riiACTiCK UK MEDKMMv
SKCTION I. SPECIFIC INFECTIOUS DISKASKS.
I. TYPHOID FEVER.
Definition. — An infectious disease, characterized anatomically by liyperphisiii ami ulceration of the lymph-follicles of the intestines, swell- ing of the mesenteric glands and spleen, and parenchymatous changes in the other organs. The bacillus of Eberth is constantly present in the lesions. Clinically the disease is marked by fever, a rose-colored eruption, diarrhoea, abdominal tenderness, tympanites, and enlargement of the spleen ; but these symptoms are extremely inconstant, and even the fever varies in its characters.
Historical Note. — The dates 1813 and 1850 include the modern discussion of the subject. Prior to the former year many observers had noted clinical differences in the continued fevers. Huxham in particular, in his remarkable essay, had recognized varieties. In 1813 Pierre Breton- neau, of Tours, distinguished "dothienenterite " as a separate disease; and Petit and Serres described entero-mesenteric fever. Trousseau and Vel- peau, students of Bretonneau, were, in 1820, instrumental in making his views known to Andral and others in Paris. In 1829 Louis' great work appeared, in which the name " typhoid " was given to the fever. At this period typhoid fever alone prevailed in Paris, and it was universally be- lieved to be identical with the continued fever of Great Britain, where in reality typhoid and typhus coexisted, and the intestinal lesion was regarded as an accidental occurrence in the course of ordinary typhus. Louis' students returning to their homes in different countries had opportunities of studying the prevalent fevers in the thorough and sys- tematic manner of their master. Among these -were certain young American physicians, to one of whom, Gerhard, of Philadelphia, is due the great honor of having first clearly laid down the differences between the two diseases. His papers in the American Journal of the Medical Sciences are undoubtedly the first in any language which give a full and 2
2 SPECIFIC INFECTIOUS DISEASES.
satisfactory account of the clinical and anatomical distinctions we now recognize. No student should fail to read these articles, among the most classical in American medical literature.
Louis' influence was early felt in Boston, to which, in 1833, James Jackson, Jr., had returned from Paris. In this year he demonstrated, in his father's wards at the Massachusetts General Hospital, the identity of the typhus of this country with the typhoid of Louis. He had already, in 1830, noticed the intestinal lesions in the common fever of New Eng- land. Though cut off at the very outset of his career, we may reason- ably attribute to his inspiration the two elaborate memoirs on typhoid fever which, in 1838 and 1839, were issued from the Massachusetts Gen- eral Hospital, by James Jackson, Sr., and Enoch Hale. These, with Ger- hard's articles, contributed to make t3^phoid fever, as distinguished from typhus, widely recognized in the profession here long before the distinc- tions were recognized generally in Europe. Thus, the diseases were de- scribed under different headings in the first edition of Bartlett's admirable work on Fevers published in 1842.
The recognition in Paris of a fever distinct from typhoid, without in- testinal lesions, was due largely to the influence of the able papers of George C. Shattuck, of Boston, and Alfred Stille, of Philadelphia, which were read before the Societe medicale d'Observation in 1838. At Louis' request, Shattuck went to the London Fever Hospital to study the disease in England, where he saw the two distinct affections, and brought back a report which was very convincing to the members of the society.
Stille had the advantage of going to Paris knowing thoroughly the clinical features of typhus fever, for he had been Gerhard's house-physician at the Philadelphia Hospital, where he had studied during the epidemic of 1836. At La Pitie, with Louis, he saw quite a different affection, while in London, Dublin, and Naples he recognized typhus as he had seen it in Philadelphia. The results of his observation were given in an exhaust- ive paper which presented in tabular form the contrasts and distinctions, clinical and anatomical, which we now recognize.
In Great Britain the non-identity of typhus and typhoid was clearly established at Glasgow, where from 183G to 1838 A. P. Stewart studied the continued fevers, and in 1840 published the results of his observations. In the decade which followed many important works were issued and more correct views gradually prevailed ; but it was not until the publica- tion of Jenner's observations between 1849 and 1851 that the question was finally settled in England.
Etiology. — Typhoid fever prevails especially in temperate climates, in which it constitutes the most common continued fever. Widely distrib- uted throughout all parts of the United States and Canada, it probably presents everywhere the same essential character.
It prevails most in the autumn months. Of 1,889 cases admitted to the Montreal General Hospital in twenty years, more than fifty per cent
TVI'IKHI) I'KVKIt. 3
wuro in tlir inoiillis of Au^nist, ScpUiinlHT, uiul (Jclolwr. Of 1,381 ciumm trcjitcd (liirin<^ twrlvc yfurs iit the 'J'onmto (n-nrnil IIoHpitiil, 7<I1 •H-cMirri'^J in these inontli.^ ((iniliain). It has hccn well cuIUmI the iiiitiiriiiial fi-v<-r.
It has h(»t'ii oljsiTVcd to prevail most in hot and dry rtru.H<inM. Acrord- in^ to IVtti^nkofcT, cpichMnics arc? nioHt corniiion whc-n the ^round-wut«r U low, under which riicnnistanci's th(? springs and watcr-Hoiin-'CH drain more thoroughly contjuuiiuitrd foci and are nioro likely to bu highly char;/«d witli poison. It may he also, as Haurngarten suggestH, that in dry seawjnH tho poison is nu)re disseminated hy the dust.
Males and females are ahoiit ecpially liable to tho disease, but nnalcH with typhoid are much more? fre(juently admitted into liospiUils.
Typhoid fever is a disease of youth and early adult life. The greatest susceptibility is between tho ages of lifteen and twenty-five. Of GGO of tho Montreal cases there were under lifteen years of age, 51 ; between fifteen and twenty-tive years, 308 ; between twenty-five and thirty-five years, 153 ; between thirty- live and forty-fivo years, 43 ; between forty-five and lifty-five years, G ; and over fifty-five years, 9. Cases are rare over sixty. It is not very infrequent in childhood, but infants are rarely attacked. Murchison has seen a case at the sixth month. It is stated that the disease may bo congenital in cases in whieli the mother has had the disease late in pregnancy.
As in other fevers, not all exposed to the infection take the disease, and there are grades of susceptibility. Some families seem more disposed to infection than others.
The Specific Germ. — The researches of Eberth, Koch, Gaffky, and others have shown tliat there is a special micro-organism constantly asso- ciated with typhoid fever. It is a rather short, thick, motile bacillus, with rounded ends, in one of which, sometimes in both (particularly in cultures), there can be seen a glistening round body, believed to be a spore; but these polar structures are probably only areas of dense protoplasm. It grows readily on various nutritive media, and on potato in a characteris- tic manner, as the growtli is invisible. This feature is not peculiar how- ever to the typhoid bacillus. It is difficult to ditferentiate from the bac- terium coli commune, except by certain chemical tests. This organism fulfils two of the requirements of Koch's law — it is constantly present, and it grows outside the body in a specific manner. The third require- ment, the production of the disease experimentally by the cultures, has not yet been met. Probably the animals used for experimentation are not sus- ceptible to typhoid fever. The bacilli inoculated in large quantities into the blood of rabbits are pathogenic, and in some instances ulcerative and necrotic lesions in the intestine may be produced. But similar intestinal lesions may be caused by other bacteria, including the bacterium colt cam- mune.
The bacilli produce various poisons, of which Brieger has described a ptomaine — typhotoxin, and Brieger and Friinkel a toxalbumin ; but our
4 SPECIFIC INFECTIOUS DISEASES.
information on these substances is still very defective. Cultures are killed at a temperature of 60° C. It is not probable that the typhoid bacillus pro- duces spores, but it resists drying for days. Bouillon cultures are destroyed by carbolic acid, 1 to 200, and by corrosive sublimate, 1 to 2,500.
In recent cases of typhoid fever the bacillus is found in the lymphoid tissues of the intestines, in the mesenteric glands, in the spleen, and in the liver. It occurs also in irregular clumps in the contents of the intestines and in the stools. The bacillus is said to have been found rarely in the blood, in the rose-colored spots (?), and in the urine.
Outside the body the bacilli retain their vitality for weeks in water. Whether an increase can occur is not yet finally settled. Bolton denies it, but the general opinion seems to be that such increase may take place to some extent. They disappear from ordinary water in competition with saprophytes in a few days. In milk they undergo rapid development with- out changing the appearance of the milk. They may increase in the soil and retain their vitality for months. They are not killed by freezing, but, as Prudden has shown, may live in ice for months. In many epidemics the bacilli have been detected in the infected water. The detection how- ever of the typhoid bacillus in drinking-water is by no means easy, and the question in individual cases must be settled by experts who have had special experience with this germ. Both Prudden and Ernst have found it in water-filters.
Modes of Conveyance. — (a) Contagion. — Typhoid fever is certainly not a very contagious disease, but the possibility of direct transmission must be acknowledged. The poison is not given off from the skin or in the breath, but in the faeces. Practically only those persons are liable to contract the disease in this way who have to do with the stools or with the body-linen of patients. I have known several instances in which nurses appear to have been infected under these conditions.
{h) Infection of water is unquestionably the most common mode of conveyance. Many epidemics have been shown to originate in the con- tamination of a well or a spring. A very striking one occurred at Ply- mouth, Pa., in 1885, which was investigated by Shakespeare. The town, with a population of eight thousand, was in part supplied with drink- ing-water from a reservoir fed by a mountain stream. During January, February, and March, in a cottage by the side of and at a distance of from sixty to eighty feet from this stream, a man was ill with typhoid fever. The attendants were in the habit at night of throwing out the evacua- tions on the ground toward the stream. During these months the ground was frozen and covered with snow. In the latter part of March and early in April there was considerable rainfall and a thaw, in which a large part of the three months' accumulation of discharges was washed into the brook, not sixty feet distant. At the very time of this thaw the patient had nu- merous and copious discharges. About the 10th of April cases of typhoid fever broke out in the town, appearing for a time at the rate of fifty a
'i^riKUD I i;vi:it. 5
(Ijiy. Ill all al»nut twelve liuMdnMl jiroph^ wrn> iifTr(!t«M|. An irnriH'TiMo ma- jority of all llu' cases were in tim [uirt nf the town wliicli rL'(;4)ivc(l wut<T from I lie infeeled reservoir.
Milk also may Im* tlio houico of irifecrtion. One of tlu' inont tlionni^lily studicMl i«|)i(lemi('M due to tliin cjiiise was that inve.sti^'ated l)y liuiiard in Isliiiijtoii. 'riu' milk may !)(» contamiiiattMl by infccicMl water usocl in (dcansiiig tiio ciins. In fresh milk it hii8 boon Hliown thut the gerniH grow rapidly.
Filth, had sowers, or cosspools can not in thcniHclvcrt cauHC typhoid fever, hut they furnish the conditions suitable for the preservation of tlio bacillus and possibly for its propai^ation.
(r) (htnt(tnn)i(tti(ni of tJiv Siiil. — i'ettenkofer holds that the j)oison is not eliminated in a condition capable of communicating the diseji^e directly, but that it must lirst undergo changes in the soil, which changes are favored by the ground-water.
It does not seem probable that typhoid fever is communicated by the air alone, as by the nuulium of sewer-gas.
Once in the intestinal canal the typhoid germs jirobalily do not like the cholera bacilli increase in the secretions, but penetrate the epithelial lining and reach the lymphoid tissue, upon which they exert their spe- citic action, causing a cell 2>roliferation greatly in excess of the physiologi- cal process. The necrosis may be regarded as the result of the maximum intensity of the action of the bacilli — an action not confined to the lym- phatic apparatus of the intestinal wall, but also met with in a typical man- ner in the enlarged mesenteric glands and in the liver and spleen.
It has not yet been definitely determined whether the constitutional disturbances in typhoid fever depend upon the toxalbumins produced in the growth of the bacilli, though this is in the highest degree probable.
Morbid Anatomy. — The statistical details under this heading are based upon sixty-four autopsies, a majority of which were performed at the Montreal General Hospital, and upon the records of two thousand post- mortems at the Munich Pathological Institute.*
Intestines. — A catarrhal condition exists throughout the small and large bowel, and to this is due, in all probability, the diarrhoea with the thin pea-soup-like stools. xVssociated with this catarrh there is during life some epithelial desquamation.
Specific changes occur in the lymphoid elements of the bowel, chiefly at the lower end of the ileum. The alterations which occur are most con- veniently described in four stages :
1. Ilijperjjlasia, which involves the glands of Peyer in the jejunum and ileum, and to a variable extent those in the large intestine. The follicles are swollen, grayish-white in color, and the patches may project to a dis- tance of from three to five mm. In exceptional cases they may be still more
* Munchener medicinische Wochenschrift, Xos. 3 and 4. 1891.
0 SPECIFIC INFECTIOUS DISEASES.
prominent. The solitary glands, which range in size from a pin's head to a large pea, are usually deeply imbedded in the submucosa, but project to a variable extent. Occasionally they are very prominent and may be almost pedunculated. Microscopical examination shows at the outset a condition of hyperaemia of the follicles. Later there is a great increase and accumulation of cells of the lymph-tissue which may even infiltrate the adjacent mucosa and the muscularis ; and the blood-vessels are more or less compressed, which gives the whitish anaemic a2:)pearance to the follicles. The cells have all the characters of ordinary lymph-corpuscles. Some of them however are larger, epithelioid, and contain several nuclei. Oc- casionally cells containing red blood-corpuscles are seen. This so-called medullary infiltration, which is always more intense toward the lower end of the ileum, reaches its height from the eighth to the tenth day and then undergoes one of two changes, resolution or necrosis. Death very rarely takes place at this stage. I have seen but one instance in my series — a girl, aged twenty-four, who died at the end of the first week with severe nervous symptoms and in whose ileum the lymph-follicles were greatly swollen, pitted and cribriform, but without necrosis. Resolution is accom- plished by a fatty and granular change in the cells, which are destroyed and absorbed. A curious condition of the patches is produced at this stage, in which they have a reticulated appearance, the 2>^(^Q.ues a surface reticulee. The swollen follicles in the patch undergo resolution and shrink more rapidly than the surrounding framework, or what is more probable the follicles alone owing to the intense hyperplasia become ne- crotic and disintegrate leaving the little pits. In this process superficial haemorrhages may result and small ulcers may originate by the fusion of these superficial losses of substance.
There is nothing distinctive in the hyperplasia of the lymph-follicles in typhoid fever. Apart from this disease we rarely see in adults a marked affection of these glands with fever. In children however it is not uncommon when death has occurred from intestinal affections. It is also met with in measles, diphtheria, and scarlet fever.
2. Necrosis and Sloughing. — When the hyperplasia of the lymph-fol- licles reaches a certain grade resolution is no longer possible. The blood- vessels become choked, there is a condition of anaemic necrosis, and sloughs form which must be separated and thrown off. The necrosis is probably due in great part to the direct action of the bacilli. The process may be superficial, affecting only the upper part of the mucous coat, or it may extend to and involve the submucosa. It is always more intense toward the ileo-caecal valve, and m very severe cases the greater part of the mucosa of the last foot of the ileum may be converted into a brownish- ])lack eschar. The necrosis in the solitary glands forms a yellowish cap whi(;h often involves only the most prominent point of a follicle. The extent to which the necrosis reaches is very variable. It may pass deep into the muscular coat reaching to or even perforating the peritonagum.
rvi'llnll) l-'KVKlt. 7
.'I. rirn'ntion. — 'I'lin Hr|mruti(tri «»f the iHMToti<j tiHuu*? — tht? hIou^Ihii^ — is ^^'raduiilly clTiM-tiMl from tin* i'(I;^'«'M iiiwjinl, iimi rrniillH in tin- foriinition of a?i ulcer, tlic sizti und cxtriit of wliirli arc dirrctly j»ro|)ortioiial«* to iIhj ivinoiiMl of necrosis. If this he Hiiperlicial, tlio entire tliicknehs of the nuieosa niav m*! hr iiivnlvcd and the loss of siihstancL* inuy he Hiniili und shallow. More < omnionly tlu) Hh»U)^h in Hejuiratin^ exj)OHeH the Huhinuc-'owi and inuscniaris, |>ait icniarly tlui hitter, which forniH thu lloor of a majority of all typhoid ulcers. It is not common for an entire I'eyer's pat<'h to slouujh away, aiul a j)erfectly ovoid ulcei- opposite to the m(;Hent4'ry \a randy seen. Irre^^ularly oval and rounded forms are most common. A Iar<i;e patch may pn^sent thnn; or four ulcers divide(l hy septa of mucouu nuMuhrane. The terminal six or eii^dit, incdies of the mucous meml)n4ne of the ileum nuiy form a lar;^'e ulcer, in which are here and there islands of mucosa. The t'd^j^es of the ulcer an; usually swollen, soft, sometimes coni^ested, and often undermined. At Ji late j)eriod the ulcers near the valve may have very irregular sinuous horders. 'J'he base of a ty})hoid ulcer is smooth and clean, usually formed of the submucosa or of the muscularis.
There may be largo ulcers near the valve and swollen hypera^mic patches of Peyer in the n])j)or })art of the ileum.
4. ncaU)i(j. — This begins with the development of a thin granulation tissue which covers the base and gives to it a soft, shining appearance. The mucosa gradually extends from the edge, and a new growth of epi- thelium is formed. The glandular elements are reformed; the healed ulcer is somewhat depressed and is usually pigmented. Occasionally an appearance is seen as if an ulcer had healed in one place and was extend- ing in another. In death during relapse healing ulcers may be seen in some patches with fresh ulcers in others.
We may say, indeed, that healing begins witli the separation of the sloughs, as, when resolution is impossible, the removal of the necrosed part is the first step in the process of repair. Practically, in fatal cases, we seldom meet with evidences of cicatrization, as the majority of deaths occur before this stage is reached.
Large Intestine. — The ca?cum and colon are affected in about one third of the cases (in nineteen of the sixty-four). Sometimes the solitary glands are greatly enlarged. The ulcers are usually larger in the caecum than in the colon. Perforation of the ca?cum is rare. The appendix may be involved. In my cases there was ulceration in two and perforation in one case. I dissected a case in Montreal in which the patient died three months after an attack of typhoid fever, and a localized abscess was found, due to perforation of the appendix. Death resulted from pylephlebitis.
Perforation of the Bowel. — In one hundred and fourteen cases of the two thousand Munich autopsies (5*7 per cent) and in fourteen instances in my series, the intestine was perforated and death caused by peritonitis. The perforation may occur in ulcers from which tlie sloughs have already
g SPECIFIC INFECTIOUS DISEASES.
separated, or it may be directly due to the extension of a necrosis through all the coats. In only a few cases is the perforation at the bottom of a clean thin-walled ulcer. In one instance the perforation occurred two weeks after the temperature had become normal. The sloughs were, as a rule, adherent about the site of perforation. A majority of the cases were in small deep ulcers. There may be two or even three perforations. The orifice is usually within the last foot of the ileum. In only one of my cases was it distant eighteen inches. Peritonitis was present in every in- stance.
Hcemorrliage from the bowels occurred in ninety-nine of the Munich cases, and in nine of my series. The bleeding seems to result directly from the separation of the sloughs. I was not able in any instance to find the bleeding vessel. In one case only a single patch had sloughed, and a firm clot was adherent to it. The bleeding may also come from the soft swollen edges of the patch.
The mesenteric glands at first show intense hyperaemia and subse- quently become greatly swollen. Spots of necrosis are common. In sev- eral of my cases suppuration had occurred. The bunch of glands in the mesentery, at the lower end of the ileum, is especially involved. The re- troperitoneal glands are also swollen.
The spleen is invariably enlarged in the early stages of the disease. In only one of my cases did it exceed (GOO grammes) 20 ounces in weight. The tissue is soft, even diffluent. Infarction is not infrequent. Rupture may occur spontaneously or as a result of injury. In the Munich autop- sies there were five instances of rupture of the spleen, one of which re- sulted from a gangrenous abscess.
The liver shows signs of parenchymatous degeneration. Early in the disease it is hypergemic, and in a majority of instances it is swollen, some- what pale, on section turbid, and microscopically the cells are very granu- lar and loaded with fat. Necrotic areas occur in many cases, as described by Ilandford. They have been studied recently by Reed in Welch's lab- oratory. No definite association could be determined between the groups of bacilli and the necrotic areas. In twelve of the Munich autopsies liver abscess wos found, and in three, acute yellow atrophy. Diphtheritic in- flammation of the gall-bladder is occasionally met with. This may lead to perforation and fatal peritonitis.
The kidneys show cloudy swelling, with granular degeneration of the cells of the convoluted tubules; less commonly an acute nephritis. A rare condition described by Rayer, Wagner, and others is the occurrence of numerous small areas infiltrated with round cells, which may have the appearance of lymphomata (Wagner), or may pass on to softening and suppuration, producing the so-called miliary abscesses. It is usually a late change. The bacilli have been found by some observers in these areas. The bacilli can be obtained by culture from the kidneys, and have been found in many instances in sections. They have also been found in
TNIMKHI) rKVKIC. 9
iho iiriiH^ ill a r*\v oumoh. Diplitiicritic iiilluriiriialioii of i)u> f><;Ivi« of tha kidiu^y may occMir. It whh prcHciit in tliruo of my niM'H, in r>nc) of which ih(i lips of tlic |)apiila» wcm also alToctcMl. Catarrh of thf lihuhh-r in not uncommon. Diplillicritic; inllammation of il may also occur. Orchitin iii occasionally iiicl witli.
'I'hc iinaloiiiical cliaii^ts in the rrspird/art/ (irt/fin.s arc not v<?ry numer- ous. Ulccrat ion of llir larviix occurs in a (certain niimlxT of cascn ; in the Munich series it was noted oiu* linn(lrc(l and .stjvcn times. It may come on at tlie saint* time as th(» ulceration in the ileum, hut tin; l>acilli liavo not yet, I helieve, l)een found in the ulcers, 'i'hey occur in the; post<;rior wall, at tlie insertion of the cords, at the l)ase of the epi^dottis, and on the ary- epi<;lottidean foMs. In the later periods catarrhal and diphtiieritif; ulcers may i)e present.
(Kdenni of the f^lottis wjis present in twenty of the Municli ca.ses, in ei^ifht of wlii(di tracheotomy was performed. Diplitheritic laryn^'itis is not very uncommon. It occurretl in a most extensive form in two of my ca-ses. In one the membrane was chielly in tlie pliarynx, and exten(U'(l only upon the epiglottis ; in the other there was a uniform membrane wliich extended into the trachea and in the tubes of the second dimension. In eiglit cases in my series there was lobar pneumonia. Hypostatic congestion and the condition of the lung spoken of as splenization are very common. Gan- grene of the lung occurred in forty cases in the ^lunich series ; abscess of the lung in fourteen ; hnemorrhagic infarction in one hundred and twenty- nine. Pleurisy is not a very common event. Fibrinous pleurisy occurred in about six per cent of the Munich cases, and empyema in nearly two per cent.
Changes in the Circulatory System. — Endocarditis is rare. It was not present in any of my cases, and existed in eleven only of the Municli autopsies, in which also there were fourteen cases of jDericarditis. Myo- carditis is not very infrequent. Dewevre,* in a series of forty-eight cases, found in sixteen granular or fatty degeneration, and in three a pro- liferating endarteritis in the small vessels. It is remarkable that even in cases of death from heart-failure, with intense fever, the cell-fibres may present little or no observable change. The arten'es are not infrequently involved in tvphoid fever. Barie distins^uishes an acute obliteratins: arteri- tis and a partial arteritis, and states that they both occur most commonly in the arteries of the lower extremities. They are responsible, no doubt, for certain of the cases of blocking of the arterial trunks. This arteritis may affect the smaller vessels, particularly those of the heart. In the veins, tlirombi are not infrequently found, particularly in the femoral veins, and more rarely in the cerebral sinuses.
Nervous System. — There are very few coarse changes met with. Men- ingitis is extremely rare. It was not present in any one of my autop-
* Archives generates de Medecine, 1887, 2.
10 SPECIFIC INFECTIOUS DISEASES.
sies, and occurred in only eleven of the two thousand Munich cases. The anatomical lesion upon which the aphasia — seen not infrequently in chil- dren— depends, is not known. Possibly, as Leyden states, it may be due to slight encephalitis. Parenchymatous changes have been met with in the peripheral nerves, and appear to be not very uncommon, even when there have been no symptoms of neuritis.
The voluntary muscles show, in certain instances, the peculiar changes described by Zenker which occur in all long-standing febrile affections and are not peculiar to typhoid fever. The muscle substance within the sarcolemma undergoes either a granular degeneration or a hyaline trans- formation. The abdominal muscles, the adductors of the thighs, and the pectorals are most commonly involved.
Symptoms. — In a disease so complex as typhoid fever it will be well first to give a general description and then to study more fully the sypmtoms, complications, and sequelae according to the individual organs.
General Description, — The period of incubation lasts from a week to ten days, during which there are feelings of lassitude and inaptitude for work. The onset is rarely abrupt. There may be prodromal symptoms, either a rigor, which is rare, or chilly feelings, headache, nausea, loss of appetite, pains in the back and legs, and nose-bleeding. These symptoms increase in severity and the patient at last takes to his bed. From this event, in a majority of cases, the definite onset of the disease may be dated. During the first iceek there is, in some cases (but by no means in all, as has long been taught), a steady rise in the fever, the evening record rising a degree or a degree and a half higher each day, reaching 103° or 104°. The pulse is rapid, from 100 to 110, full in volume, but of low tension and often dicrotic; the tongue is coated and white; the abdomen is slightly distended and tender. Unless the fever is high there is no de- lirium, but the patient complains of headache, and there is mental con- fusion and wandering at night. The bowels may be constipated, or there may be two or three loose movements daily. Toward the end of the week the spleen becomes enlarged and the rash appears in the form of rose- colored spots, seen first on the skin of the abdomen. Cough and bron- chitic symptoms are not uncommon at the outset.
In the second week^ in cases of moderate severity, the symptoms be- come aggravated ; the fever remains high and the morning remission is slight. The pulse is rapid and has lost its dicrotic character. There is no longer headache, l)ut there is mental torpor and dulness. The face looks heavy ; the lips are dry ; the tongue, in severe cases, becomes dry also. The abdominal symptoms are more marked — diarrhoea, tympanites, and tenderness. Death may occur during this week, with pronounced nervous symptoms, or, toward the end of it, from ha}morrhage or perfora- tion. In mild cases the fever declines, and by the fourteenth day may be normal.
In the third week, in cases of moderate severity, the pulse ranges from
'\'\ nmii. i'i:vi;it. 11
llii l(> l.'lo; liio tniiprrHtiirn now mIiowh iimrktMl riiornin^ reiniMxiotiM, urifl tluM't) is li ;^M-!i<liml (Icrliiir ill \\u) (over. 'IMio Iohm of ll(*Mh in now nioro noticiMihlc, aiiti t li(^ wciikiicsH is piniioiincrd. TIh- diurrho'ii iiti<l nich-or- JHiii riHiy persist. riiruv(trui)I(* HviiiptoriiH ut thin Hlii^o urn tin* pitlnio- imry cofiipliciilionM, iucriMiHiii;,' fccMoiicHH of tlio hourt, uiul pronouiKrcd (loliriiiin witli nmscular tremor. Special diiu^urH urt; pcrforution uiid luemorrlm^o.
With i\\{) /'()(( rf/i trrilx\ in :i majority of instances, convulo«cenoo be- ijjinM. The temperatun! jj^i'adiially readies i\\{\ iioi-mal point, tho diurrhcDa stops, the toiiiriie eU'aiis, and (lie desire for food returns. In seven; ciwc.s the foiirtli week may present an a;.(;j[ravate(l ])ietnrt! of the third; the patient ^rows weaker, the pulse is inon; rapid and feehlo, the tonj^uo dry, and the alxlomen disti'iided. lie lies in a condition of profound Htuj)or, with low muttering delirium and suhsultus tendinum, and pas.so8 the fan'es and urine involuntarily. Ih-art-failurt; and seconchiry complications are the eliief danjj^ers of this })i>riod.
In the ///■/// and si.rtlt week's i)rotraeted cases may still show irregular fever, and convalesccnco may not set in until after the fortieth day. In this period we nu»et with relapses in the milder forms or sliglit recru- descence of the fever. At this time, too, occur many of the complications and se(iuehe.
Special Features and Symptoms. — Mode of Onset. — As a rule, the sym})toms develop insidiously, and the patient is unahle to fix definitely the time at which he began to feel ill. The following are the most im- portant deviations from this common course :
(^7) Onset with Pronounced Nervous Manifestations. — Headache, of a severe and intractable nature, is by no means an infrequent initial symp- tom. Again, a severe facial neuralgia may for a few days put the practi- tioner off his guard. In cases in which the patients have kept about and, as they say, fought the disease, the very first manifestations may be pro- nounced delirium. Such patients may even leave home and wander about for days. In rare cases the disease sets in with the most intense cerebro- spinal symptoms, simulating meningitis — severe headache, photophobia, retraction of the head, twitching of the muscles, and even convulsions. Occasionally drowsiness, stupor, and signs of basilar meningitis may exist for ten days or more before the characteristic symptoms develop ; occasion- ally the onset is with mania.
(h) With Pronounced Pulmonary Si/mptoms. — The initial bronchial catarrh may be of great severity and disguise the other features of the disease. More striking still are those cases in which the disease sets in with a single chill, with pain in the side and all the characteristic features of lobar pneumonia.
(r) With Intense Gastro-intestinal Symptoms. — The vomiting may be incessant and uncontrollable. Occasionally there are cases with such in- tense vomiting and diarrhoea that a suspicion of poisoning may be aroused.
12
SPECIFIC INFECTIOUS DISEASES.
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{)/) With Si/in/)fntfis of tin Arutti Ar/t/iritiM. — Smoky or bloo<ly urine, witli iiiiK-li iilltiniicii luid (til)(^-(!iistH.
(/') Anihttlitloni /'W/v//. -Deserving of cHprcial lucntioii tin* tlioMo caMf of typlioid f(>V( r in wliich tlu* piitinit keeps iilxnit mid uttciii))U to do work, or pcrluipM tukuH x\ lon^ joiiriu^y to liin hoiiK*. Ho may como umler obscM'vjitioii f(»i- till' lirHt timu with u tciiipunituru of 101 ' or JO.V, und the nisli well out. Such oasos hooiu ulwiiys to run u riioru hovcto courne than others, and in ^^cnend liosj)itals they contribute lur^^'ly to tlu^ total mor- tality. I'^inally, then» are rare instances in wliich the lirst symptoms are perforation, oi* a profuse Ini'morrha^^o from the bowids.
Facial Aspect. — Karly in tho disease the cheeks arc flushed and the oyos brii^^ht. Toward the end of the lirst week the (ixpression }>ecome8 more listless, and when tho disease is well established the expression is dull and heavy.
Fever. — (a) Iirt/ular (^onrse. (Chart I.) — In the sta^c of invasion the temi)erature may rise steadily durin<^ the first live or six days. The evening temperature is about a degree or a degree and a half higher than the morning remission, so that a temperature of 104° or 105° is not un- common by tho end of the first week. Having reached the fastigium or height, the fever then persists witb slight morning remissions. The tem- perature curve follows the normal diurnal variations, the maximum oc- curring between four and eight o'clock in tlie evening and tlie minimum between four and eight in the morning. At the end of the second and throughout the third week the temperature becomes more distinctly re- mittent. Tlie dilference between the morning and evening may be three or four degrees, and the morning temperature may even be nornuil. It falls by gradual lysis, and tlie temperature is not considered normal until the evening record is at 98*2°.
{!)) Variations in tho normal temperature curve are common. We do not ahvays see the gradual step-like ascent in the early stage ; the cases do not often come under observation at this time. When the disease sets in with a chill, the temperature may rise at once to 103° or 104°. In many cases defervescence occurs at the end of the second week and the temperature may fall rapidly, reaching the normal within twelve or twenty hours. An inverse type of temperature, high in the morning and low in the evening, is occasionally seen but has no especial significance.
Sudden falls in the temperature may occur ; thus, as shown in Chart IV, a drop of 10° may follow^ an intestinal haemorrhage, and the fall may be very apparent even before the blood has appeared in the stools. Hy- perpyrexia, temperature above 106°, is not very common in typhoid fever except just before death, when I have known the thermometer to register 109-5°. (Chart II.)
{c) Post-Tijplioid Elevations — Fever of Convalescence. — During con- valescence, after the temperature has been normal, perhaps for five or six days, the fever may rise suddenly to 102° or 103°, and, after per-
14
SPECIFIC INFECTIOUS DISEASES..
sisting for from one to three days or even longer, falls to normal. With this there is no constitutional disturbance, no furring of the tongue, no dis- tention of the abdomen. These so-called recrudescences are by no means uncommon, and are of especial importance, as they cause great anxiety to the practitioner. Th*y are attributed most frequently to errors in diet, constipation, emotions, and excitement of any sort, such as seeing friends. There are cases in which the temperature declines almost to the nor- mal at the end of the third week, the tongue cleans, and the patient enters
Oct. iG
20
2i
Temp,
109
108
107
106
105
101
103
102
101
100 Pay of Disease
|
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CuART II. — Hyperpyrexia — death.
apparently upon a satisfactory convalescence. The evening temperature, however, does not reach 98-5°, but constantly keeps about 99-5° or 100°, and occasionally rises to 100-5°. This, in the late stages of convalescence, I have seen due to the post-typhoid anaemia. Complications should be carefully looked for, particularly insidious pleurisy or bone lesions.
In certain of these cases the persistence of the fever seems to be really a nervous phenomenon, and there is nothing in the condition of the patient to cause uneasiness except tlie evening elevation of temperature. If the tongue is clean, the appetite good, and there are no intestinal symptoms, it may be disregarded. I have frequently found this condition best met by allowing the patient to get up and by stopping the use of the thermometer. This prolonged slight elevation of the fever after the dis-
TV n loll) KKVKIC. 16
ap)M'!initi('(« oT iill lli() HyiMptoriiH in imohI nomninfi in chililn?!! and in jMitirnlM of marked nrrvoiis trniiH'ninM'nt.
{</) Tin' /•'ri'rr (if f/ir lirldjisf. -TIum i« u n-prtiliun in rniiny inMUnccM of the orin^iiml fr\<'r, a ;,'nidiml iiHccnt and rnaint<!nafjc<5 for a few day» at a (-(Tlaiit liciLrlil 'I'ld iIk-ii u Knidiial drcliiu;. It in Hhortcr tluiii the original j)yri»xia, jmhI rarely <*niiliiiiies mnic iliaii twn or thrccj wcokH. (Chart I.)
(v) Afchrilc Tiipltuid. — 'I'lieic arc caHes denerila'd in wliieli tlio chief foaturt's of th(» disease have Iteeii present without the existence of fever. 'Pliey are exli'emely rare '\\\ this country. No itistance (.f fin- kind }ijib oonie under iiiy ohservatioii.
Skin. — 'I'hc rash of typhoid fever is very characteriHtic. It conHiHts of a nuiulter of rose-eoh)red spots, w hieh appear from the Hcventh to the tenth (hiy, usually lirst upon the al)(h)nien. The spots are flattened papul(\s, slii^iitly raised, of a rose-red (!oh)r, disappearing^ on pressure, and ranij^inuj in diameter from two to four millinu'tres. They can Ik' felt as distinct eU'vations on tlio skin. Sometimes each spot is capped hy a small vesicle. 'Phe spots may be dark in color and occasionally become pete- chial. After persisting for two or three days they gradually disap})ear, leaving a brownish stain. They come out in successive crops, but rarely appear after the middle of the tliird week. They are present in the typ- ical relai)se. 'Phe rash is most abundant ujion the abdomen and lower thoracic zone and often abounds upon the back. It is extremely variable in degree. There are cases in which it spreads to the extremities and often to the face. I can not say that in my experience these cases with the more abundant eruption have been of specially severe type. The rash is not always present. Murchison states that it is frequently absent in children.
A branny desquamation is not rare in cases in which the sudaminal vesicles have been abundant; occasionally the skin may peel in large flakes.
The following accidental rashes are met with in typhoid fever :
1. Erythema. — It is not very uncommon in the first week of typhoid fever to find the skin of a vivid red color, almost like a scarlatinal rash. This is particularly noticeable on the abdomen and chest, but the rash may spread to the extremities. It may possibly in some instances, but certainly not always, be due to quinine. I have seen it much more fre- quently in the past five years (during which time I have rarely ordered a dose of quinine in this disease) than I did in Montreal, where we used quinine largely as an antipyretic.
2. The tache hJeudfre — Peliomata. — These are pale-blue spots, subcu- ticular, from 4 to 10 mm. in diameter, of irregular outline and most abundant about the chest, abdomen, and thighs. They sometimes give a very striking appearance to the skin. It can be readily seen that the in- jection is in the deeper tissues and not superficial. This rash is quite without sififnificance. Since mv attention was called to its association with
16 SPECIFIC INFECTIOUS DISEASES.
body lice, I have met with no instance in which these were not present. Several French observers maintain that they are due to the irritating effects of the fluid secreted by pediculi.
3. Sudaminal and miliary eruptions are common in all cases in which there is profuse sweating.
4. Urticaria is occasionally met with, and lastly herpes, but this is un- common in comparison with its frequency in malaria and pneumonia.
The tache cerebrale^ a red line with white borders, can be produced by drawing the nail over the skin. It is a vaso-motor phenomenon which, as in other fevers, can be readily elicited, particularly in nervous sub- jects. Here may be mentioned certain other cutaneous phenomena also of vaso-motor nature : thus exposure of the abdomen may be sufficient to cause a pinkish injection, which may in places change to an ivory white, giving a curious mottled appearance to the skin. A similar appearance may be seen on the arms. The general tint may be white, with irregu- lar patches or streaks of pink or dark red.
Sweats. — At the height of the fever the skin is usually dry. Profuse sweating is rare, but it is not very uncommon to see the abdomen or chest moist with perspiration, particularly in the reaction which follows the bath. Sweats in some instances constitute a striking feature of the dis- ease. They may occasionally be associated with chilly sensations or actual chills. Jaccoud and others in France have especially described this sudoral form of typhoid fever. There may be recurring paroxysms of chill, fever, and sweats (even several in twenty-four hours), and the case may be mistaken for one of intermittent fever. The fever toward the end of the second week and during the third week may be intermittent. The characteristic rash is usually present, and if absent the negative con- dition of the blood is sufficient to exclude malaria. I have seen cases of this form in Montreal, where there could have been no suspicion of ma- larial infection.
CEclema of the skin occurs :
1.. As the result of vascular obstruction, most commonly of a vein, as in thrombosis of the femoral vein.
2. In connection with nephritis.
3. In association with the anaemia and cachexia.
The hair is very apt to fall out after an attack of typhoid fever. In- stances of permanent baldness are of extreme rarity. As in other diseases associated with fever the nutrition of the nails suffers, and during and after convalescence a transverse ridge is seen.
And, lastly, it is stated that a peculiar odor is exhaled from the skin in typhoid fever. Whether due to a cutaneous exhalation or not, there cer- tainly is a very distinctive smell connected with many patients. I have repeatedly had my attention directed to it by nurses. Nathan Smith descriV)o.s it as of a " somi-cadaverous, musty character."
Circulatory System. — The blood presents important changes. The
TVi'iiniD i''i:vi:u. 17
following HtutciruMilH jin^ IhimimI oh HtiidicM whirh W. S. Thuy(?r hiw tuiults ill my wiinl. hiiriii;^' llw lirHt two wcrkH tlirrc Fiiuy Im* littlo or no clian^e in tih^ hloitii. I'lofiiso HwrutM or (M»piouH (liiirr)i<i'>i may, im Iluyi'm hof bIiowii, ciiiiHC' (he cnrpMsclcs HH ill tin- <'olliip.m« Htu;^^* of (;lioirni — U> riMC* a1)()V(^ iKtrmal. In ilir ihinl week a fall iisiialiy tJikcH phico in (;orpit>K;leH and lia'?ii(i;^dol»iii aiid llic Milliliter may hiiik rapidly t'vcn to 1,.'J()0,()0() j>ct V. mm., ;;radiially rising to normal iliirin;^ (;onval('.Hc(?n(!0. When the ])ati(>iit lirst ^I'ts up, tline may l»«' a Hli;;lit, fall in the number of tlio for- puscK's.
Tlic amount of li;inio^dol)iii is always n-ducrcl, and usually in a greater relativo proportion than the numltcr of red (M)rpU8(de8, and during rccov- ory the normal color standard is reached at a later period. 'I'iie numl>er of colorless corpuscles varies littli? from the normal stanchird (fl,0()0 ± per 0. mm.). As a rule, perhaps the numher is sli;(htly subnormal (I*ee). This fact is important, and may he at times of real dia<,Miostic value in distiiiguishinij;; typhoid fever from various sej)ti(! fevers and auute iullum- matory processes in which there is leucocytosis.
Tlie accompanying blood-chart shows tliese changes well.
The post-typhoid aiuemia may reach an extreme grade. In one of my cases the blood-corpuscles sank to 1,3{)0,()0() per cubic mm. and the haemo- globin to about twenty i)er cent. These severe grades of amemia are not common in my experience. In the Munich statistics there were fifty- four cases with general and extreme anjemia.
Of changes in tlie blood plasma very little is known.
The pulse in typhoid fever presents no special characters. It is in- creased in rapidity in i)roportion to the height of the fever. As a rule, in the first week it is above 100, full in volume and often dicrotic. There is no acute disease with which, in the early stage, a dicrotic pulse is so fre- quently associated. Even with liigh fever the pulse may not be greatly accelerated. As the disease progresses the pulse becomes more rapid, feebler, and small. In the extreme prostration of severe cases it may reach 150 or more, and is a mere undulation — the so-called running pulse. The lowered arterial pressure is manifest in the dusky lividity of the skin and coldness of tlie hands and feet.
During convalescence the pulse gradually returns to normal, and occa- sionally becomes very slow. After no other acute fever do we so fre- quently meet witli bradycardia. I have counted the pulse as low as thirty, and instances are on record of still fewer beats to the minute.
The hearf-sonnds are at first clear and loud, and free from murmur, but in severe cases, as the prostration develops, the tirst sound becomes feeble and there is often to be heard, at the apex and along the left sternal margin, a soft systolic murmur. The first sound may be gradually anni- hilated, as pointed out by Stokes. In the extreme feebleness of the ataxic forms, the first and second sound become very similar and the long pause is much sliortened.
18
SPECIFIC INFECTIOUS DISEASES.
Of cardiac complications, pericarditis is rare and has been met with chiefly in children and in association with pneumonia. It was not pres- ent in any of my cases and occurred in only fourteen of the two thousand
|
5,000,000 |
DEC , 1890 |
JANUARY, 1891 |
FEBRUARY |
MARCH -j |
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19 |
22 |
25 |
28 |
31 |
3 |
6 |
9 |
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15 |
18 |
21124 |
27 |
30 |
2l5 |
8 |
1 1 |
14l 17 |
20123 |
26 |
1 |
4 |
7 |
10 |
13 |
16 19 |
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90% |
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80^ |
4,000,000 |
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MEAN NORM.
NUMBER OF
WHITE
CORPUSCLES
BLACK, RED CORPUSCLES.
RED, HAEMOGLOBIN.
Chart III.
BLUE, COLORLESS CORPUSCLES.
Munich post-mortems. Endocarditis is also uncommon. I saw one case at the Pliiladelphia Hospital. It must be very rare, as there were only eleven cases noted in the Munich records. Myocarditis is more common. The following statement may be made with reference to the condition of the heart-muscle in this disease : In protracted cases the muscle-fibre is usually soft, flabby, and of a pale yellowish-brown color. The softening may be extreme, though rarely of the grade described by Stokes, in which, when held apex up by the vessels, the organ collapsed over the hand.
'\\ I'llnlh I'KVKU. 19
forrniiiL^ ii rniisliinnin Iil<c cap. MicnmcojMciiIly, ilic ril)rcM mny hliow Iittl<; nr no rli.iii;^'!', cNrii \\ hrii llic iiupiiUc of ilir heart haH Imm-ii extn-iiH'ly ftn?- I)l('. A ^^niiiiulMi* pan'McliyiimlniiM •IcLrcucnitioii in coiMriion. Katty <l«"j^'cri- tM'alion limy ln« prcsnit, particularly in lnii;^'-stari(liM;^' caxiM with aii.i'riiiiu Tlu^ hyaliiK" cliaii;^'(? in not cnmrnnn. TIm? Hc;,nncntin^ inytx-anlitin, in which \\\o ccincnl sulistanct^ in H(>ft4'!io(l ho that tlm niiiK<'h*-cellH Hcpunite, has also hccii fniind, l»iil il is prnhal»l\ a post -rn(»rlcrn change.
(oni/tlinthOfis in I he Arhrics. — Ohliteration of lar^'c or Hriiall arterial trunks is oiui o{ {\w raro coniplications of typhoid fever. A consithTahlo nun»l)cr of cases arc scat tercel throu;^'li tlu^ literature. The ohliteratif)ii may ho duo either to eniholisni or to thronihosis. In a majority of ca.ses tho femoral artery is involved and pin«^rene of tlio foot and leg occurs. In scn'oral cases there has heen ohliteraiioii of hoth femorals with extension of the clot into the aorta and ganj^rene of hoth \v'j[>. In a case which I saw witli Iioddiek, of Montreal, the ohliteralion of tlu; left fem<jral occurred on tho sixteenth day. On the twentieth day the patient liad ])ain in tho right leg and there was no pulsation in the femoral artery. Gangrene gradually developed in hoth feet, and death took place in the sixth week. In these cases the condition is prohahly due to thromhosis, not cmholism, and is associated with a blood state which favors clotting, or possibly with a local arteritis. The condition is not invariably fatal. Of twenty cases collected by Barchoud,* eight died.
Thrombi in the Veins. — This is a much more frequent complication, and, according to ^[urchison, is met with in about one per cent of the cases. It occurs most frequently in a crural vein, and more commonly in the left than in the right ; due possibly, as suggested by Liebermeister, to the fact that the loft common iliac vein is crossed by the right iliac artery, and does not permit of so free a flow of blood as in the right vein. Thrombosis is indicated by enlargement and a}dema of the limb, but gan- grene never results from obstruction of the vein alone. It is not a very unfavorable complication. In one case of my series the thrombus had suppurated and there was pvf^mia. Occasionally the thrombosis may extend into the pelvic veins and into the vena cava. In one instance the thrombus was in the right circumflex iliac vein alone, and the superficial veins on the right side of the abdomen were in consequence greatly en- larged. Sudden death has been caused by dislodgment of a thrombus.
Infarcts in the kidneys, spleen, and lungs are by no means uncommon in typhoid fever. They are associated usually with thrombosis in the arteries, rarely with embolism.
Digestive System. — Loss of appetite is early, and, as a rule, the relish for food is not regained until convalescence. Thirst is constant, and should be fully and freely gratified. Even when the mind becomes be- numbed and the patient no longer asks for water, it should be freely given.
* Paris Thesis. ISSl.
20 SPECIFIC INFECTIOUS DISEASES.
The tongue presents the changes inevitable in a prolonged fever, but there are no distinctive characters. Early in the disease it is moist, swollen, and coated with a thin white fur, which, as the disease progresses, becomes denser. It may remain moist throughout. In severe cases, particularly those with delirium, the tongue becomes very dry, partly owing to the fact that such patients breathe with the mouth open. It may be covered with a brown or brownish-black fur, or with crusts between which are cracks and fissures. In these cases the teeth and lips may be covered with a dark brownish matter called sordes — a mixture of food, epithelial debris^ and micro-organisms. By keeping the mouth and tongue clean from the out- set the fissures, which are extremely painful, may be prevented. During convalescence the tongue gradually becomes clean, and the fur is thrown off, either insensibly or occasionally in flakes.
The secretion of saliva is often diminished ; salivation is rare.
Parotitis is not so common as in typhus fever. It was present in forty-five of the two thousand Munich cases. It did not occur in any of my series of fatal cases. It is usually unilateral, and in a majority of cases goes on to suppuration. It is regarded as a very fatal complication, but recovery has followed in four or five of my cases. It undoubtedly may arise from extension of inflammation along Steno's duct. This is probably not so serious a form as when it arises from metastatic inflam- mation.
The pliarynx may be the seat of slight catarrh. Sometimes the fauces are deeply congested. Membranous pharyngitis is a serious and fatal complication, which may come on in the third week.
The gastric symptoms are extremely variable. Nausea and vomiting are not common. There are instances, however, in which vomiting, re- sisting all measures, is a marked feature from the outset, and may directly cause death from exhaustion. Vomiting does not often occur in the sec- ond and third week, unless associated with some serious complication. In a few of these cases ulcers have been found in the stomach.
Of intestinal symptoms, diarrhoea is the most important. In some epidemics constipation exists, but in any long series of cases diarrhoea will be found to be a prominent feature of the disease. Its absence must not be taken as an indication that the intestinal disease is of slight ex- tent. I have seen, on several occasions, the most extensive infiltration and ulceration of the Peyer's glands of the small intestine, with the colon filled with solid faeces. The diarrhoea is caused less by the ulcers than by the associated catarrh, and, as in tuberculosis, it is probable that when this is in the large intestine the discharges are more frequent. It is most common toward the end of the first and throughout the second week, but it may not occui until the third or even the fourth week. The number of discharges ranges from three to eight or ten in the twenty-four hours. They are usually abundant, thin, grayish-yellow, granular, of the con- sistency and appearance of pea-soup, and resemble very much, as Addison
'rVriKHh FKVKK.
21
rorniirkcd, tlif iiornuil rofitcntH of tin* Mriiull howi'l. Tim n-artioii in alku- liiKMUid llin odor nlTi'iiHivc. On Hliiiiiiiii^, tlid diMiliur^n'H Hi'|iunito into u thill H(M*ouM luvcr, roiitaiiiiii^ iilhiiinrii uiid huUh, and a lower Htratiitiif coii- Bintin^ of «'|)itli('lial dihris, nMimaidH of food, and rninicroiiH (^ryxtuli of triple phoKpliatos. Hlood may bo in Hinall amount^ und only recognized
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by the microscope. Sloughs of the Peyer's glands occur either as gray- ish-yellow fragments or occasionally as ovoid masses, an inch or more in length, in which portions of the bowel tissue may be found.
Hcemorrhage from the bowels is a serious complication, occurring in from 3 to 5 per cent of all cases. It occurred in ninetv-nine of the two
22 SPECIP^IC INFECTIOUS DISEASES.
tliousand Munich autopsies, and it was present in nine of my cases. There may be only a slight trace of blood in the stools, but too often it is a pro- fuse, free haemorrhage, which rapidly proves fatal. It occurs most com- monly between the end of the second and the beginning of the fourth week, the time of the separation of the sloughs. Occasionally it results simply from the intense hyperaemia. It usually comes on without warn- ing. A sensation of sinking or collapse is experienced by the patient, the temperature falls, and may, as in the annexed chart, drop eight or ten degrees in a few hours. Fatal collapse may supervene before the blood appears in the stool. Haemorrhage usually occurs in cases of considerable severity. Graves and Trousseau held that this was not a very dangerous symptom, but statistics show that death follows in from thirty to fifty per cent of the cases.
It must not be forgotten that melaena may also be part of a general hgemorrhagic tendency, in which case it is associated with petechiae and haematuria.
Meteorism is a frequent symptom, and if of moderate grade is not serious, but when excessive it is usually of ill-omen. Owing to defective tone in the walls, in severe cases owing to infiltration with serum, gas ac- cumulates in the small and large bowels, particularly in the latter. It is rightly held to be to some extent a measure of the intensity of the local lesions. When extreme, it pushes up the diaphragm and interferes very much with the action of the heart and lungs. It undoubtedly also favors perforation.
Abdominal tenderness on pressure and gurgling in the right iliac fossa exist in a large proportion of all the cases. The tenderness may be more or less diffuse over the abdomen, but it is commonly limited to the right side It is rarely excessive and may be elicited only on deep press- ure. Gurgling indicates simply the presence of gas and fluid faeces in the colon and caecum.
Perforation of an ulcer into the peritonaeum, the most serious abdom- inal complication of the disease, occurred in one hundred and fourteen of the two thousand Munich cases, and in fifteen of the sixty-four cases of my series It is usually indicated by the onset of sudden acute pain in the abdomen, and symptoms of collapse. It is most common at the end of the second or in the third week, but in one of my cases it occurred as early as the eighth day and in another in the sixth week, two weeks after the evening temperature had become normal. It is not infrequently associated with haemorrhage. The presence of indigestible food, severe vomiting, excessive meteorism, and ascaridcs have been assigned as causes. This accident is much more common in men than in women. The perforation is usually in the ileum, but may occur in the colon. As a rule it promptly causes symptoms of peritonitis — distention of the abdomen, marked ten- derness, rigidity of the abdouiinal walls, vomiting, a collapsed, pinched expression, and a rapid, smjiU pulse. In very severe cases with marked
TVi'iioiD ri:\ r.u. 28
innital (listiirliaiicr t)i<> KyinphwiiM iiiay not oxcito MUMiiicioii, hut tliL* tern- prrutiin* usually fallH iiiul tlu* HyniptoiiiH of (;oIlupHo lire well niurkcd. Tim (lia^^niosis is rasy, cxcrpt in vuhvh in wlii(;h lynipanilcH iiihI ivtulvnwHn have Ix'cn prominent fratuics, wlu-n i( nuiy Im- vny (liniciilt to Muy ulirllior pci'Toration lias occurred. An indication of value in hucIi inHt^inceM Im the ohlitoration of I he liver dulness l»y ^'as in tin? peritoneal cavity, u Hynijitorn upon which Alon/o Clark and I'linl laid ^reut KtresH, and the vuliie of which 1 have on several occasions heen aide to demonstrate. It i.s Konic- what lesseiu'tl hy the fact that extreme tympany nniy almost, if not quite, ohlilt»rate tht» liver dulness. Recovery from perforation is undouht<'dly ])()ssil)I(», thou«,di rare.
Peritonitis without j)crforati(»ii may also occur by extension from the ulcer or occasionally hy rupture of a softened mesenteric gland. It waa present in *v'v per cent of the Munich autopsies.
The spleen is invariahly enlari^ed in typhoid fever, and in a majority of cast\s the edj^e can he felt below the costal mar^jin. Uy the end of the first week tlie enlar«;ement is evident, unless there is ^reat distention of the coh)n, when the sjdeen may be ])ushed far back and difHcult to feel. Even [\\v normal area of dulness may not be obtainable. I have seen a very large spleen post mortem, when during life the increase in size was not observ- able. Toward the fourth week it diminishes in size. In four of my auto})sies it weiglied less than normal. Infarcts and abscesses are occa- sionally found. Rupture of the spleen in ty])hoid fever, due to a slight blow, has been seen by Bartholow. Spontaneous rupture may also occur.
Liver. — Symptoms on the part of this organ are rare. Enlargement is occasionlly detected. Jaundice is a very rare complication. It may be either of a catarrhal nature or due to parenchymatous changes. It was present in only Tl per cent of the ^lunicli autopsies. Abscess of the liver is a very rare sequela.
Respiratory System. — Episfaxis is an early symptom in many cases, and precedes typhoid fever more commonly than it does any other febrile affection. It is occasionally profuse and serious.
Lanjngitis is not very common. The nlcers and the perichondritis have already been described. (Edema apart from nlceration is rare. In this country the laryngeal complications of typhoid fever seem much less frequent than on the Continent. I have seen ulcers in only four or five instances, and twice only perichondritis, both of which cases recovered, one after the expectoration of large portions of the thyroid cartilage.
Bronchitis is one of the most frequent initial symptoms. It is indi- cated by the presence of numerous piping rales. It may come on with great severity, and in a case at the Philadelphia Hospital I regard 3d for several days the bronchial catarrh as the primary affection. The smaller tubes may be involved, producing urgent cough and even slight cyanosis. Col- lapse and lobular pneumonia may also occur.
Lobar j^iicumonia is met with under two conditions :
24 SPECIFIC INFECTIOUS DISEASES.
1. It may be the initial symptom of the disease. After an indisposition of a day or so, the patient is seized with a chill, has high fever, pain in the side, and within forty-eight hours there are signs of consolidation, and the evidences of an ordinary lobar pneumonia. The intestinal symptoms may not develop until toward the end of the first week or later ; the pul- monary symptoms persist, crisis does not occur ; the aspect of the patient changes, and by the end of the second week the clinical picture is that of typhoid fever. Spots may then be present and doubts as to the nature of the case are solved. In other instances, in the absence of a characteristic eruption the case remains dubious, and it is impossible to say whether the disease has been pneumonia, in which the so-called typhoid symp- toms have developed, or whether it was typhoid fever with early im- plication of the lungs. Whether this condition depends upon the pneu- mococcus or is the result of an early localization of the typhoid bacillus has not yet been settled. I have twice performed autopsies in cases of this pneumo-typhus^ as it is called by the French and Germans, and can speak positively of its onset with all the symptoms of a frank pneumonia.
2. Lobar pneumonia forms a serious and by no means infrequent complication of the second or third week. It was present in over 8 per cent of the Munich cases and occurred in nine of my cases. The symp- toms are usually not marked There may be no rusty sputa, and, unless sought for, the condition is frequently overlooked. Infarction, abscess and gangrene are occasional pulmonary complications.
Hypostatic congestion of the lungs and oedema, due to enfeebled circu- lation in the later periods of the disease, are very common. The physical signs are defective resonance at the bases, feeble breath-sounds, and, on deep inspiration, moist rales. Pleurisy is by no means an uncommon complication. It was present in about 8 per cent of the Munich autop- sies. It may develop slowly in convalescence, in which case it is almost always purulent. Another occasional pulmonary complication is hcemopty- sis, which I once saw at the height of the disease. After death, no lesions of the lungs or bronchi were discovered. Miliary tuberculosis occasionally develops, and some writers hold that there is a greater susceptibility to infection with the tubercle bacillus after this than after otlicr fevers.
Nervous System. — As already noted, the disease may set in witli in- tense and persisting headache or an aggravated form of neuralgia. There are cases in which the effect of the poison is manifested on the nervous system early and with the greatest intensity. There are headache, photo- phobia, retraction of the neck, marked twitching of the muscles, rigidity, and even convulsions. In such cases tlie diagnosis of meningitis is in- variably made. I have examined post mortem three such cases, in two of which the diagnosis of cerebro-spinal fever had been made. In not one of them was there any trace of meningeal inflammation, only the most in- tense congestion of the cerebral and spinal pia. Meningitis, however, may occur, but is extremely rare, as shown by the Munich record, in which
TVI'llolh KKVKU. 25
ihvvv were only clcvri) ainoii^^ tin* two tlioiiHiiii<l rtiHon. tSl4>k«tH'M didum tliiit '' I line is no niii^^^lo iirrvoiiM Myrii)itorii wliiih riwiy not uimI doeii not ()('(nir iiKlrpciHlriitly of any iip|in'cijiljlc lusiijii of llic liniin, iitTVeNf or H]>injil cord,'' is too oftni forj^'oltcri.
/ic/iriinii is piTsnit in all srNcrc chmch. It in (•(•rtuinly Ii'hh frequiTit iiiidri- a I'ii'it! |»l;iii nf liy(lrnili('ra|iy. Il may \>r pn-Kofit from the outM^t, hut usually docs not dcvclo)) until tlic second and HoiiictitiicH not until the tliird week. It nuiy l)e sli;4ht and only nocturnal. It is, an a ruh*, a (juiet delirium, lliou^di thero are cases in which the patient is very noisy and constantly tries to f^ct out of hed, and, uidess carefully watched, may escape. The patient does not often become maniacal. In heavy drinkcTH the delirium may have tho character of dcliiium tremens. Kven in eaxeH which have no positive delirium, the mental processes are usually dulleil and the ])atient is listless and apathetic. In severe ca.ses the ]>atient pa.«.seH into a condition of unconsciousness. The eyes may be open, hut he is ob- livious to all BurrouTidin<; circumstances and lU'itluT knows nor can iiuli- cato his wants. The mine and fa-ces are j)assed involuntarily. In this })seudo-wakeful state, or coma vii^il as it is called, the eyes are open and the patient is constantly muttering. The lips and tongue are tremulous; there is twitcliing of the fingers and wrists — subsultus tendinum and carphologia. Jle })ieks at the bedclothes or grasps at invisible objects. These are among the most serious symptoms of the disease, and always indicate danger.
Among important complications and sequelae are several nervous af- fections. The para J i/ses are due in the majority of instances to neuritis. It may be of a paraplegic type, or may involve only one or two nerves. Occasionally, as in a case reported by George Ross,* all four limbs are alfected.
Possibly some of these cases are due to poliomyelitis, not to neuritis. This affection does not always follow, but may come on at the height of the disease, as in a case recently under my care, in which during the second week neuritis developed in both arms. Among other sequences may be mentioned aphasia, which is more apt to occur in young children, and great slowness of speech, which may or may not be associated with mental weakness.
Post-febrile iusauiti/ is perhaps more frequent after typhoid than after any other disease. Wood regards it as confusional insanity, the result of impaired nutrition and exhaustion of the nervous centres. Five cases have come under my observation, in four of which recovery took place.
Disturbances of the organs of the special senses are rare. Otitis media occasionally develops. Ocular symptoms are uncommon.
Renal System. — Retention of urine is an early symptom in many
* Paralysis in Typhoid Fever. Transactions of the Association of American Physi- cians, vol. iii.
26 SPECIFIC INFECTIOUS DISEASES.
cases, and is more frequent in some epidemics than in others. The nrine is usually diminished at first, has the ordinary febrile characters, and the pigments are increased. Later in the disease it is more abundant and lighter in color.
Ehrlich has described a reaction, which he believes is rarely met with except in typhoid fever. This so-called diazo-reaction is produced as fol- lows: Two solutions are employed, kept in separate bottles: one con- taining a saturated solution of sulphanilic acid in a solution of hydro- chloric acid (50 c. c. to 1,000 c. c.) ; the other a ^ per cent solution of sodium nitrite. To make the test, a few cubic centimetres of urine are placed in a small test-tube with an equal quantity of a mixture of solution of the sulphanilic acid (40 c. c.) and the sodium nitrite (1 c. c), the whole being thoroughly shaken. One cubic centimetre of ammonia is then allowed to flow carefully down the side of the tube, forming a colorless zone above the yellow urine, and at the junction of the two a deep brown- ish-red ring will be seen if the reaction is present. AVith normal urine a lighter brownish ring is produced, without a shade of red. The color of the foam of the mixed urine and reagent, and the tint they produce when largely diluted with water, are characteristic, being in both cases of a deli- cate rose-red if the diazo-reaction be present ; but if not, brownish- yellow.
In twenty-six cases at my clinic, Simon found the reaction in twenty- two. It may be present previous to the occurrence of the rash, and as late as the twenty-second day. The value of the test is lessened by its occur- rence in cases of miliary tuberculosis, and occasionally in the acute dis- eases associated with high fever.
The renal complications in typhoid fever may be thus grouped :
{a) Febrile albuminuria, which is very common and of no special sig- nificance ; thus, in the first seventy-five cases admitted to the Johns Hop. kins Hospital, albumen was present in forty-six, and in twenty-five cases casts were also found. In only two of these cases were there indications of an acute B right's disease.
{h) Acute nephritis occurring at the onset or during the height of the disease — the nepliro-typlius of the Germans, the fievre typho'ide a forme renale of the French — may set in, with all the symptoms of the most in- tense Bright's disease, masking in many instances the true nature of the malady. After an indisposition of a few days there may be fever, pain in the back, and the passage of a small amount of bloody urine. In a recent case * the early symptoms were all those of the most severe nephritis, and death occurred on tlie fourteenth day from perforation of the bowel. In other instances, as in a case reported in the same paper, the nephritis sets in at the end of the first or during the second week, and may modify con-
* Acute Nephritis in Typhoid Fever. Johns Hopkins Hospital Reports, February, 1800.
TVI'llnlh ri'lVKK. 27
Hi(l('ni))lv 111*' cli.'ir.'U'lcr nf iIk- tli-iaM-, aii<i rsrn rtri<l«T tin* «h;i;'ri«»-iM (loitl)! fill.
((•) 'I'Ih- iKpliriiis nf ( (»ii\ali>.rii('r. 'I'liin in moro ('oniriion hut Ivfn scrioiiM. Il (l('\r|(i|iM afii-r tlir fall nf tiit) fovor, niid JH UHiiiilly iixH^K.'iiiUMl with (I'dcniu. It (IncM iKd prosoiit cliHriictcrH dilTrrciit from i\w (inliimry poHt-fci)!'!!*' iicpliritiM.
(</) TIh' i«'iMarkiil>l(» lymplmrnatniis ncjtliritis (Icscnhrd hy ]•". \Va;^MMT and olIuTs, and already ndcrri'd to in tlio Hcction on inorljid aniitoiny, pro- duces, as li v\\]{\ no synjptoniH.
(/■) l\ist-fiiitln)i(i pt/r/ifis. — In this ilir pelves of the kidney and tho eali('(\s are jit first covered with a nicinhianoiis exudation, but erosion and uh'cration may suhse(|uently occiii-. 'I'hrro may l)c hlood and pus in the urine. This condition occurred in tliri'C of my cases, in one of whidi it was associaliMl witli extensive membranous inlhunmation of tlie bladder.
Sim})Ie eatarrli of the bladder is rare.
Orchitis is occasionally niet with durin<( convalescence. Sadrain col- lected sixteen cases in the literature. It is usually associated with a catarrhal urethritis. Induration or atrophy nuiy occur, and more rarely su})puration.
Osseous System. — A multiple arthritis occasionally occurs; more com- monly it is limited to a single joint, and nuiy pass on to su})j)uration. Spontaneous luxation may develop. Necrosis is not uncommon during convalescence. Keen collected thirty-seven cases after typhoid fever. It is probably always the result of a secondary infection. Its most usual seat is the tibia.
The )}fusrh'f( sliow in some cases the degeneration already referred to, but it does not cause any symptoms. Iliemorrhage occasionally occurs into the muscles, and late in the disease abscess may develop.
Association of other Diseases. — Erysipelas is a rare complica- tion, most commonly met with during convalescence. In 1,420 cases at Basle it occurred ten times. Griesinger states that it is met with in "2 per cent.
Measles may develop during the fever or in convalescence. Chicken- pox and noma have been reported in children. Pseudo-membranous in- Hammations may occur in the pharynx, larynx, or genitals. ^lalarial and typlioid fevers may be associated, but a majority of the cases of so-called typho-malarial fever are either remittent or true typhoid.
Varieties of Typhoid. — Typhoid fever is an extremely complex disease. ^lany forms have been described, some of which present exag- geration of common symptoms, others modification in the course, others again greater intensity of action on certain organs. As we have seen, when the nervous system is specially involved, it has been called the cerebro-spinal form ; when the kidneys are early and severely affected, nephro-typhoid ; when the disease begins with pulmonary symptoms, pneumo-typhoid ; when the disease is characterized throughout by profuse
28 SPECIFIC INFECTIOUS DISEASES.
sweats, the sudoral form of the disease. It is a mistake, 1 think, to rec- oornize or speak of these as varieties. It is enough to remember that typhoid may set in occasionally with symptoms localised in certain organs, and that many of its symptoms are extremely inconstant — in one epidemic uniform and text-book-like, in another slight or not met with. This di- versified symptomatology has led to many clinical errors, and in the ab- sence of the salutary lessons of morbid anatomy it is not surprising that practitioners have so often been led astray. We may recognize, with Murchison, the following varieties :
1. The mild and abort ive forms. It is very important for the practi- tioner to recognize the mild type of typhoid fever, often spoken of as gastric fever or even regarded as simple febricula. In this form, the typhus levissirnus of Griesinger, the symptoms are similar in kind but altogether less intense than in the graver attacks, although the onset may be sudden and severe. The temperature rarely reaches 103°, and the fever of onset may not show the gradual ascending evening record. The spleen is enlarged, the rose-spots may be marked ; often they are very few in number. The diarrhoea is variable, sometimes it is not present. In such cases the symptoms may persist for from sixteen to twenty days.
In the abortive form the symptoms of onset may be marked with shiv- ering and fever of 103° or even higher. The date of onset is often defi- nite, a point upon which Jiirgensen lays great stress. Rose-spots may occur from the second to the fifth day. Early in the second week or at the end of the first week the fever falls, often with profuse sweating, and conva- lescence is established. In this abortive form relapse may occur and may occasionally prove severe. When typhoid fever prevails extensively these cases are not uncommon. I agree with J. C. Wilson, who states that they are not nearly so common in this country as in Europe.
2. The grave form is usually characterized by high fever and pro- nounced nervous symptoms. In this category, too, come the very severe cases setting in with pneumonia and Bright's disease, and with the very intense gastro-intestinal or cerebro-spinal symptoms.
3. The latent or amhidatory form of typhoid fever, which is particu- larly common in hospital practice. The symptoms are often very slight, and the patient scarcely feels ill enough to go to bed. He has languor, perhaps slight diarrhoea, but keeps about and may even attend to his work throughout the entire attack. In other instances delirium sets in. The worst cases of this form are seen in sailors, who keep uj) and about, though feeling ill and feverish. When brought to the hospital they often develop symptoms of a most severe type of the disease. Haemorrhage or perfora- tion may be the first symptom of this ambulatory type. Sir W. Jenner has called attention to the dangers of this form, and particularly to the grave prognosis in the case of persons who have travelled far with the dis- ease in progress.
•rvnioii) FKVKK. 29
'I'hcn^ in u raro and fatal fmni c.f typlioni ffvcr, (.•Imra^jUTiixti wy outancnuM and imicniis lia'nn»rrlia^'<-H.
An (tfvhnlc typlioid frvtr in nM<»;;ni/.rd l»y uuthorM. liiclMTrnoiMtfr wivi (hat iIh* ('as(*H W(«ro not uncoiMnioii at Baxlu. The palienU prcM'iiU'fl lassitude, d(|ii( ssinii, hcadajdn', fnrrrd lon^juc, Iohh al apiM'tiU;, hIow j»u1m% and even tilt' spots and cnlar^i'd splmi. I havf in» {KTHonal knowledge <>f such cases.
Typhoid Fev«r in Children. Mpistaxis rarely occurs; the rine in tenipcraluie is less ;,M"a<lual ; the initial hroncliial catarrh in often oh- Hcrved. The iumvous syinptorns aic nfieii prominent; there arc wukcfnl- lu'ss and deliiiiini ; diarrlnea is often ah.-eiit. The ijinh may 1k» very Hli^dit, but tho nH)st copious eruption 1 have ever seen was in a (ddld of ei^'ht. (hldly enough, considering the readiness with which the lymph (dementi* of tho inti'stine in (diildrcn are involved, the ahdonnnal symptoms are slii^ht. Fatal Ineniorrhage and perforation are rare. Among the secjuela*, aphasia and bone lesions may be mentioned as more common in children than in adidts. The mortality of tv])hoid fever in (diildren is low. Forch- lieimer, in the Cincinnati epidemic in 1888, treated seventy cases without a death.
Typhoid Fever in the Aged. — After the fortieth year the disease runs a less favorable course, and the mortality is very high. Of sixty-four fatal cases, seven were over forty years of age ; one was aged sixty-three, another seventy. The fever is not so high, but complications are more common, jiarticularly pneumonia and heart failure.
Relapse. — Helapses vary in frequency in different epidemics, and, it appears, in different places. The percentages of ditTcrent authors range from 3 per cent (Murchison), 11 per cent (Biiumler) to 15 or 18 per cent (Immerniann). In Wagner's clinic, from 188*-3 to 188G, there were 49 relapses in 5G1 cases. F. C. Shattuck reports 21 relapses in 129 cases. R. L. MacDonnell 1 relapse in 100 cases. A relapse is a repetition, sometimes only a summary, of the original attack. Von Zicmssen in- sists correctly that two of the three important symptoms— step-like tem- perature at onset, roseola, and enlarged spleen — should be present to de- termine the diagnosis of a relapse. The intestinal lesions are repeated, though with less intensity and regularity. It is to be carefully distin- guished from the fever of convalescence — or recrudescence — which has already been described. This is usually transitory, not lasting longer than a day or two. There are occasional instances in which the fever lasts for four or five days without rose-spots, or without enlargement of the spleen, and it may be impossible to determine whether there has been a relapse or not. The true relapse usually sets in after complete deferves- cence. Irvine noted the average duration of the interval in his cases at a little over five days. In eleven of Shattuck's cases the relapse began before complete defervescence. The onset is nsually abrupt, though the step-like ascent is sometimes well seen, as in Chart I. The
30 SPECIFIC INFECTIOUS DISEASES.
eruption may be seen as early as the third or fourth day. The attack is usually less severe and of shorter duration. Of Murchison's fifty-three cases the mean duration of the first attack was about twenty-six, of the interval eleven, of the relajise fifteen days. The mortality of the relapse is not high. The relapse may be repeated, and a third and fourth relapse may occur.
The relapse is a reinfection from within, but we are still quite ignorant of the conditions favoring its occurrence. It is not at all likely that any special methods of treatment favor the relapse, though hydrotherapy has labored under this reproach.
Diagnosis. — If the patient is seen from the outset there is rarely any difficulty in diagnosing typhoid fever of typical course. In the prefebrile period the headache, weakness, loss of appetite and epistaxis are extremely suggestive, and, with an ascending pyrexia, scarcely need the distinctive rash to clinch the diagnosis.
The early and intense localisation of the symptoms in certain organs is a frequent source of error in diagnosis.
Cases coming on with severe headache, photophobia, delirium, twitch- ingf of the muscles and retraction of the head are almost invariablv regarded as cerebro-spinal meningitis. Under such circumstances it may for a few days be impossible to make a satisfactory diagnosis. I have thrice performed autopsies on cases of this kind in which no suspicion of tvphoid fever had been present; the intense cerebro-spinal manifestations having dominated the scene. Until the appearance of abdominal symp- toms or the rash, it may be quite impossible to determine the nature of the case. Cerebro-spinal meningitis is, however, a rare disease ; typhoid fever a very common one, and the onset with severe nervous symptoms is by no means infrequent. Fully one half of the cases of the so-called brain- fever belong to this category.
I have already spoken of the misleading pulmonary symptoms, which occasionally develop at the very outset of the disease. The bronchitis rarely causes error, though it may be intense and attract the chief at- tention. More difficult are the cases setting in with chill and followed rapidly by pneumonia. I have brought such a case before the class one week as typical pneumonia, and a fortnight later shown the same case as undoubtedly one of typlioid fever. In another case, in which the onset was with definite pneumonia, no spots developed, and, though there were diarrhoea, meteorism, and the most pronounced nervous symptoms, the doubt still remains whether it was a case of typhoid fever or one of pneumonia in wliich severe secondary symptoms developed. Tliere is less danger of mistaking tlie pneumonia which develops at the height of the disease, and yet this is possible, as in a case admitted a few months ago to my wards — a man aged seventy, insensible, witli a dry tongue, tremor, ecchymoses upon the wrists and ankles, no rose-spots, enlarge- ment of the spleen, and consolidation of his right lower lobe. It was very
'rNI'llolD KKVKIt. 3]
ijjitiinil, i»:irliiiiljirly ninco (Ihto wum ho luHtory, to n-j^'unl Hiirh a com* bm 8iMiil(^ piirtiiiioMiti with proroiiiiil cniiHlitutioiml (liHttirlmiict% but the uiu topsy hIiowciI the chaniclrriHlir N-kIoiih of typhoi<l frvi-r.
Id riiularial ic;^noiiH typhoid ami rt'iiiiltriit ft?V(TH an? vrry fn-rpiciitly coMfoimdcil. I coiifrMM myself iiiial)l<' to difTrrcntiiitc^ rcrt4ii?i cawn of nia- hirial rfinitlciil I'loiii typhoid fi'vrr, without the \)\(kh\ cxiiniirmtion. I have r(-|)ral('dly, l)oth in iMiihi(h'lplna and Uiiltitiion^ Kciit vhm'h to the wui'ds as typhoid fi'vcr wliicli sid)S('(pi('iitiy proved to \)v ordinary inahirial reriiitle!it. 'IMie |)atieiit comes with a Idstory of ;//^//^//.v^, weakiiesH, diar- riuea, perhaps vomitini,^ ; the loii^nie is furred and white, the chcckH are flushed, the spleen is sliL,ditIy eidari,'ed, temperaturo 102" or 10.'J°. 'i'hcTc may inch'ed he (h'liriiini, and the clinical j»ictni-e of the early stage of typhoid fover may he complete. On at, least two occasions I have shown siudi cases to my class as typhoid fever, and several times patients have heen sent to the wards with instructions to have the head shaved and to he^in the bat lis. The oidy safeguard ai^ainst error is the exaniiiuition of the blood, which should be done systenuitically in regions in which malaria l>revails. The presence of Laveran's organisms is distinctive and abso- lutely diagnostic.
Acute miliary tuberculosis is not infrequently mistaken for typhoid fever. The })oints in ditTerential diagnosis will be discussed under that disease. Tuberculous peritonitis in certain of its forms may closely simu- late typhoid fever.
Puncture of the spleen for the purpose of obtaining cultures is justifi- able only in exceptional circumstances.
Prognosis. — The mortality ranges from 10 to 30 per cent. Of the enormous number of deaths analyzed by Murchison, the mortality was nearly 19 per cent. The death-rate at the Montreal General Hospital, for twenty years, was 11 "2 per cent. In recent years the mortality in typhoid fever has certainly diminished, and, nnder the influence of Brand, the reintroduction of hydrotherapy has reduced the mortality in institu- tions in a remarkable manner, even as low as 5 or G per cent. Especially unfavorable sym]>toms are high fever, delirium with toxic symptoms, luvmorrhage — though by some this is not thought very unfavorable — and peritonitis.
Si(d(Ie?i Death. — It is difficult in many cases to explain this most lam- entable of accidents in the disease. There are cases in which neither cerebral, renal, nor cardiac changes have been found, and instances too in which it does not seem likely that there could have been a special localisa- tion of the toxic poisons in the pnenmogastric centres. McPhedran, in reporting a case of the kind, in which the post-mortem showed no ade- quate cause of death, suggests that the experiments of McWilliams on sudden cardiac failure probably explain the occurrence of death in cer- tain of these cases in which neither embolism nor uremia is present. Under conditions of abnormal nutrition there is sometimes induced a state
32 SPECIFIC INFECTIOUS DISEASES.
of delirium cordis^ which may develop spontaneously, or, in the case of animals, on slight irritation of the heart, with the result of extreme irreg- ularity and finally failure of action. It occurs more frequently in men than in women, according to Dewevre's statistics, in a proportion of 114 to 2G. It may occur at the height of the fever, and, as pointed out by Graves, may also happen during convalescence.
Fat subjects stand typhoid fever badly. The mortality in women is greater than in men. The complications and dangers are more serious in the ambulatory form in which the patient has kept about for a week or ten days. Early involvement of the nervous system is a bad indication ; and the low, muttering delirium with tremor means a close fight for life. Prog- nostic signs from the fever alone are deceptive. A temperature above 104° may be well borne for many days if the nervous system is not involved.
Prophylaxis. — In cities the prevalence of typhoid fever is directly proportionate to the inefficiency of the drainage and the water-supply. There is no truer indication of the sanitary condition of a town than the returns of the number of cases of this disease. With the improvement in drainage the mortality in many cities has been reduced one half or even more. One of the most striking instances is afforded by the city of Munich. Von Ziemssen has published charts illustrating the extraordinary reduc- tion in the prevalence of typhoid fever since the completion of the drain- age system of that city. The average yearly number of admissions to hospital of cases of t3^phoid fever was, between the years 1866 and 1880, 594, while from 1881 to 1888 inclusive, the average has been only about 100. During this same period the typhoid mortality of the whole city presented a yearly average of 208, but from 1881 to 1888 the yearly average was only 40.
By most rigid methods of disinfection much may be done to prevent the spread of the infection.
The following procedures, suggested by Fitz, should be carried out in hospital practice, and, with modifications, in private houses :
1. " Mattresses and pillows (when liable to become soiled) are to be protected by close-fitting rubber covers.
2. " Bed and body linen are to be changed daily. Bed-spreads, blank- ets, rubber sheets and rubber covers are to be changed at once when soiled. Avoid shaking any of the articles.
3. " All changed linens, bath-towels, rubber slieets and covers are to be immediately wrapped in a sheet soaked in carbolic acid (one to forty). Kemove them to the rinse-house as soon as possible, and soak six hours in carbolic acid (one to forty). Then boil the linen for a half-hour, and wash witli soft soap. Tlie rubber slieets and covers are to be rinsed in cold water, dried, and aired for eight hours. The bed-spreads and blankets are to be aired eight hours daily.
4. " Feeding-utensils, immediately after using, are to be thoroughly cleansed in boiling water.
'^^ ni<»!i) I'liVKit. ^3
T). " DcjcctioiiH an* t<» !•(• hummvimI into u lu'd-jmti ronUiinin;^ half a pint of carliolic acid (mir to twenty). The naU'rt iiri^ to Im* clciiiiMiMl with paper, and afterward with a compn'SM doth wet with carholif! a''i(l (ont; to forty).
tl. '^ Add two (piartM of ('ar))oli(MU'id (ono to twenty), in (lividcMl jKir- tions, to the cniilciits of the l»i'd-pan ; mix tli(>rou;^hly hy Hliukin^ and throw the li(|iiid into the liopju-r. 'I'ho h(Mi-pan and hopper are to \)0 cleansed with carholic aiMd (ono to twenty) and wiped dry. 'I'lie cloth nsed for the al)oV(» purpose i.s to he at once hnrned.
7. "Tiie cor])ao is to he covered with a sheet wet with carholic acid (one to foity).
S. *' After tlie discharr^e of the patient from the lio.«pital, the mat- tresses arc to i)e aired every day for a week, 'i'he hedstead is to be washed with corro.sive suhlimate (one to one thousand).
1). "These directions are to he followed until the patient is free from fever.''
When epidemics are prevalent tlie drinking-water and the milk used in families should he boiled. These precautions should be taken also by recent residents in any locality, and it is much safer for travellers to drink li^lit wines or mineral water rather than ordinary water or milk.
Treatment. — (^0 General Management— 'J'he profession was lone: in learniuLC ihiit typhoid fever is not a disease to be treated by medicines. Careful nursing and a regulated diet are the essentials in a majority of the cases. The patient should be in a well-ventilated room (or in summer out of doors during the day), strictly confined to bed from the outset, and there remain until convalescence is well established. The bed sliould be single, not too high, and the mattress sliould not be too hard. The woven wire bed, with soft hair mattress, upon which are two folds of blanket, combines the two great qualities of a sick-bed, smoothness and elasticity. A rubber cloth should be placed under the sheet. An intelligent nurse should be in charge. When this is impossible, the attending physician should write out specific instructions regarding diet, treatment of the dis- charges, and the bed-linen.
(I)) Diet, — Those forms of food should be given which are digested with the greatest ease, and which leave behind the smallest amount of resi- due to form fieces. Milk is the most suitable food. If used alone, three pints at least may be given to an adult in twenty-four hours, always diluted with water, lime-water, or aerated waters. Partially peptonized milk, when not distasteful to the patient, is occasionally serviceable. The stools of a patient on a strictly milk diet should be examined from time to time, to see if the milk is entirely digested. Fever patients often receive more than they can utilize, in which case masses of curds are seen in the stools, or microscopically fat-corpuscles in extraordinary abundance. Under these circumstances it is best to substitute, for part of the milk, mutton or chicken broths, or beef -juice, or a clear consomme, all of which mav be made
31 SPECIFIC INFECTIOUS DISEASES.
very palatable by the addition of fresh vegetable juices. Some patients will take whey or buttermilk when the ordinary milk is distasteful. Thin barley-gruel, well strained, is an excellent food for typhoid-fever patients. Eggs may be given, either beaten up in milk or, better still, in the form of albumen-water. This is prepared by straining the whites of eggs through a cloth and mixing them with an equal quantity of water. It may be flavored with lemon, and, if the patient is taking spirits, whisky or brandy is very conveniently given with this. Patients who are unable to take milk can subsist for a time on this alone.
The patient should be encouraged to drink water freely, which may be pleasantly cold. Iced tea, barley-water, or lemonade may also be given, and there is no objection to coffee or cocoa in moderate quantities. Fruits are not, as a rule, allowable, though the juice of lemon or orange may be given. Typhoid patients should be fed at stated intervals through the day. At night it depends upon the general condition of the patient whether he should be aroused from sleep, or not. In mild cases it is not well to disturb the patient. When there is stupor, however, the patient should be roused for food at the regular intervals night and day.
Alcohol is not necessary in all cases, but may be given when the weak- ness is marked, the fever high, and the pulse failing. In young healthy adults, without nervous symptoms and without very high fever, alcohol is not required ; but in any case, when the heart-beat is feeble and the first sound becomes obscure, if there is a muttering delirium, subsultus tendi- num and a dry tongue, brandy or whisky should be freely given. In such a case from eight to twelve ounces of brandy in the twenty- four hours is a moderate amount.
(c) Treatment of the Fever. — The persistent pyrexia is in itself a danger, but perhaps not the chief danger. Cases with high fever alone, without delirium or signs of involvement of the nervous system, are not nearly so serious as those cases in which, with a temperature of 104°, there are pronounced nervous symptoms. For the fever and its concomitants there is no treatment so efficacious as that by cold water, introduced at the end of the last century by Currie, of Liverpool, and of late years forced upon the profession by Brand, of Stettin. In institutions a rigid system of hydrotherapy should be carried out. At my clinic the follow- ing plan is followed : Every third hour, if the temperature is above 102*5°, the patient is placed in a bath (at 70° Fahr.), which is wheeled to the bed- side. In this he remains from fifteen to twenty minutes, and is then taken out, wrapped in a dry slieet and covered with a light blanket. Enough water is used to cover the patient's body to the neck. The head is sponged during the bjith, and, if there is much torpor, cold water is poured over it from a height of a foot or two. The rectal temperature is taken immediately after the bath, and again three quarters of an hour later. The patient often complains bitterly when in the bath, and shiver- ing and blueness are almost a constant sequence. Food is usually given
•rvi'iioiD ii:vi:i:
85
with a Htiinnlnrjt iiftcr lln« luu li. 'I'lir «»nly rrintni-itKlicntiofiH firo (HTito- nitiH iukI li:i<iii(M'rliii;^'(\ NcitluM' broiicliitiH nor piiniiiioniii tin* mo n'^iinl- <•(!. It is nol ncccMsjirv t«» n'lu'W the wntrr in tin* liutli niorr Uian oiico in lIu' Iwi'iity-foiir Ikuiim. 'I'Iu' ju;(!()rn|mnyinj; churl -Ik.u^ flu- numlxT of
Ni>.
.//iviu«^>t^ Admitted
//.
Ward
/
Jtltli'tA
n
Tomp 100
lOR
107
100
lOA
104
m
iw
101
1001
09
«8
VI
96 Tomp-
Pulse Resp.
Stools
Urine
Day of Disease.
:*;)?4A\f..:.jA**.J.w.J?^...i.J>*Jl».J.M?.M*.ji^^
|6
1|
18
«l
19
I I I
Chart V.
baths and the influence on the fever during two days of treatment. The good etfoots of the baths are: (1) the reduction of the fever: ('2) the in- tellect becomes clearer, the stu})or lessens, and the muscular twitchings disappear; (3) a general tonic action, particularly on the heart; (4) in- somnia is lessened, the patient usually falling asleep for two or three hours after each bath: and (5), most important of all, the mortality is, under this plan of treatment, reduced to a minimum. This rigid method is not, however, without serious drawbacks, and personally I sympathize with those who designate it as entirely barbarous. To transfer a patient from a warm bed to a tub at 70° Fahr., and to keep him there twenty minutes or longer in spite of his piteous entreaties, does seem harsh treatment ; and the subsequent shivering and blueness look distressing. A majority of our patients complain of it bitterly, and in private practice it is scarcely feasible. The convincing statistics of the Brand method, as it is called, have
36 SPECIFIC INFECTIOUS DISEASES.
long been before the profession ; but so far they have made but little im- pression in English-speaking communities. Cayley, of London, has been a warm advocate, but the rigid treatment is not often carried out in Eng- lish or American institutions. J. C. Wilson, of Philadelphia, and Baruch, of New York, have pleaded for its general introduction into our hospitals. Among the most striking figures are those recently published by Hare, from the Brisbane Hospital, Australia. Under the expectant plan, 1,838 cases — mortality, 14*8 per cent; incomplete bath treatment, 171 cases — mortality, 12-3 per cent ; strict bath treatment, 797 cases — mortality, 7 per cent.
The lukewarm bath, gradually cooled, is much more satisfactory in private practice. A bath at from 90° to 80°, and cooled down 10° or 12° by pouring cold water on the patient, will be found very satisfactory. When an insuperable objection to the bath exists, other hydr ©therapeutic measures may be taken. The body may be sponged with tepid or cold water every time the temperature rises above 102*5°. If done thoroughly, taking limb by limb first, and then the trunk, occupying from twenty minutes to half an hour in the process, the rectal temperature may be re- duced two or even three degrees. In private practice, when the bath is not available, the cold-pack is a good substitute. The patient is wrapped in a sheet wrung out of water at 60° or 65°, and cold water is sprinkled over him with an ordinary watering-pot. This is very efficacious in cases with pronounced nervous symptoms.
Medicinal antipyretics are rarely indicated. Quinine, which was em- ployed so much in former years, has a slight though positive action, but its use has very wisely been restricted. The same may be said of the nK)re recent antipyretics. Personally, I abandoned their employment some years ago. If given, antifebrin is the most suitable in doses of from four to eight grains. The action is prompt, and it is less depressing than antipyrin.
(d) Antiseptic Medication. — Very laudable endeavors have been made in many quarters to introduce methods of treatment directed toward the destruction of the typhoid bacilli, or the toxic agent which they produce, but so far without success. Good results have been claimed from the car- bolic and iodine treatment. Others advocate corrosive sublimate or calo- mel, )8-iuiphthol, and the salicin preparations. I can testify to the ineffi- ciency of the carbolic acid and iodine and of the /?-naphthol. With the mercurial preparations I have no experience. Fortunately for the patients, a majority of these medicines meet one of the two objects which Hip- pocrates says the physician should always have in view — they do no harm. Recently Burney Yeo has advocated the use of chlorine water and quinine as having a marked antiseptic action.
{(') Treatment of the Special Symptoms.— The abdominal pain and tympanites are best treated by fomentations or turpentine stupes. The latter, if well ap])lied, give great relief. Sir William Jenner, at his clinic,
'IN ri loll) FKVKIC. 87
used to liiy /^rnit Htn^sH on tiir ailviiiita^^'H of ii wcll-ap|ili<'il iiir|Hiiiiit(r Kliipc. lie (lin'clcMl it to Im' applird us fdllowK: A tlun?M'l mllrr wum plty-i'd lu'iiculli tlx* pnlinit, ami tlicri a liiMildi; layer of tliiii llaiincif wriiii^' out of hot \vat('r, wiili a fcvs ili-i»|)s of turpcntiiK* Hprinklcd upon it, wuh applied to the altdoiiini ainl cnvricd \sitli (lie cikIm of the I'olh'r.
'\'\n' nir/mrisni is u dillicnlt and distrt'HHing H)'rnj»tom to treat. When thi^ ^a.s is ill the lar^«' howel, a tiii)e may he juixsed or ii tnirpeiitiiie enernu tjiveii. l''or tyinpaiiites, willi a dry toii^nie, turpentine wan ext^-nwively used hv the (►liter huhlin physicians, and it wan introdueed into thirt <'ountrv hy the late(ieor;'e H. Wo<m1. I'nfortunatelv it is of very little Bcrviee in the soveror eases, ^vhieh too ofieii resist all treatment. 'I'he routine adminis- tration of liii|t('iitiiie in all eases of typhoid fever is a useless pructicc, for tlu» pei-petiKilion of which, in this ^^'eni'ration, H. C Wood is lar^'ely re- sponsihle. Slokcs protested airainst it in his day, and very truly said that its use should be limited to the later periods of the disease, when it may sometimes be used with advantage, as (iraves directs, in dnichm doses every six houis. Sometimes, if beef-juice and albumen-water are substi- tuted for milk, the distention lessens. Charcoal, bismuth, and )3-naphthol may be tried.
For the duirvluva^ if severe — that is, if there are more than three or four stools daily — a starch and oi)ium enema may be given ; or, by the mouth, a combination of bismuth, in large doses, with Dover's powder; or the acid diarrhiea mixture, acetate of lead (grs. 2), dilute acetic acid (in, 15-20), and acetate of morphia (gr. J-J). The stools should be ex- amined to see that the diarrhani is not aggravated by the presence of curds.
Constipation is present in many cases, and, thougli I liave never seen it do harm, yet it is well every third or fourth day to give an ordinary enema. I have never used the initial dose of calomel, which is so highly recommended by some practitioners. If a laxative is needed during the course of the disease, the Ilunyadi-janos or Friedriclishall water may be given.
Hannorrhage from the bowels is best treated with full doses of acetate of lead and opium. As absolute rest is essential, the greatest care should be taken in the use of the bed-pan. It is perhaps better to allow the patient to pass the motions into the draw sheet. Ice may be freely given, and the amount of food should be restricted for eight or ten hours. If there is a tendency to collapse, stimulants should be given and, if necessary, hypodermic injections of ether. The patient may be spared the usual styptic mixtures with which he is so often drenched. Turpentine is warmly recommended by certain authors.
Peritonitis. — In a majority of the cases this is an inevitably fatal complication. The only hope lies in restriction of the inflammation. Cases have unquestionably recovered. Morphia should be given sub- cutaneously. If the peritonitis be due to perforation, the question of
38 SPECIFIC INFPXTIOUS DISEASES.
laparotomy may be discussed. If perforation has occurred in the second or third week, it would be useless under the circumstances to attempt to stitch a slit in the intestine ; if, on the other hand, it occurs during con- valescence, it is only right to give the patient a chance, and the operation should be performed.
Progressive lieart-failure is one of the most frequent and perhaps one of the most serious of the conditions which the physician has to combat. As in other specific affections, this is in part due to the prolonged action of the fever and in part is a toxic effect. Alcohol is here our mainstay and can be given freely. Str3'chnine is most useful and may be given hypodermically in full doses. Whether digitalis is indicated in the failing heart of fevers is not yet settled. Personally, I am by no means convinced that it does good. Hypodermic injections of ether may be resorted to, and are sometimes helpful in tiding the patient over a critical period.
The nervous symptoms of typhoid fever are best treated by hydro- tlierapy. One special advantage of this plan is., that the restlessness is allayed, the delirium quieted, and sedatives are rarely needed. In the cases which set in early with severe headache, meningeal symptoms and high fever, the cold bath, or in private practice the cold-pack, should be employed. An ice-cap may be placed on the head, and if necessary mor- phia administered hypodermically. The practice, in such cases, of apply- ing blisters to the nape of the neck and to the extremities is, to paraphrase Huxham's words, an iinivliolesome severity^ which should long ago have been discarded by the profession. For the nocturnal restlessness, so dis- tressing in some cases, Dover's powder should be given. As a rule, if a hypnotic is indicated, it is best to give opium in some form. Pulmonary complications should, if severe, receive appropriate treatment.
In protracted cases ver}^ special care should be taken to guard against bed-sores. Absolute cleanliness and careful drying of the parts after an evacuation should be enjoined. The patient should be turned from side to side and propped with pillows, and the back can then be sponged with spirits. On the first appearance of a sore, the water or air bed should be used.
(/) The Management of Convalescence.— With the fall of the tem- perature to normal in the evening, and the disappearance of the other symptoms, the patient enters upon a stage which is often more difficult to manage than the attack itself. Convalescents from typhoid fever frequently cause greater anxiety than patients in the attack. The question of food has to be met at once, as the patient develops a ravenous appetite and clamors for a fuller diet. My custom has been not to allow solid food until the temperature has been normal for ten days. This is, I think, a safe rule, leaning perhaps to the side of extreme caution ; but after all with eggs, milk toast, milk puddings, and jellies, the patient can take a fairly varied diet. Many leading practitioners allow solid food to a patient so soon as he desires it. Peabody gives it on the disajipearance of
'IVninlD l-KVKIC. 39
(lie f(\(i-, lli(^ Into AiiHtiii l«'liii( wiiH aUd in favor of ^'ivin^ Holiil foo<l early; and Naimyn, at llir ShuHhiir;; MiMlical ('Iiiii<*, told iiii- timt tliiii was his practice. I had iiii early le.sson in this matter which I have never for«j;otteii. A \<nin;( la«l iti the Montreal (ient-ral lIoHpital, in wliow euMj 1 Was niiich interested, passed tlimn;;!! a tnlerahly nharp attack of typlioid fever. Two weeks afli-r the evmin;^ ternp<'nitiire had l»e«-n normal, and only a (lay oi" two hefore his inteiKh-d dis(dnirp', In? ut« HC'VtTai mutton chops, and within twenty-four hourH wan in u state of eollapHo frr)ni per- foration. A small transvers(» rent was fouiul at the l>ott<im of an ulcer which was in process of healin;.^. it is not easy to Kuy why Holid fcxxl, particularly uu-ats, sijould disa^n-ee, but in so many instu?iet'8 an indiHcrc- tion in diet is followed hy slii^ht fever, the so-culled fvhris carnisy tluit it is in the best interests of the patient to restrict the diet for some time after the fever has fallen. An indiscretion in diet may indeed precipitate a relapse. 'Plu» patient may he allowed to sit up fora short time about tlie end of the lirst week of convalescence, and the })eriod may be prolon;:ed with a <::radual return of strenj^th. He should move about slowly, and when tlu^ weather is favorable should be in the open air as much as possible. The patient should be guarded at this period against all un- necessary excitement. Emotional disturbance not infrecpiently is the cause of a recrudescence of the fever. Constipation is not uncommon in convalescence and is best treated by enemata. A protracted diarrha'u, which is usually due to ulceration in the colon, may retard recovery. In such cases the diet should be restricted to milk, and the patient should be confined to bed ; large doses of bismuth and astringent injections will prove useful.
The recrudescence of the fever does not require special treatment. The treatment of the relapse is essentially that of the original attack.
Among the dangers of convalescence may be mentioned tuberculosis, which is said by Murchison to be more common after this than after any other fever. There are facts in the literature favoring this view, but it is a rare sequence in this country.
II. TYPHUS FEVER.
Definition. — An acute infectious disease characterised by sudden onset, a maculated rash, marked nervous symptoms, and a termination, usually by crisis, about the end of the second week.
Etiology. — The disease has long been known under the names of hospital fever, spotted fever, jail fever, camp fever, and ship fever. In Germany it is known as exantliematic typhus, in contradistinction to abdominal typhus.
Typhus is now a rare disease. Sporadic cases occur from time to time in the large centres of population, but epidemics are infrequent. In this 4
40 SPECIFIC INFECTIOUS DISEASES.
country during the past ten years there have been very few outbreaks. In New York in 1881-'82 seven hundred and thirty-five cases were admitted into the Riverside Hospital ; in Philadelphia a small epidemic occurred in 1883 at the Philadelphia Hospital.
The special elements in the etiology of typhus are overcrowding and poverty. As Hirsch tersely puts it, " Die Geschichte des Typhus ist die des menschlichen Elends." Overcrowding, lack of cleanliness, intem- perance and bad food are predisposing causes. The disease still lurks in the worst quarters of London and Glasgow, and is seen occasionally in New York and Philadelphia. It is more common in Great Britain and Ireland than in other parts of Europe. Murchison held that the disease might originate spontaneously under favorable conditions. This opinion is suggested by the occurrence of local outbreaks under circumstances vv^hich render it difficult to explain its importation, but the analogy of other infectious diseases is directly against it. In 1877 there occurred a local outbreak of typhus at the House of Refuge, in Montreal, in which city the disease had not existed for many years. The overcrowding was so great in the basement-rooms of the refuge that at night there were not more than eighty-eight cubic feet of space to each person. Eleven per- sons were affected. It was not possible to trace the source of infection.
Typhus is one of the most highly contagious of febrile affections. In epidemics nurses and doctors in attendance upon the sick are almost inva- riably attacked. There is no disease which has so many victims in the profession. In the extensive epidemic in the early and middle part of this century many hundred physicians died in the discharge of their duty. Casual attendance upon cases in limited epidemics does not appear to be very risky, but when cases are aggregated together in wards the poison appears concentrated and the danger of infection is much enhanced. Bedding and clothes retain the poison for a long time.
The microbe of typhus fever has not yet been determined. Illava found in twenty of thirty-three bodies, and twice during life, a strepto-ba- cillus, the relation of which to the disease has not yet been determined.
Morbid Anatomy. — The anatomical changes are those which result from intense fever. The blood is dark and fluid, the muscles are of a deep red color and often show a granular degeneration, particularly in the heart; the liver is enlarged and soft and may have a dull clay-like lustre; the kidneys are swollen ; there is moderate enlargement of the spleen, and a general hyperplasia of the lymph-follicles. Peyer's glands are not ulcer- ated. Bronchial catarrh is usually, and hypostatic congestion of the lungs often, present. The skin shows the petechial rash.
Symptoms. — Incubation. — This is placed at about twelve days, but it may bo less. Tliere may be ill-defined feelings of discomfort. As a rule, however, the invasion is abrupt and marked by chills or a single rigor, followed by fever. The chills may recur during the first few days, and there is headache with pains in the back and legs. There is early pros-
rVIMIIS I'KVKK. 41
tnition, 1111)1 ilir |i;iliriit in ^linl Id lake In \\\h Ix'd at oiirv. TIm* ti'iiiju'ru* tiir(> is iii;;h nl lirst, iind iiiny ill tain itn niiixiiiiiiiii on the m'coiid or third (lav. Tlic |)iils(< is full, rapid, and not ho frr«|ncntly di<Toti(' um in tv|>)ioi(l. 'V\iv ton^iu* is fiirii'd and wl»it»>, and tlirn* is an early trnd»;ncy to drv- nosH. Tlu' face is HiisImmI, the ('Vcm an; con^rMti'd, ilir cxjircHMioii in dull iiiid Hlupiii. NniiiiiiiiL^ may in* a distri'HHin^ Hyinptoiii. In Hoverc; cumch nuMilal syiiiploms aic present, frnm the outset, cithrr a tnild fi'hrile delir- iiiin or an cxeitc)!, active, alnmst rnaniaeal condition. lironchiiil catarrh is eoininoii.
Sta^O 1)1' Kruptioil.— l-'roni the third to thu lifth day the eruption ap- pears tirst upnii the ahdonu-n and upj>er part of tin? chest, and then iij)()n the exti-emiiies and face; developin<r so rapidly that in two or throo (lays it is all nut. Tliei-c are two elements in the ei-iij)ti(>n : a nuh- cuticular m()ttlini,% "a line, invi^ndar, dusky red niottlin|(, as if helow the surface of the skin some little distance, and seen throu^^h u semi- ojuique medium" (Buiduman); and distinct })a])ular rose-s])ot8 which change to petechiie. In some instances the petechial rash comes out with the rose-spots. Collie describes the rash as consisting of three parts — rose-colored spots wliich disappear on })ressure, dark-red spots which are modified by pressure, and petechiiL' upon which ])ressure produces no elTect. In children the rash at lirst may ])resent a striking resem- blance to measles, and give as a wliole a curiously mottled apj)earance to the skin. The term mulberry rash is sometimes ai)plied to it. In mild cases the eruption is slight, but even then is largely petechial in character. As the rash is largely hj^morrhagic, it is permanent and does not disappear after deatli. Usually the skin is dry, so that sudaminal vesicles are not common. It is stated by some authors that a distinctive odor is present. During the second week the general symptoms are usually much aggra- vated. The prostration becomes more marked, the delirium more intense, and the fever rises. The patient lies on his back with a dull expressionless face, flushed cheeks, injected conjunctivae, and contracted pupils. The pulse increases in frequency and is feebler, the face is dusky, and the condition becomes more serious. Retention of urine is common. Coma- vigil is frequent, a condition in which the patient lies with open eyes, but quite unconscious. Subsultus tendinum and picking at the bedclothes are frequently seen. The tongue is dry, brown, and cracked, and there are sordes on the teeth. Respiration is accelerated, the heart's action becomes more and more enfeebled, and death takes place from exhaustion. In favorable cases, about the end of the second w^ek occurs the crisis, in which, often after a deep sleep, the patient awakes feeling much better and with a clear mind. The temperature falls, and although the prostra- tion may be extreme, convalescence is rapid and relapse very rare. This abrupt termination by crisis is in striking contrast to the mode of termi- nation in typhoid fever.
Fever. — The temperature rises steadily durins: the firet four or five
42 SPECIFIC INFECTIOUS DISEASES.
days, and the morning remissions are not marked. The maximum tem- perature is usually reached by the fifth day, when the temperature may reach 105°, 10G°, or 107°. In mild cases it seldom rises above 103°. After reaching its maximum the temperature generally continues with slight morning remissions until the twelfth or fourteenth day, when the crisis occurs, during which the temperature may fall below normal with- in twelve or twenty-four hours. Preceding a fatal termination, there is usually a rapid rise in the fever to 108° or even 109°.
The heart may early show signs of weakness. The first sound becomes feeble and almost inaudible, and a systolic murmur at the apex is not in- frequent. Hypostatic congestion of the lungs occurs in all severe cases.
The brain symptoms are usually more pronounced than in typhoid, and the delirium is more constant.
The urine in typhus shows the usual febrile increase of urea and uric acid. The chlorides diminish or disappear. Albumen is present in a large proportion of the cases, but nephritis seldom occurs.
Variations in the course of the disease are naturally common. There are malignant cases which rapidly prove fatal within two or three days ; the so-called typhus siderans. On the other hand, during epidemics there are extremely mild cases in which the fever is slight, the delirium absent, and convalescence is established by the tenth day.
Complications and Sequelae. — Broncho-pneumonia is perhaps the most common complication. It may pass on to gangrene. In certain epidemics gangrene of the toes, the hands, or the nose, and in children noma or cancrum oris, have occurred. Meningitis is rare. Paralyses, which are probably due to the post-febrile neuritis, are not very uncommon. Septic processes, such as parotitis and abscesses in the subcutaneous tissues and in the joints, are occasionally met. Nephritis is rare. Haematemesis may occur.
Prognosis. — The mortality ranges in different epidemics from 12 to 20 per cent. It is very slight in the young. Children, who are quite as frequently attacked as adults, rarely die. After middle age the mortality is high, in some epidemics 50 per cent. Death usually occurs toward the close of the second week and is due to the toxaemia. In the third week it is more commonly due to pneumonia.
Diagnosis. — During an epidemic there is rarely any doubt, for tlie disease presents distinctive general characters. Isolated cases may be very difficult to distinguish from typhoid fever. While in typical instances the eruption in the two affections is very different, yet taken alone it may be deceptive, since in typhoid fever a roseolous rash may be abundant and there is occasionally a subcuticular mottling and even petechiae. The difference in the onset, particularly in the temperature, is marked ; but cases in which it is important to make an accurate diagnosis are not usu- ally seen until the fourth or fifth day. The suddenness of the onset, the greater frequency of the chill, and the early prostration are the distinctive
TV I'll IS I'KVKK. 43
fcHliiics in tvplniM. Tin' hriiiii HyiiijitnmH too iiro cfirlittr. It Im CHHy to put down on paper cliilMinilc (iilTrrmtial iliHtinctioriM, which an; prur- tii-ally UHch'SH at (lie hcdsich', parliculurly wlini i\\ti «lim'a>M? in not pn*- vaiiin;^ as an cpidrtnic. In spitradic casrM th«> dia^'iioMiH iri »uirn<rtirn(*M (>\l I'cnirlv dilliciilt. I hav(^ M-m Miin-hison liini.^rlf in <h)iiht, and iii(;ri; than oiicf I li:i\r known a dia^^niosis to he d«'f«'rn*d until tho Mrr/i'o rada- iwris. SuvcMV crrchro-spinal fever may closely ninndate typhuH at the out- set, hut the dia«^n()sis is usually clear within a few days. Mali^'iiant vari- ola also has certain features in c(»ininon with sevenj typhus, hut tin? greater extent (»f the ha'inorrha<^es and the hleeding from the nuirouH inonihranes make the dia|::nosis clear within a short time. 'J'he rasli at tirst resemhles that of measles, hut in tins disease; tlu? eruption is hrighter rod in color, often crescent ic or irregular in arrangement, and a])pears lirst in the face.
'I'hc frecjuency with which other diseases are mistaken for typhus is shown hy the fact that during and following the e})idemic of 1881 in New York one hundred and eiglit cases were wrongly diagnosed — one eighth of t]u> entire numher — aiul sent to tlie Kiverside Hospital (K. W. ('lia])in).
Treatment. — Practically tlie general management of the disease is like tliat of typlu)id fever. Hydrotherapy should he thoroughly and sys- tematically em})loyed. Judging from the good results which we have ohtained by this method in typhoid cases with nervous sym})toms much may be expected from it. Certain authorities have spoken against it, but it should be given a more extended trial. Medicinal antipyretics are less suitable than in typhoid, as the tendency to heart-weakness is often more pronounced. As a rule the patients require from the outset a supporting treatment; water should be freely given, and alcohol in suitable doses according to the condition of the pulse.
The bowels may be kept open by mild aperients. The so-called spe- cific medication, by sulphocarbolates, the sulphides, carbolic acid, etc., is not commended by those who have had the largest experience. The spe- cial nervous symptoms and the pulmonary symptoms should be dealt with as in typhoid fever. In epidemics, when the conditions of the climate are suitable, the cases are best treated in tents in the open air.
HI. RELAPSING FEVER {Fehris recurrens).
Definition. — A specific infectious disease caused by the spirochjste (spirillum) of Obermeier, characterised by definite febrile paroxysms which usually last six days and are followed by a remission of about the same length of time, then by a second paroxysm, which may be repeated three or even four times, whence the name relapsing fever.
Etiology. — This disease, which has also the names "famine fever" and " seven-day fever," has been known since the early part of the
44r SPECIFIC INFECTIOUS DISEASES.
eighteenth century, and has from time to time extensively prevailed in Europe and in Ireland. It is common in India, where the conditions for its development seem always to be present. The subject has been spe- cially studied by Vandyke Carter, of Bombay. It was first seen in this country in 1844, when cases were admitted to the Philadelphia Hospital, which are described by Meredith Clymer in his work on fevers. Flint saw cases in 1850-'51. In 1869 it prevailed extensively in epidemic form in New York and Philadelphia; since then it has not appeared.
The special conditions under which it develops are very similar to those of tyj^hus fever. Overcrowding and deficient food are the condi- tions which seem to promote the rapid spread of the virus. Neither age, sex, nor season seems to have any special influence. It is a contagious disease and may be communicated from person to person, but is not so contagious as typhus. Murchison thinks it may be transported by fomites. One attack does not confer immunity from subsequent attacks. In 18T3 Obermeier described an organism in the blood which is now recognised as the specific agent. This spirillum, or more correctly spirocha^te, is from three to six times the length of the diameter of a red blood-cor- puscle, and forms a narrow spiral filament which is readily seen moving among the red corpuscles during a paroxysm. They are present in the blood only during the fever. Shortly before the crisis and in the inter- vals they are not found, though small glistening bodies, which are stated to be their spores, appear in the blood. The disease has been produced in human beings by inoculation of the blood during the paroxysm. It has also been produced in monkeys. Nothing is yet known with refer- ence to the life history of the spirochgete.
Morbid Anatomy. — There are no characteristic anatomical appear- ances in relapsing fever. If death takes place during the paroxysm the spleen is large and soft, and the liver, kidneys and heart show cloudy swelling. There may be infarcts in the kidneys and spleen. The bone marrow has been found in a condition of hyperplasia. Ecchymoses are not uncommon.
Symptoms. — Incuhation appears to be short, and in some instances the attack develops promptly after exposure ; more frequently, however, from five to seven days elapse.
The invasion is abrupt, with chill, fever, and intense pain in the back and limbs. In young persons there may be nausea, vomiting, and convul- sions. The temperature rises rapidly and may reach 104° on the evening of the first day. Sweats are common. The pulse is rapid, ranging from 110 to 130. There may be delirium if the fever is high. Swelling of the spleen can be detected early. Jaundice is common in some epidemics. The gastric symptoms may be severe. There are seldom intestinal symp- toms. Cough may be present. Occasionally herpes is noted, and there may be miliary vesicles and petechijE. During the paroxysm the blood invariably shows the spirochoete. After persisting with severity or even
Ui:L\rsiN(i FKVKU.
45
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Chart VT. — Uolnpsing fever (Murchison).
Tho crisis may occur as early as tlie tliinl day, or it may be tlehiyed to the tenth ; it usually comes, however, about the end of the first week. In delicate and elderly persons there may be collapse. Tlie convalescence is rapid, and in a few days the patient is up and about. Then in a week, usually on tlie fourteenth day, he again has a rigor, or a series of chills ; the fever returns and the attuck is repeated. A second crisis occurs from the twentieth to the twenty-third day, and again the patient recovers rapidly. As a rule the relapse is shorter than the original attack. A second and a third may occur, and there are instances on record of even a fourth and a fifth. In epidemics there are cases terminating by crisis on the seventh or eighth day without the occurrence of relapse. In pro- tracted cases the convalescence is very tedious, as the patient is much exhausted.
Relapsing fever is not a very fatal disease. Murchison states that the mortality is about 4 per cent. In the enfeebled and old, death may occur at the height of the original attack.
Complications are not frequent. In some epidemics nephritis and hn?maturia have occurred. Pneumonia appears to be frequent and may interrupt tlie typical course of the disease. The acute enlargement of the spleen may end in rupture, and the haemorrhage from the stomach which has been met with occasionally is probably associated with this enlarge- ment. Post-febrile paralyses may occur. Ophthalmia has followed cer- tain epidemics, and may prove a very tedious and serious complication. Jaundice has already been mentioned. In pregnant women abortion usu- ally takes place.
46 SPECIFIC INFECTIOUS DISEASES.
Diagnosis. — The onset and general symptoms may not at first be distinctive. At the beginning of an epidemic the cases are usually regarded as anomalous typhoid ; but once the typical course is followed in a case tlie diagnosis is clear. The blood examination, which should be made in all doubtful cases of fever, affords a definite criterion by which the diagnosis can readily be made.
Treatment. — The paroxysm can neither be cut short nor its recur- rence prevented It might be thought that quinine, with its powerful ac- tion, would certainly meet the indications, but it does not seem to have the slightest influence. The disease must be treated like any other continued fever by careful nursing, a regular diet, and ordinary hygienic measures. Of special symptoms, pains in the back and in the limbs and joints demand opium. In enfeebled persons the collapse at the crisis may be serious, and stimulants with ammonia and digitalis should be given freely.
IV. SMALL-POX (Variola).
Definition. — An acute infectious disease characterised by an erup- tion which passes through the stages of papule, vesicle, pustule and crust. The mucous membranes in contact with the air may also be affected. Severe cases may be complicated with cutaneous and visceral haemorrhages.
Etiology. — It has not yet been determined in what country small- pox originated. The disease is said to have existed in China many centu- ries before Christ. The j!?e5/a magna described by Galen (and of which Marcus Aurelius died) is believed to be small-pox. In the sixth century it prevailed, and subsequently, at the time of the Crusades, became wide- spread. It was brought to America by the Spaniards early in the sixteenth century. The first accurate account was given by Rliazes, an Arabian phy- sician who lived in the ninth century, and whose admirable description is available in Greenhill's translation for the Sydenham Society. In the seventeenth century a thorough study of the disease was made by the illus- trious Sydenham, who still remains one of the most trustworthy authori- ties on the subject.
Special events in the history of the disease are the introduction of inoculation into Europe, by Lady Mary Wortley Montagu, in 1718, and the discovery of vaccination by Jenner, in 1798.
Small-pox is one of the most virulent of contagious diseases, and per- sons exposed, if unprotected by vaccination, are almost invariably attacked. There are instances on record of persons insusceptible to the disease. It is said that Diemerbrock, a celebrated Utrecht professor in the seventeenth century, was not only himself exempt, but likewise many members of his family. One of the nurses in the small-pox department of the Montreal (Jeneral Hospital stated that she had never been successfully vaccinated.
SMAI.L-I'OX. 17
iiiid H\\i<i ccrhiiMly \uu\ no nmrk. Siidi lUMtancrH, liowrvrr, of niitiirul im- rimnity arc vciv nin*.
Afft'. Sin:ill-|M)\ in cntniiioii at all u^^^m, but in purticuliirly fulul to y()mi«( cliildrrti ; thus, in Ihc Mmitrcul (•piilriiii(! of 1 HH/), Hl{ (M)r cent of tlu' (leal lis well' (if ('liil(lr«ii iimlrr tni y<MirH of a^c. TImj fulit/t in niero mav 1)0 attackcil, Imt mily if tin- mntlin- luTsolf in the Hiibjoct of the? (iin- iMisi>. Tho cliild may ho honi with the rash out or with tho Hcarx, Mon- coinniouly the fo'lus is not alTcrtcil, and children horn in a Hrnall-f)ox hos- pital, if vaccinated iiinnediat«'ly, nuiy escape the disease; usually, howe\er, tiloy die i-aily.
iScX. — Males and females are e(|iially alTected.
/utrr. — Amoti^ abori^dnal races Hmall-])()x is terribly fatal. Wlien tho disease was lirst introduced into America the Mtixieans died by thousands, and the North American Indians liavc also been frequjmtly decimated by this plague. It is stated that the negro is especially sus- ceptible.
77/^ Co)if(((/iinn develops in the system ()f tlie small-j)ox patient and is reproduced in the pustules. It exists in the secretions and excretions, and in the exhalations from the lungs and the skin. 'J'he dried scales con- stitute by far the most important element, and as a dust-like powder are distributed everywhere in the room during convalescence, becoming at- tached to clothing and various articles of furniture. The disease is proba- bly contagious from a very early stage, though I think it hiis not yet been determined whether the contagion is active before the eruption develops. The poison is of unnsual tenacity and clings to infected localities. It is convevod bv persons who have been in contact with the sick and by fomites. During epidemics it is no doubt widely spread in street-cars and public con- veyances. It must not be forgotten that an unprotected person may con- tract a very virulent form of the disease from the mild varioloid.
The disease smoulders here and there in different localities, and when conditions are favorable becomes epidemic. Perhaps the most remarkable instance in modern times of the rapid extension of the disease occurred in Montreal in 1885. Small-pox had been prevalent in that city between 1870 and 1875, when it died out, in part owing to the exhaustion of suit- able material and in part owing to the introduction of animal vaccination. The health reports show that the city was free from the disease until 1885. During these years vaccination, to which many of the French Canadians are opposed, was much neglected, so that a large unprotected population grew up in the city. On February *'38th a Pullman-car conductor, who had travelled from Chicago, where the disease had been slightly prevalent, was admitted into the Hotel-Dieu, the civic small-pox hospital being at the time closed. Isolation was not carried out, and on the 1st of April a serv- ant in the hospital died of small-pox. Following her decease, with a neg- ligence absolutely criminal, the authorities of the hospital dismissed all patients presenting no symptoms of contagion, who could go home. The
48 SPECIFIC INFECTIOUS DISEASES.
disease spread like fire in dry grass, and within nine months there died in the city, of small-pox, 3,164 persons.
The nature of the contagion of small-pox is still unknown. Weigert and others have described micro-organisms in the pock, but they are the ordinary pus cocci, and the part which they play in the affection is by no means certain. Still less definite are the observations on the occur- rence of sporozoa in the pocks. It is not a little remarkable that in a disease which is rightly regarded as the type of all infectious maladies, the specific virus still remains unknown.
Morbid Anatomy. — A section of a papule as it is passing into the vesicular stage shows in the rete mucosum^ close to the true skin, an area in which the cells are smooth, granular, and do not take the staining fluid. This represents a focus of coagulation-necrosis due, according to Weigert, to the presence of micrococci. Around this area there is active inflamma- tory reaction, and in the vesicular stage the rete mucosum presents re- ticuli, or spaces, which contain serum, leucocytes and fibrin filaments. The central depression or umbilication corresponds to the area of primary necrosis. In the stage of maturation the reticular spaces become filled with leucocytes and many of the cells of the rete mucosum become vesicu- lar. The papillae of the true skin below the pustule are swollen and infil- trated with embryonic cells to a variable degree. If the suppuration ex- tends into this layer, scarring inevitably results; but if it is confined to the upper layer, it does not necessarily follow. In the haemorrhagic cases, red corpuscles pass out in large numbers from the vessels and occupy the vesicular spaces. They infiltrate also the deeper layers of the epidermis in the skin adjacent to the papules. Frequently a hair- follicle passes through the centre of a papule.
In the mouth the pustules may be seen upon the tongue and the buccal mucosa, and on the palate. The eruption may be abundant also in the pharynx and the upper part of the oesophagus. In exceptionally rare cases the eruption extends down the oesophagus and even into the stom- ach. Swelling of the Peyer's follicles is not uncommon ; the pustules have been seen in the rectum.
In the larynx the eruption may be associated with a fibrinous exudate and sometimes with oedema. Occasionally the inflammation passes deeply and involves the cartilages. In the trachea and bronchi there may be ulcerative erosions, but true pocks, such as are seen on the skin, do not occur. There are no special lesions of the lungs, but congestion and bron- cho-pneumonia are very common. The liver is sometimes fatty. A diffuse hepatitis, associated with intense congestion of the vessels and migration of the leucocytes, has been described ; Weigert has noted small areas of necrosis.
There is nothing special in the condition of the blood, and even in the most malignant cases there are no microscopic alterations. In the blood- drop, however, it will be seen that the corpuscles, instead of forming
SMALIi-PoX. 49
n)ul«MUix, a^^'n-j^'iih' t(»^rtlur in irrr;^Milar cliirnim. 'I'lir lirurt orru^ioimlly shows iiivocjudiul clmn^^i'H, |»an'ruliMiiiiioiiM iiikI futty ; i'ii«l<><iir«l»liM aii<l |M'ri<'iir(lilis nrc luicoiiimoii. I-'ii'IkIi wrilris lm\«' (IrnrrilH'd an riHliirliTiliH of till' coroimry vt'sscls in coniUM'tion with hmijiII-jiox. '!'hi5 M))leen m murk- 4'(lly t'lihiri^ctl. A|i;nl fi<»m the cloiuly HWciliu^ and art'iiH of <'oa>(uhil ion- net rosiH, Irsions of ihc ki(lni<y.s aro not coininon. N«'phritiH n my occur tluiin«^ convah'sci'iico. (liiMri has called attention to the frc'ineney of orchitis in this disease, 'riicre are scattered areas of necrosis with cell in- liltration.
In tlic hainorrhairiir form extravasations are fonnd on the HerotiH and mucous surfaces, in the pnrciu'liyma of orpins, in tlie connective titwucH, and about the ncrvc-shcatlis. In one instance 1 found the entire retro- peritoneal tissue inliltrated with a lar;^'e coa;;ulum, and there were also ex- tensivi» extravasations in the course of the thoracic aorta. IIa'nn)rrhage.s in the hone-nuirrow have also been des<'ril)ed by (tolgi. There may be li;vmorrha<^es into the muscles. ]*ontick has described the 8j)leen as very tirm and hard in h;cnu>rrha<j:ic small-pox, and >nch was the case in seven instances whicli I examined. The liver has been described as fatty in these rapid cases, but in live of my seven cases it was of normal size, dense, and tirm. In two it was large and fatty ; but one man had necro- sis of the tibia, and the other was a drunkard. The ecchymoses are scat- tered over the meninges of the brain and cord, and in one case there vrixs a clot in the riirht ventricle. In five of the cases there were areas of haem- orrhagio infarction of the lung. In four instances the pelves of the kidney were blocked with dark clots, which extended into the calices and down the •ureters. In one instance the coats of the bladder were uni- forndy ha^norrhagic and not a trace of normal tissue could be seen. The extravasations in the mucous membrane of the stomach and intestines were numerous and large. Peyer's glands were swollen and prominent in four instances.
Symptoms. — Three forms of small-pox are described :
1. Wiriola vera ; (a) Discrete, (b) Confluent.
2. Variola Invmorrhagica ; {a) Purpura variolosa or black small-pox ; {!)) lIa?morrhagic pustular form, variola hiemorrhagiea pustulosa.
3. Varioloid^ or small-pox modified by vaccination.
1. Variola Vera. — The affection may be conveniently described under various stages : {a) Incuhation. This is variously estimated at from seven to twelve days, or even longer. I have seen it develop on the eighth day after exposure to infection, and there are well-authenticated instances in which the stage of incubation has been prolonged to twenty days. It is unusual for patients to complain of any symptoms in this stage.
{b) Invasion. — In adults a chill and in children a convulsion are com- mon initial symptoms. There may be repeated chills within the first twenty-four hours. Intense frontal headache, severe lumbar pains and vomiting are very constant features. The pains in the back and in the
60
SPECIFIC INFECTIOUS DISEASES.
limbs are more severe in the initial stage of this than of any other erup- tive fever, and their combination with headache and vomiting is so sug-
9 10 11 12 13 14 15 16 i:
18
40 0°
39 O*
38-0°
3ro«
IBHHHBIIIIIIBIBHIHUB
wamm
IIIHIIIiH
Initial Fever Eruption.
Suppurative Fever. Chart VII. — Tnie small-pox.
gestive that in epidemics precautionary measures may often be taken several days before the eruption decides positively the nature of the dis- ease. The temperature rises quickly, and may on the first day be 103° or 104°. The pulse is rapid and full, not often dicrotic. In severe cases there may be marked delirium, particularly if the fever is high. The patient is restless and distressed, the face is flushed, and the eyes are bright and clear. The skin is usually dry, though occasionally there are profuse sweats. One cannot judge from these initial symptoms whether a case is likely to be discrete or confluent, as the most intense backache and fever may precede a very mild attack. Convulsions are not uncommon in children.
In this stage of invasion the so-called initial rashes may occur, of which two forms can be distinguished — the diffuse, scarlatinal, and the macular or measly form ; either of which may be associated with petechiae and occupy a variable extent of surface. In some instances they are gen- eral, but as a rule they are limited, as pointed out by Simon, either to the lower abdominal areas, to the inner surfaces of the thighs, and to the lat- eral thoracic region or to the axillae. Occasionally they are found over the extensor surfaces, particularly in the neighborhood of the knees and elbows. These rashes, usually purpuric, are often associated with an erythematous or erysipelatous blush. The scarlatinal rash may come out as early as the second day and be as diffuse and vivid as in a true scarla- tina. The measly rash may also be diffuse and identical in character with that of measles. Urticaria is only occasionally seen. It was present once in my Montreal cases. Apparently these initial rashes are more abundant in some epidemics than in others; thus they were certainly more numerous in the Montreal epidemics between 1870 and 1875 than they were in the more extensive epidemic in 1885. They occur in from 10 to 16 per cent
SMALL pox. ft I
of ciiHCH. Ill the «Mim'H iifHlrr Miy run- in tlic Mfimll-pox dijuirt iiniil at tlio Moiilrnil (inicnil il(>s)iilal lln' prn'mla^'r wjw l.'i.* Am will !>«; miiIihc- ((iiciilly riM'Mliniifd llir.m^ iiiiliiil niHlirM lmv«' <M»nHi<li'nil)l<' jliii^'rioHtiir vuliu*.
(r) /''rn/i/iii/i. (I) In I lie discnh' /'or///, iiHiially «»ii tlio fourth liuy, Kinall hmI sjiols appear on tlir forrjirad, part icniarly at tlu? jiin(;tioii with tlic hair, and mi the wriHtn. \N illiin llic lirHt twi'iity-foiir hourH from thrir appearance tliey oeeur on (dlier parts of tin? face ami on tin* I'Xtn'initirH, and a f(»vv are seen on the trunk. As the rash eorn«'H out the ternperatwrc falls, the ^'(Mieral syniptonis snl)side, and the j)atient feeln eornfortahle. On tile liflh or sixth day the papules ehan;^(» into vosicIeH with (•lour HurnmitH. Kach one is elevated, eircidar, and presents ii little deprcHsion in the cen- tre, th(» so-called uinhilieation. .Ahout the ei^dith day the; veHJclcs change into pustuhvs, the und)ilieation disappears, tlu^ ilat top assunieH a ^lohular form and hiu'oines grayish yellow in color, owin^ to th(^ contained pus. There is an areola of injection ai)out the pustides and the skin between them is swollen. 'This maturation first takes j)lace on the face, and follows the order of tlu» appearance of the eruption, 'i'ho temperature now rises — secondary fever — and the <j^eneral symptoms return. The swelling about tlie pustules is attended with a ^ood deal of tension and })ain in the face ; the eyelids become swollen and closed. In the discrete form the temj)er- ature of maturation does not usually renuiin high for more than twenty- four or twenty-six hours, so that on the tenth or eleventh day the fever disappears and the stage of convalescence begins. The pustules rapidly dry, first on the face and then on the other parts, and by the fourteenth or fifteenth day desquamation may be far advanced on the face. There may be in addition vesicles in the mouth, pharynx, and larynx, causing sore- ness and swelling in these parts, with loss of voice. Whether pitting takes place depends a good deal npon the severity of the disease. In a majority of cases Sydenham's statement holds good, that " it is very rarely the case that the distinct small-pox leaves its mark."
(2) Tlie Confluent Form. — With the same initial symptoms, though usually of greater severity, the rash appears on the fourth, or, according to Sydenham, on the third day. The more the eruption shows itself before the fourth day, the more sure it is to become confluent (Sydenham). The papules at first may be isolated and it is only later in the stage of matu- ration that the eruption is confluent. But in severer cases the skin is swollen and hypera?mic and the papules are very close together. On the feet and hands, too, the papules are thickly set ; more scattered on the limbs ; and quite discrete on the trunk. With the appearance of the eruption the symptoms subside and the fever remits, but not to the same extent as in the discrete form. Occasionally the temperature falls to normal and the patient may be very comfortable. Then, usually on the eighth day, the temperature again rises, the vesicles begin to change to
*The Initial Rashes of Small-pox. Canada Medical and Surgical Journal, 1875.
52 SPECIFIC INFECTIOUS DISEASES.
pustules, the hyperaemia about them becomes intense, the swelling of the face and hands increases, and by the tenth day the pustules have fully maturated, many of them have coalesced and the entire skin of the head and extremities is a superficial abscess. The fever rises to 103° or 104°, the pulse is from 110 to 120, and there is often delirium. As pointed out by Sydenham, salivation in adults and diarrhoea in children are common symptoms of this stage. There is usually much thirst. The eruption may also be present in the mouth, and usually the pharynx and larynx are involved and the voice is husky. Great swelling of the cervical lymphatic glands occurs. At this stage the patient presents a terrible picture, un- equalled in any other disease ; one which fully justifies the horror and fright with which small-pox is associated in the public mind. Even when the rash is confluent on the face, hands, and feet, the pustules remain discrete on the trunk. The danger, as pointed out by Sydenham, is in proportion to the number upon the face. " If upon the face they are as thick as sand it is no advantage to have them few and far between on the rest of the body." In fatal cases, by the tenth or eleventh day the pulse gets feebler and more rapid, the delirium is marked, there is subsultus, sometimes diarrhoea, and with these symptoms the patient dies. In other instances between the eighth and eleventh day haemorrhagic symptoms develop. When recovery takes place, the patient enters on the eleven tli or twelfth day the period of —
(d) Desiccatio7i. — The pustules break and the pus exudes and forms crusts. Throughout the third week the desiccation proceeds and in cases of moderate severity the secondary fever subsides ; but in others it may persist until the fourth week. The crusts in confluent small-pox adhere for a long time and the process of scarring may take three or four weeks. The crusts on the face fall oif, but the tough epidermis of the hands and feet may be shed entire. We had in the small-pox department of the Mon- treal General Hospital several moulds in epithelium of the hands and feet.
2. Hsemorrhagic small-pox occurs in two forms. In one the special symptoms appear early and death follows in from two to six days. This is the so-called petechial or black small-pox — purpura variolosa. In the other form the case progresses as one of ordinary variola, and it is not until the vesicular or pustular stage that hffimorrhage takes place into the pocks or from the mucous membranes. This is sometimes called variola hcBmorrhagica pustulosa.
Haemorrhagic small-pox is more common in some epidemics than in others. It is less frequent in children than in adults. Of twenty-seven cases admitted to the small-pox department of the Montreal General Hos- pital there were three under ten years, four between fifteen and twenty, nine between twenty and twenty-five, seven between twenty-five and thirty- five, three between thirty-five and forty-five, and one above fifty. Young and vigorous persons seem more liable to this form. Several of my cases were above the average in muscular development. Men are more fre-
8M.\IJ- I'<'\
fi8
(jiictitiv alTccicd tliaii woiiirn ; thiiH in my lint there were twi-tity-oiio iiiuli'M niul only nix fi'iimlrs. 'V\w iiilliimcr of varciniitioii Im hIiowii in the fiict tliiit of tlie ciiKi'M foiirlcMiM wen? imvucciriutiMl, wliil<* u*>\ «.iii. «,f i)ii. thir((M'ii who had scar.M had hreu revacciimtcd.
The cliiiiral rcaliircs of Hit- fnims of ha'iiiorrlja|(ic Hiiuill-pox are Hoine- whal dilVf iciii.
In /inr/inr(( rariolosd llic ilhirss startH with i\w UHiuil Hyiiij)toniH, hut with more intense constitutional disturhance. On th(^ evening of tlic second or on the third day tliere is a dilTuse hy|»era*inic rash, j)urti(;ulurly in tlio groins, with small puiictiforni lueinorrha^oH. The rush cxtendn, becomes more distinctly h:cmorrlia;^M(', ami \\\r spotfl increaHe in Hize. Ecehymoses appear on the conjunctiviv, and as early aH the third day thcn^ may he Incmorrha^es from the mucous memhraiies. Death may take place before the rash appears. 'Phis is truly a terribh? affection and well developed cases present a frii:;htful appearance. 'Die skin may have a uniforndy })urplish hue and the unfortunate victim may even look plum- colored. The face is swollen and lar^e conjunctival hiemorrliages with the deeply sunken cornea? give a ghastly appearance to the features.
The mind may renuiin clear to tlie end. Death occurs from the tliird to the sixth day ; thus in thirteen of my cases deatli took place on or be- fore this date. The earliest death was on the third day and there were no traces of papules. There may be no mucous ha?morrhages ; thus in one case of a most virulent character death occurred without bleeding early on the fourth day. ILvmaturia is perhaps most common, next hae- matemesis, and mehvna was noticed in a third of the cases. Metrorrhagia was noticed in one only of the six females on my list. ILTmoptysis oc- curred in five cases. The pulse in this form of small-pox is ra])id and often hard and small. The respira- tions are greatly increased in fre- quency and out of all proportion to the intensity of the fever. In the case of a negro, whose respirations the morning after admission were 32 and temperature 101°, after ex- amining the lungs and finding noth- ing to account for the increased breathing, my suspicions were aroused, and even on the dark skin I was able on careful inspection to detect haemorrhages in and about the papules.
The annexed chart is from a case of malignant small-pox which
came on abruptly on Thursday, October 24, 18T4. and which terminated early on the fourth day. It shows the moderate temperature range.
Temp. ^• 104
IS
w
103
108
101
100
99 Day of Disease.
Chart VIII. — HiTinorrhagic small-pox.
54 SPECIFIC INFECTIOUS DISEASES.
In variola pustiilosa hmmorrhagica the disease progresses as an ordi- nary case of severe variola, and the haemorrhages do not develop until the vesicular or pustular stage. The earlier the haemorrhage the greater is the danger. There are undoubtedly instances of recovery when the bleed- ing has taken place at the stage of maturation. Bleeding from the mu- cous membranes is also common in this form, and the great majority of the cases prove fatal, usually on the seventh, eighth, or ninth day.
There is a form of haemorrhagic small-pox in which bleeding takes place into the pocks in the vesicular stage and is followed by a rapid abortion of the rash and a speedy recovery. Six instances of this kind came under my observation,* In four the haemorrhage took place on the fourth day ; in two on the fifth day, just at the time of transition of the papule into the vesicle. Extravasation takes place chiefly into the pocks on the lower extremities and trunk, in only two instances occurring in those of the arms. The eruption in all proved abortive, and no patients under my care with an equal extent of eruption made such rapid recover- ies. With these cases are to be grouped those in which the haemorrhages occur in the pustules of the legs in patients who have in their delirium got out of bed and wandered about. This modified form of haemorrhagic small-pox is also described by Scheby-Buck.
3. Varioloid. — This term is applied to the modified form of small-pox which affects persons who have been vaccinated. It may set in with abruptness and severity, the temperature reaching 103°. More common- ly it is in every respect milder in its initial symptoms, though the head- ache and backache may be very distressing. The papules appear on the evening of the third or on the fourth day. They are few in number and may be confined to the face and hands. The fever drops at once and the patient feels perfectly comfortable. The vesiculation and maturation of the pocks take place rapidly and there is no secondary fever. There is rarely any scarring. As a rule, when small-pox attacks a person who has been vaccinated within five or six years the disease is mild, but there are instances in which it is very severe, and it may even prove fatal.
There are several forms of rash ; thus in what has been known as horn- pox, crystalline pox, and wart-pox the papules come out in numbers on the third or fourth day, and by the fifth or sixth day have dried to a hard, horny consistence.
Writers describe a variola sine er2(ptio7iey which is met with during epidemics in young persons who have been well vaccinated, and who pre- sent simply the initial symptoms of fever, headache and backache. In a somewhat extensive experience in Montreal I do not remember to have met with an instance of this kind or to have heard of one.
We do not now see the modified form of small-pox, resulting from inoculation, in which by the seventh or eighth day a pustule forms at the
* Clinical Notes on Small-pox. Montreal, 1876.
HMALL roX. 55
ROJit of iiKMiilulioM ; llicn p-iunil fever Hctn ifi, ami with it, ulioiit thu ulcvnitli tliiy, a /^^-luTal iTuplimi, uHuaily liiiiiu-d in «l«'^r<"r.
Complications. Considrrin^' tim wvc^rity of muiiy of the vum'H Kiid thu gciinal rliaruchr of iIh* diHciuiis lUiKociutcd willi niiiltiplo foci of Hiipitiiialidii, tl»o conipliciitionH in Hniall-pox urn roinurkubly few.
liaivnj^itis is serious in threes ways : it may prodm-e a fatal <i'<l<nia <»f the ^htltis; it is lial>h» to extend and invohe tiie <'artihi;^M'H, produrin^ ncHTosis ; and l>y diminishing th(^ Hensibility of tlie larynx, it allowH irri- tating^' paiticlrs to reach the h»\sei- aii-passages, when; tjjey excite bron- chitis or hroucho -pnciimoiiia.
Hronclio-pnenmonia is indeed one of the most common complications, and is ahnosl invariably })r(!sent in fatal cases. Lobar pneumonia is rare, riourisy is common in some epidemics.
'Tho cardiac complications are also rare. In the heiglit of the fever a systolic; murmur at the apex is not uncommon ; Ijut endocarditis, either simple or malii::nant, is larely met with. Pericarditis too is very uncom- mon. Myocarditis seems to be more fre(pient, and may be associated with endarteritis of the coroiuiry vessels.
Of complications in the di<;estivc system, parotitis is rare. In severe cases there is extensive pseudo-diphtheritic angina. Vomiting, which is so marked a symptom in the early stage, is rarely persistent. Diarrhcea is not uncommon, as noted by Sydenham, and is very constantly present in children.
Albumimiria is frequent, but true nephritis is rare. Inflammation of the testes and of the ovaries may occur.
Among the most interesting and serious complications are those per- taining to the nervous system. In children convulsions are common. In adults the delirium of the early stage may persist and become violent, and Ihially subside into a fatal coma. Post-febrile insanity is occasionally met with during convalescence, and very rarely epilepsy. Many of the old writers spoke of paraplegia in connection with the intense backache of the early stage, but it is probably associated with the severe agonising lumbar and crural pains and is not a true paraplegia. It must be sepa- rated from the form occurring in convalescence, which may be due to peripheral neuritis or to a diffuse myelitis (Westphal). The neuritis may as in diphtheria involve the pharynx alone, or it may be multiple. Of this nature, in all probability, is the so-called pseudo-tabes, or ataxie- varioUqne. Hemiplegia and aphasia have been met with in a few in- stances, the result of encephalitis.
Among the most constant and troublesome complications of small-pox are those involving the skin. During convalescence boils are very fre- quent and may be severe. Acne and ecthyma are also met with. Local gangrene in various parts may occur.
Arthritis may develop, usually in the period of desquamation. It is 5
56 SPECIFIC INFECTIOUS DISEASES.
probably not a genuine rheumatism. Acute necrosis of the bone is some- times met with.
Special Senses. — The eye affections which were formerly so common and serious are not now so frequent, owing to the care which is given to keeping the conjunctivae clean. A catarrhal and purulent conjunctivitis is common in severe cases. The secretions cause adhesions of the eyelids, and unless great care is taken a diffuse keratitis is excited, which may go on to ulceration and perforation. Iritis is not very uncommon. Otitis media is an occasional complication, and usually results from an extension of disease through the Eustachian tubes.
Prognosis. — In unprotected persons small-pox is a very fatal disease. In different epidemics the death-rate is from 25 to 35 per cent. The haemorrhagic form is invariably fatal, and a majority of those attacked with the severer confluent forms die. In young children it is particularly fatal. In the Montreal epidemic of 1885 and 1886, of 3,164 deaths there were 2,717 under ten years. The intemperate and debilitated succumb more readily to the disease. As Sydenham observed, the danger is direct- ly proportionate to the intensity of the disease on the face and hands. " When the fever increases after the appearance of the pustules, it is a bad sign ; but, if it is lessened on their appearance, that is a good sign " (Rhazes). In the confluent cases, when maturation does not proceed and the pocks are flat and if haemorrhage occurs, the outlook is usually bad. In such cases the general symptoms are apt to be severe. Very high fever, with delirium and subsultus, are symptoms of ill omen. The disease is particularly fatal in pregnant women and abortion usually takes place. It is not, however, uniformly fatal, and I have twice known severe cases to recover after miscarriage. Moreover, abortion is not inevitable. Very severe pharyngitis and laryngitis are fatal complications.
Death results in the early stage from the action of the poison upon the nervous system. In the later stages it usually occurs about the eleventh or twelfth day, at the height of the eruption. In children, and occasion- ally in adults, the laryngeal and pulmonary complications prove fatal.
Diagnosis. — During an epidemic, the initial chill, followed by fever, headache, vomiting, and the severe pain in the back, are symptoms which should put the attending physician on his guard. Mistakes arise in the initial stage owing to the presence of the scarlatinal or measly rashes which may be extremely deceptive. The scarlatinal rash has not always the intensity of the true rash of this disease. In my Montreal experience I did not meet with an instance in which this rash led to an error, though I heard of several cases in which the mistake was made. These are doubt- less the instances to which the older writers refer of scarlet fever and small-pox occurring together. The measly rash cannot always be dis- tinguished from true measles, instances of which may be mistaken for the initial rash. I found in the ward one morning a young man who had been sent in on the previous evening with a diagnosis of small-pox. He
SMALL rox. 57
hiul a fading macular rasli wifli (llMlincI Hmall papiilrH, wljuh hu'l not however (lie Hliitttv lianiiicHH of variola. In tiir cvciiiii^ lliin raMli wiix Ichji iiiarkiMl, aiul as I felt, Hiin- that a iniHtaki" lia<l \n-r\\ iiuul«*, hr wax ilinin- footcd and sent Imiiic In aiiotluT inHtanci; a ciiiM Ixdiovcd U> hav<! Hriiull- jM>\ was ailinittrd, l)iil, it proved lo Imvn niinply ineartlrH. Neither of llu'ioj CU80H took Hniail-[n»\. Ill a third ciihu, wliich I Haw at tin; City IIoM|»ital, tho inotlh'd papnhir rasli was niislakcn for Kniall-pox and tin* \onn^' man 8('nt to th(> hos|)ital. I saw him thu day after admission, when there wjw no (pieslion that llie disease was meash'S and not variola. Less fortumit4) than the oihci- caHeH, ho took Hnndl-pox in a wvy Kcvcro form. Tlit* f^vu- oral eondilion of the patient and t hi; nature of the pi-<idromal HymptornH are often hettei- i,Miides than t he charac^ter (»f the rash. Jn any case it in not well, as a rule, to send a patient to a snudl-j)ox hospital until tlio ehar- ucteristie papules appear about the forehead ami on the wrists.
In the most malignant type of luemorrhagie small-])ox the patient may die before the charaetoristic rash develops, though as a rule small, shotty papules nuxy be felt about the wrists or at the roots of the hair. In only one of twenty-soven cases of luvmorrhagic snuiU-pox, in which death occurred on the third day, did inspection fail to reveal the })a})ule8. In three cases in which death took place on the fourth day the characteristic rash was beginning to appear.
The disease may be mistaken for cerebro-spinal fever, in which purpuric symptoms are not uncommon. A four-year-old child was taken suddenly ill with fever, i)ains in the back and head, and on the second or third day petechii^ appeared on the skin. There was retraction of the head, and marked rigidity of the limbs. The haemorrhages became more abundant ; and finally hi\3matemesis occurred and the child died on the sixth day. At the post-mortem there were no lesions of cerebro-spinal fever and in the deeply ha?morrhagic skin the papules could be readily seen. The post- mortem diagnosis of small-pox was unhappily confirmed by the mother taking the disease and dying of it.
It might be thonght scarcely possible to mistake any ether disease for small-pox in the pustular stage. Yet I had an instance of a young man sent to me with a copious pustular eruption, chiefly on the trunk and cov- ered portions of the body, which, so far as the pustules themselves were concerned, was almost identical with that of variola ; but the history and the distribution left no question that it was a pustular syphilide. It is not to be forgotten, however, that fever, which Avas absent in this case, may be present in certain instances of diffuse pustular syphilis. Lastly, chicken- pox and small-pox may be confounded. Indeed, sometimes it is not easy to distinguish between them, though in well-defined cases of varicella the more vesicular character of the pnistules, their irregularity, the short stage of invasion, the slight constitutional disturbance, and the greater intensity of the rash on the trunk, should make the diagnosis clear. It is stated that the Chicago case, w^hich was the starting-point in Montreal of the
58 SPECIFIC INFECTIOUS DISEASES.
epidemic of 1885, was regarded as varicella and not isolated. If so, the mistake was one which led to one of the most fatal of modern outbreaks of the disease.
Glanders in the pustular form has been mistaken for small-pox, and I know of an instance (during an epidemic) which was isolated on the sup- position that it was variola.
Treatment. — In the interests of public health cases of small-pox should invariably be removed to special hospitals, since it is impossible to take the proper precautions in private houses. The general hygienic arrangements of the room should be suitable for an infectious disease. All unnecessary furniture and the curtains and carpets should be removed. The greatest care should be taken to keep the patient thoroughly clean, and the linen should be frequently changed. The bedclothing should be light. It is curious that the old-fashioned notion, which Sydenham tried so hard to combat, that small-pox patients should be kept hot and warm, still prevails ; and I have frequently had to protest against the patient being, as Sydenham expresses it, stifled in his bed. Special care should be taken to sterilize thoroughly everything that has been in contact with the patient.
In the early stage the pain in the back and limbs requires opium, which, as advised by Sydenham, may be freely given. The diet should consist of milk and broths, and of " all articles which give no trouble to digestion." Cold drinks may be freely given. Barley-water and the Scotch borse (oatmeal and water) are both nutritious and palatable. After the preliminary vomiting, which is often very hard to check by ordinary measures, the appetite is usually good, and, if the throat is not very sore, patients with the confluent form take nourishment well. In the haemorrhagic cases the vomiting is usually aggravating and per- sistent.
The fever when high must be kept within limits, and it is best to use either cold sponging or the cold bath. When the pyrexia is combined with delirium and subsultus, the patient should be placed in a bath at 70°, and this repeated as often as every three hours if the temperature rises above 103°. When it is not practicable to give the cold bath, the cold pack can be employed. These measures are much preferable in small-pox to the administration of medicinal antipyretics.
The treatment of the eruption has naturally engaged the special atten- tion of the profession. The question of the preventing of pitting, so much discussed, is really not in the hands of the physician. It depends entirely upon the depth to which the individual pustules reach. After trying all sorts of remedies, such as puncturing the pustules with nitrate of silver, or treating them with iodine and various ointments, I came to Sydenham's conclusion that in guarding the face against being disfigured by the scars " the only effect of oils, liniments, and the like, was to make the white scurfs slower in coming ofi!." There is, I believe, something in protecting
SMALL I'oX. 59
i\w ripening |»ipiiIrM fmiii l\w li^'lit, uikI tiio roiiMtant upj)li('ution on th» fiUH) uiid liaixis of lliit sdiikrd in cnlil wiitcr, to whidi uiitiHrptirM Hiich an (•iirl)nli(' acid or Wicldoridn may '"' aildcil, Ih prrliapK tlm iiioMt Hiiita)d«) treat iim'mL It is very plrasant to i\\r patifiil, and for IIh; fnai il in W(dl to inal\(^ a mask in lint, wliirli can tlu'ii l>t) (.'ovi^nMl with oiled Milk. \\ hen I lie cnists lu'^^Mii In form, tlic cliirf point is to keep them tlioroii^ldy njoist, which mav Im- done l»y nil or ^dyccrin. TliiH pri^vt'ntH tln! dcHi<;ca- tion and dilTusinn of ihr Hakes of <'pid<'rmis. \'asclin<! is particniarly iimc- ful, and at this sla^^c may l)c freely nse(l upon tln^ fac<'. It fn'fjnently relieves tlu^ itchini; also. I''or tlu; odor, which is HometimcH ho character- istic! and disa«(reeahle, the dihit(^ carl)oli<r solutions arc probably be«t. If the eruption is ahuiidaiit on the Hcalp, the hair should Ix; cut short to prevent inattin«j^ and dccnmjtnsiiinii nf the (;ruHt8. During convulescencc frequent, bathing is advisable, because it helps to soften the crusts. The care of the eyes is particularly important, 'i'he lids should be thorougldy cleansed three or four tinu'S a day, and the conjunctiviu washed with some antiseptic solution, in the conlluent cases, when the eyelids are much swollen and tlu' lids glued together, it is only by watchfulness that kerati- tis can be prevented. The mouth and tliroat should be kept clean, and if crusts form in the nose tliey should be softened by frequent injections. Ice can be given, and is very grateful when there is much angina. In moderate cases, so soon as the fever subsides the patient should be allowed to get up, a practice which Sydenham warmly urged. The diarrha^a, when severe, should be checked with paregoric. When the pulse becomes feeble and rapid, stimulants may be freely given. The delirium is occasionally maniacal and may require chloroform, but for the nervous symptoms the bath or cold pack is the best. For the severe haemorrhages of the malig- nant cases nothing can be done, and it is only cruel to drench the unfortu- nate patient with iron, ergot, and other drugs. Symptoms of obstruction in the larynx, usually from oedema, may call for tracheotomy. In the late stages of the disease, should the patient be extremely debilitated and the subject of abscesses and bed-sores, he may be placed on a water-bed or treated by the continuous warm bath. During convalescence the patient should bathe daily and use carbolic soap freely in order to get rid of the crusts and scabs. The patient should not be considered free from danger to others until the skin is perfectly smooth and clean, and free from any trace of scabs. I have not mentioned any of the so-called specifics or the internal antiseptics, which have been advised in such numbers ; because, so far as I know, the experience of those who have seen the most of the disease does not favor their use.
eo SPECIFIC INFECTIOUS DISEASES.
V. VACCINIA {Cow-pox)-V ACCINATION.
Definition. — An eruptive disease of the cow, the virus of which, inocu- lated into man (vaccination), produces a local pock with constitutional dis- turbance, which affords protection, more or less permanent, from small-pox.
The vaccine is got either directly from the calf — animal lymph — in which the disease is propagated at regular stations, or is obtained from persons vaccinated (humanised lymph).
It was in 1798 that Edward Jenner, a friend and pupil of Hunter, practising in Gloucestershire, announced that persons accidentally inocu- lated with the cow-pox were subsequently insusceptible to small-pox. From that time the process has extended over the civilized world and proved an incalculable boon to humanity. For many years arm-to-arm vaccination was practised, or the lymph was collected from the vesicle of a child, or the dried scabs were used. The humanised lymph in all proba- bility underwent changes and was certainly more frequently followed by evil results. Of late years animal vaccination has superseded it in great part, and now the lymph is derived either directly from the calf or from one or two removes.
The precise nature of the vaccination virus is as yet unknown. Sev- eral forms of micro-organisms have been isolated, and Quist has cultivated micrococci which, he states, produce in the child a typical vaccine vesicle. Several attempts have since been made to isolate the virus, but without definite success. Ernst and Martin, of Boston, have isolated from the bovine lymph a germ which grows on culture media and produces, when inoculated in the calf or in children, characteristic vesicles.
Phenomena of Vaccination. — In a primary vaccination, at the end of twenty-four or thirty-six hours there is seen at the point of inser- tion of the virus a slight papular elevation surrounded by a reddish zone. The papule gradually increases and on the fifth or sixth day shows a defi- nite vesicle, the margins of which are raised while the centre is depressed. By the eighth day the vesicle has attained its maximum size. It is round and distended with a limpid fluid, the margin hard and prominent, and the umbilication is more distinct. By the tenth day the vesicle is still large and is surrounded by an extensive areola. The skin is also swollen, indurated, and often painful. On the eleventh or twelfth day the hyperae- mia diminishes, the lymph becomes more opaque and begins to dry. By the end of the second week the vesicle is converted into a brownish scab which gradually becomes dry and hard, and in about a week (that is, about the twenty-first or twenty-fifth day from the vaccination) separates and leaves a circular pitted scar. If the points of inoculation have been close together, the vesicles fuse and may form a large combined vesicle. Con- stitutional symptoms of a more or less marked degree follow the vaccina- tion. Usually on the third or fourth day the temperature rises, and may persist, increasing until the eighth or ninth day. In children it is common
VACCINIA— VACCINATION'. ^J
to lmv(^ with tlu' f«<vor roHtloHHiu'HM, jMirti<'iiliirly lit nij(l»t, tiwl irrituhility ; but as 11 rule these syiMptotiiM un< triviiil. If tlui iiirxMiliitidii jh nuulo on tho arm, the avilhirv ^'hiiids hecoiiu" hir^'r and novt' \ if <in the Icjr, the in^^'iiinul ^laiiils. 'I'he al>nve may Im» taken as represent in;^' thr' typieiil conrHiMif viie- cinatioii, whcl her performed with \\ni hnnianiKecl or with tho imirnal lymph.
Suoci'ssful vaeeinati(»n is, for a tinio at h-ast, an infallihhj protection against small-pox. The dnralion of the immunity in extreriiely variable, dif- ferin;^ in dilTeriMit individmds. In somo instances it is permanent, but a nuijority of persons within ten or twelv(! years aj^^ain become susceptiblo.
licvaccination should be ])crformed between the tenth and fifteenth year, and whenever snuill-pox is epideniio. The susceptibility to revucci- nation is curiously variable, and when snuill-pox is prevalent it Ih not well, if unsuccessful, to l)e content with a sin^de attempt. The ve«iele in re- vaccination is usually smaller, has less induration and hyper;emia, and the rcsultinijj scar is less juMfcct. Particular care should be taken to watch the vesicle of rcvaccination, as it not infrc(iucntly ha])pens that a spurious poi'k is formed, w liich reaches its hei<j;lit early and dries to a scab by the eighth or ninth day. The constitutional symptoms in revaccinaticjii are sometimes quite severe.
An irregular course is uncommon in })rimary vaccination, but we occa- sionally meet with instances in which tlie vesicle develo])S rapidly with much itching, has not the characteristic flattened appearance, tlie lymph early becomes opaque, and the crust forms by the seventh or eighth day. In such cases the operation should again be performed with fresh lymph.
Complications. — In unhealthy subjects, or as a result of uncleanli- ness, or sometimes injury, the vesicles inflame and deep excavated ulcers result. Sloughing and deep cellulitis may follow. In debilitated chil- dren there may be with this a purpuric rash. Erysipelas may occur, or there may be deep gangrenous ulceration. Such instances are rare, but I have seen two which proved fatal. In one there was deep sloughing and in the other erysipelas. Cases of local dermatitis must not be mistaken for erysipelas. Among the most common complications are certain skin eruptions, some of which are due to the vaccine virus ; others result from a mixed infection. Vaccine vesicles not infrequently break out in the immediate vicinity of the primary sores. Less commonly there is a gen- eral eruption of vesicles — generalized vaccinia — due to absorption of the virus. More frequent, perhaps, is the erythematous or roseolous rash. Contagious impetigo can also be inoculated with the virus, and may appear as a general eruption.
A question of special importance with reference to vaccination is the transmission of other diseases. For a time physicians were unwilling to acknowledo^e that constitutional disorders could be transmitted bv vaccina- tion, but it is now universallv recos^nized that such transmission mav take place, and this has emphasised the scrupulous care which should be taken in the performance of the operation.
62
SPECIFIC INFECTIOUS DISEASES.
Vaccino-Syphilis. — For a knowledge of this most serious of all accidents during vaccination we are largely indebted to Jonathan Hutchinson. It is a true instance of a mixed infection. The vaccine vesicles take as a rule their usual course, and it is not until they have healed or are in process of healing that the local changes characteristic of syphilis are manifested. The fact that syphilis may be transmitted in this way should put the prac- titioner on his guard in selecting humanised lymph. He should take it only from subjects with whose constitution he is perfectly familiar. Fortunately, the instances are extremely rare. They are, in fact, much less frequent than is usually supposed, and in a majority of the cases in which vaccino-syphilis is suspected the condition is really that of inflamed and indurated vaccinal ulcer. As the subject is of daily interest to the practitioner, and one which he may at any moment be called upon to de- cide, I here insert a table of differential features between vaccinal ulcers and vaccino-syphilis, and between the vaccination rashes and the secondary syphilitic eruptions, compiled by C. E. Shelly * from Fournier's lectures.
YACCIXO-SY PHILIS.
Chancre developed on the site of usually one or two only of the vac- cination punctures.
Inflammation is slight.
Loss of substance superflcial only.
Suppuration scanty or absent, scabs or crusts formed.
Border of chancre smooth, slight- ly elevated, gradually merging into floor.
Surface of floor smooth.
Induration " parchment - like "
and specific, not merely inflammatory.
Inflammatory areola very slight.
Gland swelling constant, indo- lent (syphilitic) bubo. Complications rare.
Chancre never developed before the fifteenth day after vaccination ; usually not until after three to five weeks ; still in its earlier stage twenty days after vaccination.
VACCINATION^ ULCERS.
Ulceration affects all the punct- ures as a rule.
Inflammation and ulceration se- vere.
Ulcer deeply excavated. Much suppuration.
Margin of ulcer irregular, as in " soft chancre."
mg.
Floor of ulcer uneven, suppurat- Induration inflammatory only.
Areola inflammatory and ery- sipelatous in character.
Gland swelling often absent; if present, merely inflammatory.
Complications — sloughing, ery- sipelas, etc. — often present.
Ulceration is present twelve or fifteen days after vaccination and is fully developed by the twentieth day after vaccination.
* Fowler's Dictionary of Medicine. Article Vaccination.
VACCINIA VACCINATION.
08
MKCONDAItY HYI'IIIMTIC Kill' ITION
(liM» lo Inic viicciii(»-sN philis.
AppcjirH, at I1m» (»arlit's(, nine or ten weeks jifler vaeeinalioii.
Ko(iuii-es, ill every caso, tlie pre- oxisteiice of a specilie ulcer (elumcro) lit tho site of vaeeiiiation.
Exhibits tlio characters of a true apecitic eruption.
Fever often sli^^ht.
Lasts for a K)iig time.
Usually accompanied by specific appearances on mucous membranes.
VACCIXO-SYPIIILIS.
Begins witli a local infection, chancre and indolent bubo.
Typical development in four stages, viz., incubation, chancre, second incubation, generalization (secondary eruptions, etc.).
Never appears earlier than the ninth or tenth week after vaccina- tion.
VA<X'INATlO.V KAHIIKH
(iiieludin^ToMeohi varcinaiiM,niiliuria vueejiuiliH, vaeeinia biilloHu, vaccinia lui'Miorrha^'ica); ulHouccidtrritul erup- tions— rub<5olu, Hcarlatina, liclurn, urticaria, etc.
A true va<*eimil ranh appearn })C- tween tlu! ninth and fifte(;nth day afti'r vac(!ination.
Absence of inoculation chancre.
Kru})tion does not exhibit Hpe- cilic characters.
Fever always present. Evanescent.
HKUKDITAUV SYF'HIMS SHOWING ITSELF AIJOUT THE TIME OF VACCINATION.
No chancre ; begins with gen- eral phenomena.
Has no typical development in connection with vaccination.
Time of development quite inde- pendent of vaccination.
Is attended by the characteristic syphilitic bodily aspect.
Other manifestations of heredi- tary syphilis may be present.
The history may indicate syphilis.
Choice of Lymph. — Humanised lymph should be taken on the eighth day and only from perfectly formed unbroken vesicles, which have had a typical course, and have not yet developed areolae. Pricking or scratching the surface, the greatest care being taken not to draw blood, allows the lymph to exude, and it may then be collected on ivory points or in capillary tubes. The child from which the lymph is taken should be healthy, strong, and known to be of good stock, free from tuberculous or syphilitic taint. Under these circumstances humanised lymph, one or
64 SPECIFIC INFECTIOUS DISEASES.
two removes from the calf, is usually very satisfactory in its action and is perfectly reliable.
In the case of the calf the most scrupulous care should be exercised in the vaccine farms to secure animals which are healthy and strong. The risk, however, that the calf has any disease which can be transmitted to man is exceedingly slight, as tuberculosis is very rare in cattle when young. Unquestionably, however, there may be risk in the case of a calf born of tuberculous parents, and special care should be taken in the selection of proper animals. There is no essential difference in the pocks which fol- low humanised lymph and bovine lymph. It was, I believe, a common experience in Montreal that children inoculated with bovine lymph had more constitutional disturbance and often sorer arms than those vaccinated with humanised lymph at one or two removes.
In the performance of the operation that part of the arm about the in- sertion of the deltoid is usually selected. Mothers " in society " prefer to have girl babies vaccinated on the leg. The skin should be cleansed and put upon the stretch. Then, with a lancet or the ivory point, cross- scratches should be made in one or more places. When the lymph has dried on the points it is best to moisten it in warm water. The clothing of the child should not be adjusted until the spot has dried, and it should be protected for a day or two with lint or a soft handkerchief. If erysipe- las is prevalent, or if there are cases of suppuration in the same house, it is well to apply a pad of antiseptic cotton. Vaccination is usually per- formed at the second or third month. If unsuccessful, it should be re- peated from time to time. A person exposed to the contagion of small- pox should always be revaccinated. This, if successful, will usually pro- tect; but not always, as there are many instances in which, though the vaccination takes, variola also appears.
The Value ofVaccination. — Vaccination is not claimed to be an invariable and permanent preventive of small-pox, but in an immense ma- jority of cases successful inoculation renders the person for many years insusceptible. Communities in which vaccination and revaccination are thoroughly and systematically carried out are those in which small-pox has the fewest victims. On the other hand communities in which vacci- nation and revaccination are persistently neglected are those in which epi- demics are most prevalent. In the German army the practice of revaccina- tion has stamped out the disease. Nothing in recent times has been more instructive in this connection than the fatal statistics of Montreal. The epidemic which started in 1870-'71 was severe in Lower Canada, and per- sisted in Montreal until 1875. A great deal of feeling had been aroused among the French Canadians by the occurrence of several serious cases of ulceration, possibly of syphilitic disease, following vaccination ; and several agitators, among them a French physician of some standing, aroused a popular and wide-spread prejudice against the practice. There were in- deed vaccination riots. The introduction of animal lymph was distinctly
VACCINIA— VACCINATION. ^
bciK^nciul ill ('XlcMilin^ i\w \trnv.iir.i) iiruoii^' tin* lower cIummi-m, but rompiil- Horv vacciiiiitinii could not Imi nirrird out. Ilftwcrn tlw y«'iirH 1H70 uikI IHHl ji «'oMsi(l(«nil)lo uiiproU'ctiMl )Mipitliitioii ^'n-w up and lln* rniilrriiilH woro riiM' fnr an (vxtrnsivd opidoinir. Tlu' Hoil had Immmi prrparrd with tlio ^riuit(>Ht care and it <'idy luuMlcd tin- introduction of the hccd, wldcji in (hictiiuc cainc as already HtaU^I with the I'nlhuan-cur conductor from Chica'^^o, on tlu^ *>ISih of Kcljruary, 1HS:». Within the next t4'ii inoiithn thousands of p(>isons were stricken with the disj-ase, and .'J, 104 died.
Alth()u;^h tlu^ elTt'cts of a single vaccination nuiy wear out, iw wo hh\\ and tlie individual ai;ain heconie susceptihh^ to small-pox, yet the mortal- ity in such cases ia vory much lower tlian in persons who have never been vacciiuiteil. Thi' mortality in persons wiio have been vacriruited is from G to 8 per cent, whereas in the unvaceinated it is at least 35 per cent, ^farson jiointed out some years a^o that there is a definite ratio l)etween the number of deatlis and tiu^ number of <^ood vaccimition marks in post- vaccinal snudl-]>ox. With ^ood marks the nu)rtality is between 3 and 4 per cent, and wiili indilTeront marks at least 10 or 11 per cent.
VI. VARICELLA (Chicken-pox).
Definition. — An acute contagious disease of children, characterised by an erui)tion of vesicles on the skin.
Etiology. — The disease occurs in epidemics, but sporadic cases are also met with. It may prevail at the same time as small-pox or may fol- low or precede epidemics of this disease. An attack of chicken-pox is no protection against small-pox. It is a disease of childhood ; a majority of the cases occur between the second and sixth years. It is rarely seen in adults. The bacteriological examination of the vesicles has shown