THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA PRESENTED BY PROF. CHARLES A. KOFOID AND MRS. PRUDENCE W. KOFOID '^if^'ici^^., 4 ^ y. U—i-' A / /. 7/ LECTUliES F E V E E S . ALFRED L. L00:MIS, A.M., M.D., IROFESSOR OP PATHOLOGY AND PRACTICAL MEDICINR IN THE MEDICAL DEPARTMENT OF THE L'NIVEUSITV OF THE CITY OF NEW YORK ; CONSULTING PHYSICIAN TO THE CHARITY HOSPITAL —TO THE BUREAU OF OUT-DOOR RELIEF— lO THE NORTH-WESTERN DISPENSARY— TO THE CENTRAL DISPENSARY : LATE VISITING PHYSICIAN TO THE BLACKWELL'S ISLAND FEVER HOSPITAL; VISITING PHYSICIAN TO BELLEVUE HOSPITAL— TO THE MOUNT SINAI HOSPITAL, ETC., ETC. NEW YORK: AV I L L I A >r ^\' () < » 1 ) it C O M r A N Y , 27 GuEAT Josns STurF.r. 1S77. COPTKIGHT, BY WILLIAM WOOD & CO., isrr. Trow's Printing and Bookbinding Co., printers and bookbinders, 205-213 Kasi \itli St.. NEW YORK. (Jo tV ALUMNI AND STUDENTS OF Tiir; MEDICAL DF.rARTMENr OF THE UNIVERSITY OF THE CITY OF NEW YORK, THESE LECTURES ARE DEDICATED BY THEIR SINCERE FRIEND, THE AUTHOR. ivrT--^o.iP2 PREFACE. These lectures were delivered in the Medical Department of the University of the City of Xew York, to the Class of lS7(>-77. With iinimpoitant alterations, I now olfcr them as they were phonogiaphically reported by Dr. Wm. M. Carpenter. As in the preparation of my "Lectures on Diseases of the Lungs, Heart, and Kidneys," it has been my custom, after careful reading and close analysis of the subject of each lecture, to trust that the stimulus of the class would enable me to present the most recent views of ncknowledged authorities, combined with the results of my own clinical observation and experience, in so simple, intelligible, and concise a manner that each student might master the prom- inent points. I have adopted an etiological basis in the classification of fevers, and have endeavored to include in a few gen- eral classes all the numerous types described by diifinvnt writers. I have referred to theoretical questions only so far as was necessary in oidcr to the projier understanding of subjects under consideration. The Bibliograi)hy which accompanies these lectures in- cludes those books, monographs, and theses which havn been published since I80O, nearly nil of which Jiuve bem written, or arc in circulation, in this country. A few old books have been referred to, because they con- Vi PREFACE. tain many of the so-called new tlieories and modes of treat- ing fevers. My aim has been to give a summary of the literature of fevers in this country, and so much of foreign literature upon this subject as might be of interest and service to the student who desires to thoroughly investigate the subject of fevers. No notice has been taken of papers which have only appeared in medical journals. These lectures are the result of careful stud}^ of the litera- ture referred to in the Bibliography, combined with exten- sive clinical experience. I have endeavored to be unbiassed in my statements of facts. It is my purpose at some future time to publish, in similar form, lectures upon other infectious diseases. 42 West Twenty -prFTH Street, August, 1877. CONTENTS. LECTURE I. FEA^RS. PAOE Introduction— Classification— Typhoid Fever— Morbid Anatomy 1 LECTURE II. TYPnorO FEVER. Jlorbid Anatomy (continued) — Intestinal Lesions — Etiology 14 LECTURE in. TYPHOID FEVER. 07 Symptoms. "' LECTURE IV. TTPnoro FEVER. Symptoms (continued) — DifiEerential Diagnosis 39 LECTURE V. TYrnoiD FE\'ER. Prognosis — Duration— Relapses 50 LECTURE VI. TYPHOID FEVER. Treatment 61 LECTURE VIL TYPHOID FEVER. Treatment (continued) ' ^ Vlll CONTENTS. LECTURE VIII. YELLOW FEVER. PAGE Morbid Anatomy — Etiology — Symptoms 85 LECTURE IX, YELLOW FEVER. Symptoms (continued) — Differential Diagnosis — Prognosis — Treatment. ... 95 LECTURE X. MALARL4.L FEVERS. Introduction 109 LECTURE XI. SISrPLE INTERMITTENT FEVER. Morbid Anatomy — Etiology — Symptoms — Differential Diagnosis — Prognosis —Treatment 119 LECTURE XII. SniPLE REMITTENT FEVER. Morbid Anatomy — Etiology — Symptoms — Differential Diagnosis — Prognosis. 133 LECTURE Xin. PERNICIOUS FEVER. Treatment of Simple Remittent Fever — Morbid Anatomy — Etiology — Symptoms , 145 LECTURE XIV. PERNICIOUS FEVER. Symptoms (continued) — Differential Diagnosis — Prognosis — Treatment 157 LECTURE XV. DENGUE FEVER. Morbid Anatomy — Etiology — Symptoms — Differential Diagnosis — Treatment — Chronic Malarial Infection 169 LECTURE XVI. TYPHO-5IALARIAL FEVER. Introduction — Morbid Anatomy — Etiology — Symptoms 181 CONTENTS. I X LECTURE XVII. TYrilO-MAI-AUIAL FKVER. TA'IF. Symptoms (coutinued)— Dillcrential Diagnosis— Proguosis—Treatment lUO LECTURE XVIII. TYPHUS FKVKU. Introduction — Morbid Anatomy — Etiologj' 205 LECTURE XIX. TYPHUS FEVER. Symptoms '■^^'^ LECTURE XX. TYPUCS FEVER. Symptoms (continued) — Differential Diagnosis — Prognosis 229 LECTURE XXI. TYPHUS FEVER. Treatment 243 LECTURE XXII. RELAPSING FEVER. Morbid Anatomy — Etiology — Symptoms — Differential Diagnosis— Treatment. 256 LECTURE XXIIL EXANTIIEM.\TOUS FEVERS. Small-Pox — Morbid Anatomy — Etiology — Symptoms 208 LECTURE XXIV. SMAI.L-POX. Symptoms (continued) — Differential Diagnosis— Prognosis 280 LECTURE XXV. SMALL-POX. Treatment (continued) — Inoculation — Vaccination — Varioloid 293 X CONTENTS. LECTURE XXVI. SCARLET FEVER. PAGE Introduction— Morbid Anatomy— Etiology— Symptoms 304 LECTURE XXVII. SCARLET FEVER. Symptoms (continued)— Complications— Sequelas 315 LECTURE XXVIII. SCARLET FEVER. Differential Diagnosis— Prognosis— Treatment 326 LECTURE XXIX. MEASLES. Morbid Anatomy— Etiology— Symptoms 337 LECTURE XXX. MEASLES. Differential Diagnosis— Prognosis— Treatment— Roseola— Miliary Fever 348 MIASMATIC-CONTAGIOUS FEVERS. LECTURE I. FEVERS. Introduction. — Classification.— Typhoid Fever.— Morhid Anatomy, Gentlemen : — AVe will commence this course of lectures with the study of those diseases which depend upon morbid conditions of the blood., produced by morl)ific agents de- veloped exterior to tlie body of tlie affected. Such mor- bific agents may give rise, either directly or indirectly, to morbid processes ; either by the clianges which the}" pro- duce in the blood, or by their action on the different organs tiiul tissues of the body to which they are conveyed by the ])l()()d-vessels and lynijihatics. The class of morbific agents which will now especially en- gage our attention may be included under the general head of viruses. By the term virus I mean a morbific substance which is developed either from animal or vegetable tissues in the process of d(*compositif)n, or from the excretions of diseased living beings. Many viruses are volatile, and may be con- veyed either by air, by fiuids, or by solids, and when so conveyed they become the means by which diseases known as contagious or infectious are transmitted. Some viruses are palpable poisons, and may be transmitted from the dis- eased to the healthy by inoculation. When the virus which gives rise to a disease has its origin only in a living being, from whom it is excreted in an active 2 INTRODUCTION. state, capable of conveyance from one person to another, tlien the disease which it produces is called contagious, and the virus is called a contagion. If the morbific agent which has the power of developing disease has originated from decomposing organic matter, and has been diffused through the air or water, so that infection may have resulted without contact with one al- ready diseased, the disease is called miasmatic, and the virus is called a miasm. For instance, intermittent fever is a miasmatic disease, while small-pox and measles are contagious diseases. With our present knowledge of the nature and origin of viruses, we can make no classification, except that which is based on their differences of action. We speak of typhus, typhoid, and malarial poisons, but these different poisons have as yet no known physical or chemical proper- ties by which we are able to distinguish one from another. We can only recognize their presence by the peculiar mor- bid phenomena which each has the power of developing in the animal economy. The different diseases which are developed by the morbid processes excited by these different viruses are, at the pres- ent time, classed under the head of infectious diseases, and the influence of these viruses upon the body is called infec- tion. It is also important for you to remember that all of those diseases which are included under the general head of infectious diseases have their own sx^ecific morbid pro- duct, which will produce these, and only these, diseases ; and although these different diseases may have very many symptoms in common, and may very closely resemble each other in the phenomena which attend their development, yet the specific character of the morbific agent which has produced them stamps them as distinct diseases. There is reason to believe that not one of this class is of spontaneous origin, but that each depends on its own specific poison. As to the exact nature of such a poison, and its element of power in the production of disease, we have no positive knowledge ; at the present time, in regard to it, there are two prominent theories. TNTKODTC'IFOX. 6 Tilt' J/rsf is based upon clicmU'al i)r()(.'ossos ; tlie second, \\\)on tlic iiiultiplk'ation oL' liviiii; oru:anisnis. 'Y\\Q chemical theory mwrnUun^ tliat afhT (Ik^ infectious element has been received into I lie blood it acts as a i'er- nient, and gives rise to certain morbid ])rocesses upon the ])rinciple of catalysis. The theory of organisms:^ or the germ theory, as it is called, maintains that the infectious poisons are living organisms, wliicli. being received into the blood, reprodnce themselves indelinitely, and by their reproduction morbid processes are excited wliicli are characteristic of certain types of disease. This is a very seductive theory, and at the x^i'i'sient time is quite extensively adopted by nu'dical theorists, as it so readily explains very man}^ remarkable facts connected with the development and reproduction of the class of diseases which are soon to engage our atten- tion. It is readily understood, and there are so many ani- mal poisons which a])]iear to act in this manner, that to one AvliosH opinions are not based upon clinical ex])erience and actual contact with disease, the arguments in its favor seem conclusive. According to this theory all the different forms of disease included under the head of contagious or infections may be reduced to, or embraced in, two classes : First, infectious diseases which depend for their devel- opment upon a living animal organism. Second,, those which depend for their jiroduction upon a living vegetable organism. Unfortunatel}' for this theor}^ the special or- ganism of any one of the infectious diseases has never been so plainly described by any one competent observer that all others in the same field of stndy could with certainty recog- nize it. The bacterian theory, which recently has so occu- pied the attention of medical men, especially in German3% is rapidly being disproved, and consequently as ra])idly being abandont.'d. In this country it can scarcely be lu-ld to have ever gained a foothold. It seems to me that one who has watched bacterian dt^'elopment must arrive at the conclusion that bacteria found in connection with the de- velopment of disease are the product and not the cause of 4 INTRODUCTIOlsr. the diseased process ; certain it is tliat the theory that there exists distinct typhoid, typhus, and diphtheritic living germs, which are the propagating element of these different diseases, still lacks that proof which will lead the practical physician to adopt it. The question then comes back to us, what is the real nature of those morbific substances which, when received into the human organism, have the power of manifesting phenomena which characterize that class of disease which we term infectious? Every day's experience must convince the careful observer that each one of this class of diseases has a distinct producing cause — that the poison of typhus will not produce typhoid fever, neither will the poison of measles develop scarlatina. Although the phenomena which attend the development of these differing diseases may have many points of resem- blance, yet each has a distinct origin, that is, has its own specific infection, which specific morbific substance, when- ever introduced into the animal economy, either through the skin, respiratory organs, or digestive surfaces, interferes in a greater or less degree with the functions of organic life. This interference is caused either by changes Avhich it produces in the constituents of the blood, or in the solid organs and tissues to which it is conveyed by the blood- vessels and lymphatics. After reviewing these differing theories and giving careful attention to the facts presented in their support, we arrive at this conclusion — that the exact nature of these morbific agents is unknown. We know that they exist, from the dis- eased action which they produce ; and from the manner in which these diseases are propagated we decide that their poisons are distinct from all other poisons, and that each is specific and can reproduce itself to an unlimited extent. The germ theory best explains the phenomena of develop- ment. The chemical theory has decided claims on our acceptance ; but until our explorations shall have been car- ried so far as to determine, beyond question, what is the exact nature of several of these poisons, we shall be com- pelled to call tliem unknown morbific agents, governed by certain fixed laws of development and propagation. At IXTIIODI'CTIOX. O the present time investigation in this diivrtion lias scarcely begun. As we pass from the general causation of this group of diseases to their chissiiication, we find ourselves still in doubt. The symptomatic basis of classiJication of the earlier writers gave place to the more scientilic and compre- hensive anatomical basis of classification. This for a long period has been almost universally adopted, yet now is giving place to the recent and more definite etiological clas- silication of the present day. When these diseases are classified upon an etiological basis, very naturally they divide themselves into three classes. J^irst.—A. class in which the morbific agent cannot be developed exterior to a living being, but, when developed witliin the system of one individual, can be transferred to another through the atmosphere. Such is the case in mea- sles, small- pox, and typhus fever. Second.— We have another class called miasmatic or ma- larial diseases, in which the morbific agent is developed exterior to a physical organization, and cannot be conveyed from one individual to another. 77^ //y7.— There is a class in which the morbific agent is developed within, and reproduced exterior to a physical organization. In this class, the poison is developed within the body, but in order that it may be reproduced it must be deposited in decomposing organic matter exterior to the body ; it is then rapidly reproduced, and when received into a healthy organism gives rise to diseased processes. It can- not be directly conveyed from the sick to the healthy, but only through the excrements of th<^ sick, or through de- com])Osing organic matt(M- exterior to the body, with which such excrements must have been in contact. There may be all the elements necessaiy to its reproduction, such as decomposing animal and vegetable matter, but the disease will not be develoi)ed unless there has been added to this decomposing mass the specific poison of tlie disease. The diseases thus developed have- been called inicsinatic- coutaijious, of winch typhoid fever is the best example. 6 CLASSIFICATIOTT OF FEVERS. All the different forms of acute contagions-miasmatic or miasmatic-contagions disease may be either endemic or e^yi- demic. They are epidemic when they attack a large number of persons at the same time and in the same manner. They are endemic when they are often repeated in the same locality. If they attack individuals without regard to time and place, they are called sporadic. With this brief introduction, we will enter upon the study of that class of diseases which during the present century have been included under the general head of fevers. Adopting an etiological basis of classification, I shall divide fevers into three classes. Fb'st. Contagious Fevers. — I shall include under this head all those fevers which depend for tlieir development on a specific morbific agent, which agent must originate in an individual suffering from a like specific disease. Second. Miasmatic or Malarial Fevers. — I shall in- clude under this heading all those fevers which depend for their development on a morbific agent developed exterior to the body, and not connected with any previously diseased phj^sical organization. Third. Miasmatic-Contagious Fevers. — I shall include under this head those fevers which depend upon a morbific agent developed exterior to the body in animal and vege- table decompositions, to which has been added the specific poison of the fever which has had its origin in a diseased physical organization. The following is the classification which I shall adopt : classification of fevers. First Class. — Contagious. Typhus Fever, Relapsing Fever, Small-Pox, Scarlet Fevp:r, Measles, Miliary Fever. CLASSIFICATION OF FEVKIIS. 7 ScconfT Class. — Malarial. SlMPI.K INTERMITTKNT FlCVEll, SIMPLF: RkMITTENT FeVEU, Peunicious Fevek, Dknoue Fever, Typiio-mai.akiai, Fkveh. T/i trd Class.— Miasinatic-Cuiitaii (Oils. Typhoid Fever, Yellow Fevkr. Tlio tliird class of fevers is a connecting link between the first and second class. In their patholoixy and clinical liistories the fevers of this class have many things in coiuinon with those of each of the other classes, as also in their origin, natui'e of poison, etc. On this account, and from the fact that during tin? course of every fever some of the phenomena of t}phoid fever are presented. I shall iirst describe those fevers in- cluded in the third class, and shall commence with tyi)liold fewr. TYPHOID FEVER. This is the most universally prevalent of all fevers. So far as we know, there is no place where it may not be develo])ed and spread. It more frequfMitly prevails in the tem})Hrate zone than in the torrid or frigid, but it is ])ossible for it to be developed in all latitudes and in all countries. This disease, which is essentially the same in all countries, is designated by dilferent names. American writers describe it under the name of typlioid femr . The French call it the typlioid affection, or doth inerderia. English writers describe the same form of disease under the head of enteric fecer. The Germans call it abdominal typhus, or gastric femr. I prefer the name typhoid fever, and will commence its his- tory by describing its anatomical lesions. MoKBiD Anatomy. — As soon as the disease is fully estab- lished a change in the blood occurs. It becomes darker in color, coagulating imixnfectly, the serum being imi)erfectly separated from the solid constituents, and is of an unnatu- rally yellow color. The question arises — did these changes take place in the blood ]irior to the oc(uirrence of the fever, between the exposure and the period of attack I It is cer- 8 TYPHOID FEYEK. tain that as soon as the characteristic symptoms of the dis- ease are present, the diminution in the fibrin of the blood is in exact proportion to the severity of the fever, and the number of white globules is increased in a similar ratio. As a consequence of these blood changes, or in connection with them, a series of changes takes place in those organs and tissues of the body in which the processes of waste and rej)air are most rapidly going on. These changes are of the nature of parenchymatous degeneration — the essential con- stituents of the affected organs and tissues being involved. Similar parenchymatous changes are met with not only in typhoid fever, but to a greater or less extent are charac- teristic of other fevers and acute infectious diseases. Spleen. — The organ in which parenchymatous degenera- tion occurs earliest and most extensively is the spleen. We find this organ undergoing three distinct changes. First. — It is increased in size, sometimes enormously. The enlargement commences soon after the beginning of the disease, and goes on rapidly until the third week, after which it ceases, and after a few days the spleen begins to diminish in size. If recovery takes place, by the time it is reached the spleen will have returned to its normal size. The splenic enlargement is apparently due to congestion and to an increase of normal elements. Second. — As soon as the spleen reaches its maximum size, its consistency becomes soft ; this softening is some- times so marked that, if a post-mortem be made at the end of the third week, the spleen will present the appearance of a dark, jelly-like mass, which is easily broken down. Third. — The organ becomes almost black in color, owing to the intense congestion which attends its enlargement, and to the deposit of a brown pigment in its substance. These changes in the spleen take place, in a greater or less degree, in ninety-eight cases out of every hundred. At the post-mortem of those who have died of typhoid fever, infarctions are sometimes found, although there is nothing peculiar about them. In rare instances, rupture of the spleen occurs without infarctions. LiYER. — Changes in the liver are by no means as common MolM'.in ANATOMY. 9 as tliose in tlie s})l('i'ii. The liviT may bo foiiiid presenting its normal appearance, or it may be soft and llabby. When soft and flabby, a microscopic examination shows the liver cells more or less grannlar and fatty, tiie nnclei of the oi^lls can no longer be seen, and the degeneration may become so extensive that the outline of the hepatic cells is lost, and nothing but a mass of grannies remain. Occasionally there will be found in the liver of those wlio have died of typhoid fever small grayish nodules situated along the course of the small veins ; these nodules consist of lymphoid cells. The lining membrane of the gall-bladder sometimes pre- sents evidences of catarrhal or diphtheritic inflammation, when there has been no evidence of its existence during life ; cases are recorded where it has been found ulcerated. Kidneys. — Degenerative changes in the kidneys are of not infrequent occurrence in the course of typhoid fever ; they vary in extent with the duration and severity of the fever. When present, they are more marked in the cortical than in the medullary portion of the organ. In some cases they are confined to the epithelial elements, while in other cases degeneration of all the anatomical elements of the organs can be found. Such extensive changes are less lia- ble to occur in typhoid tlian in typhus fever. Small gray nodules similar to those referred to as occurring in the liver are sometimes found. If the epithelial degeneration of tli<^ cortical substance is extensive, the cells finally break down into a granular detritus, and the cut surface assumes a yellow color and is softer than normal. Infarctions are sometimes met with in the kidne3^s of those dying of t^'phoid fever. TiKAirr. — The parenchymatous changes which take place in the heart are more marked than those in any other or- gan, for its anatomical elements undergo waste and rejiair more actively tlian those of any other oigan ; and if faulty nutrition is an important element in these degenerative changes, this organ must become ver}' nuirkedly invi.lv.d. In a large proportion of cases it becomes soft and tial)l)y, and is of a grayish or brown color. Sometimes it is so much 10 TYPHOID FEVER. changed that its tissues are easily broken down by moderate pressure ; it loses its normal outline, and when remoA-ed from the body the walls of its cavities readily fall together. When its muscular tissue is examined microscopically, in many instances it will be found that granular changes, affecting the ultimate muscular fibres, have occurred ; this granular muscular degeneration may involve a large por- tion of the organ, or it may be confined to a few muscular fibres. It may be a general or a localized parenchymatous degeneration. Occasionally the muscular fibres are infil- trated with brown pigment. If, as is sometimes the case, the heart retains its normal outline, is friable, and its cut surface glistens, the muscular fibres will be found to have undergone a change which closely resembles amyloid degeneration ; the muscular fibres will be filled with a material which presents the same shining appear- ance as the amyloid substance, but on applying the iodine test the same reaction does not take place. It is a form of degeneration which occurs in typhoid fever and is not confined to the muscular tissue of the heart, but is found to a greater or less extent in the voluntary muscles of the body. Thrombi are sometimes found in the heart, and vegeta- tions adhering to the valves and chordae tendinese. These may give rise to infarctions in the different organs of the body. The existence of the degenerative changes in the heart, to which I have referred, may be recognized during the life of the patient, for the heart sounds become feeble according to the extent of the degeneration. In some cases the first sound of the heart will be absent, and it has been claimed that when this phenomenon is present the use of stimulants in large quantities is indicated. Lungs. — The lungs undergo changes which have received the name of splenization. This is a form of pulmonary congestion which has received its name from the close re- semblance which the affected portion of lung tissue bears 1o the spleen. The affected lung tissue is of a darker color than normal, and scattered through its substance will be seen little red :\r()rjuD anatomy. 11 or y(>llowisli white points ; these litth; points are scanty blood extravasations. Lung tissue in a condition oL' sjilcnization is ol' a (hnk reddish blue, brown, or black color ; its consistcMicy is liiin.'i than normal, crei)itates less freely, has a more unifonii, homogeneous ap]iearance upon its cut surface, and is less moist than normal lung tissue ; a dark fluid will sonit-times ooze from its cut surface, but not as freely as in hypenemia, and tile fluid is more watery in appearance. A microscopical examination of lung tissue in this condi- tion shows the capillary vessels filled with blood, and the alveoli containing a variable number of cells. In other words, it is a condition closely resembling that condition known as static pneumonia, but no inflammatory process exists ; it is simply a stasis in the capillary circulation, accompanied by a slight increase in the cell elements in tlie alveoli. BnoNCiiiAL Tubes. — You will rarely make an autopsy u])oii one who has died of ty})hoid fever, without finding evidences of a more or less extensive catarrhal inflammation alYecting the bronchial tubes. So constantly is catarrhal bronchitis present in this fever, that Dr. Stokes proposed to call typhoid fever bronchial typhus. In most cases this catarrh is not extensive, affecting only the larger bronchi ; it may, however, extend to the smaller tubes and give i-ise to cai)illary bronchitis and broncho-pneumonia. Pulmo- nary infarctions are frequently found in the lungs of those who have died of typhoid fever. They are sometimes ipiite numerous, are usually of small size, and vary in a]i])earance according to the stage of tlieir development. Wlien recent they are of dark color, and feel like consolidated lung tis- sue ; later, the color changes to yellow; they may soften and break down. LaTvYnx. — The larynx, as well as the In-onchial tubes, is frecpiently the seat of catarrhal iiithnniriatiou ; less fre- quently it is the seat of diphtheiitic inllammati(jn. in con- nection with these laryngeal inflammations, ulcers aji])ear in the larynx; these have received the name of "ty])iioid ulcers of the larynx;" sometimes they give rise to quite 12 TYPHOID FEVEK. extensive hemorrhages. In connection with, or independent of these Uiryngeal ulcers, ulceration of the mucous mem- brane of the mouth and pharynx may occur ; at times it involves the epiglottis in such a manner as to clixD off its edges. These ulcers may develop on the mucous membrane of the Eustachian tube. In those cases where permanent deafness follows an attack of typhoid fever, it will usually be found due to ulceration of the mucous membrane of the Eustachian tube. Beaix and Nervous System. — As yet we have not been able to determine Avhether there are any structural changes in the brain or nervous system so constant that the}^ may be regarded as lesions of typhoid fever, although it is rea- sonable to infer that in a disease where such severe func- tional distui;bances of the cerebro-spinal system exist there must be constant and dehnite parenchymatous changes. GEdema of the pia mater and of the brain substance, with occasionally quite extensive adhesions of the dura mater to the cranium, not infrequently exist. Punctate extravasa- tions into brain substance are found in a certain number of cases, but even in severe cases they are not always present. Stomach. — The changes which occur in the stomach are equall}^ important with those that occur in the other inter- nal organs, and are degenerative in their nature. Softening and degeneration of its glandular structure is sometimes so extensive, that if recovery from the fever takes place, a very long time must elapse before the organ can perform its normal function. It is the existence of these degenerative changes that gives rise to the disturbance in digestion which is present in so many cases, not only during the continuance of the fever, but during convalescence. Muscles.— In addition to the degenerative changes which I have described as occurring in the internal organs in typhoid fever, I must say a word concerning those which so recently have been found almost invariably present in the voluntary muscles. This muscular degeneration is of two varieties : First, a granular degeneration, which corresponds to ordinary fatty degeneration. Second, a waxy degeneration, which consists in the conversion of the MOKl'.II) AXA'IOMV. 13 contractile substance of tlie "i)rimiliv(> buiullcs into a lionio- ^•(Micous, waxy sliiiiiiiu- mass. Often l)o(li Conns of dcuvn- eration occur (olii'IIu'i-. soiiiriiincs one and soiiicliuifs llic other ])ii'(loniinalin_i;-. In both foi'ins of dcLCcncration tlic muscular libivs brcomc lliickcrand nioi'c brii i ].> ili.-in normal. In the liiulicst dc- muscle remains. During convalescence tlie noi-mal I'ed color of tlie mnscle retui'us. Tliis muscular degeneration, howevei'. is iu)t })eculiar to typhoid fever, but is met with in all severe infectious diseases. Tlie want of muscular power, A\hich is so prominent a sym]itoni during the iKMglit of the fever, may depend on th(^ disturbances of the nervous system, but the excessive loss of muscular power which is so oft(Mi ])resent during conva- lescence is due almost entirely to the muscular changes. The physical strength returns graduall}^ during convales- cence as the muscles are reg(3nerated, and it may be months before it is full}- re-established. The muscles of the tongue undtM'go degeneration in the same way as the other vol- untary muscles, which accounts in some degree for the interference with the function of that organ so often a pronunent ]ihenomenon of the diseas(\ TIk' soli r a nj glands enlarge, become lirni and tense, and assume a more or less brown-yellow coloi'. Tiiey have the consistency of cartilage. Late in the disease the hardness diminishes, and they assume a red cohu". These changes are due to a ]xirenchymatous degeneration of the glands, whicli has ])een preceded by a cellular liyper})lasia. It accounts to a certain extent for the diminution of tlie salivary secretion, causing adryiiess of rhe patient's mouth. which is so marked and constant an attendant of the fever. Similar cellular and ]iarenchymatous changes take ])Iace in the pancreas. Changes similar to these occur in other febrile diseases, so that tiiey cannot be regarded as characteristic of ty])hoid fever. LECTURE II. TYPHOID FEVER. MorMd Anatomy {continued).— Intestinal Lesions. — Eti- ology. At my last lecture I completed the history of those pa- renchymatous changes which are most frequently met with in typhoid fever. I mentioned that th&se changes could not be regarded as characteristic of this type of fever, for they are present in other diseases. By some these degen- erations are regarded as the necessary result of a pro- longed high temperature, but they are in no way different from those degenerations which occur as the result of blood-poisoning where prolonged high temperature does not occur. Especially is this the case in those diseases which are marked by their malignity rather than by their high temperature, as, for instance, acute yellow atrophy of the liver. Continuing the history of the morbid anatomy of this fever, I now come to those changes which occur in the lymphatic system of the intestinal track. The Intestinal Lesions. — These are the most impor- tant pathological lesions, and have been called the charac- teristic lesions of the disease, as these intestinal changes distinguish this fever from all other forms of acute disease. As the poison of small-pox manifests itself by certain changes in the tegumentary investment of the body, and the poison of epidemic cerebro- spinal meningitis by the formation of pus in the meshes of the pia mater, so the poi- Morjun AXATo.^[Y. 15 son of typhoid fever acts directly U])oii tlie mucous mem- brane of the small intestine, <2:ivin,<; rise to a catarrhal inflammation accompanied by changes in its anatomical structure, which, in the order of their develojmient, are characteristic of the disease. The character and extent of these changes depend U])on the duration of the fever and their nearness to the ileo-cjccal valve; the changes are most markiHl in the patches nearest to the valve, and less mark<^d in those farthest removed from the valve. In drscribing these intestinal lesions, I will suppose that we are examining a severe, well-developed case, which runs its regnlar conrse withont complication. Th(^ changes can be most conveniently studied by first considering those which occur within the lirst week of the disease ; tlLen^ those which are developed within the second week; next^ those which are most commonly found in the third week ; and lastly those which occur within the fourth week. They appear to begin as a catarrhal inflammation of the mucous membrane. During the first iceek the mn(;ons membrane surrounding the glands, especially that surrounding the Peyerian patches, becomes hyperjemic and swollen ; gradu- ally the glands become more and more elevated, their sur- face assumes a dark reddish color, interlaced by white lines; this is known as the '^shaven-heard appearance.^'' These changes begin and are most marked in the glands nearest the ileo-ca3cal valve ; they are generally well marked within forty-eight hours after the commencement of the disease, but are not fully developed until the end of the iirst week. By the end of the first \yeek all the glands are involved which are likely to undergo change. In {\\e second iceek, the mucous membrane of the intes- tine becomes less red; the agminated and the solitary glands more elevated ; the white lines upon their surface disappear, and they assume a uniformly red color. An unusually lapid cell development takes place in the folli- cles. By this excessive development and tin- multii»li«-ation of the cell elements of this gland structure, the follicles become swollen in all directions. Usually the new cell growth extends beyond the limit of the follicles, so that the 16 TYPHOID FEVER. adjoining mucous membrane is also infiltrated with cells. These newly formed cells may wander through the muscu- lar coat and penetrate the sub-serous tissue. By the mid- dle or latter part of the second week the process passes into its second stage, and necrotic changes are established in the newly formed tissue. These morbid changes may terminate in two ways : first, the new elements in these ductless glands may become disintegrated and undergo absorption, and in this way they may gradually undergo resolution ; second, individual follicles of the agminated glands may rupture and discharge their contents into the intestine ; third, the most frequent and characteristic ter- mination of the typhoid process is the separation of the dead tissue as a slough, and the formation of the typhoid ulcer. Usually the sloughing and removal of the necrotic tissue does not take place until the third week of the disease. The surface of the ulcers now presents a yellow appearance, simply because they have been stained yellow by the bile. As the sloughs gradually loosen and fall off, there is a loss of substance which extends to the deeper layer of the mucous membrane, removing the entire gland and the mucous tissue surrounding it, laying bare the muscular coat of the intestine. The necrotic process may extend and involve the muscular tissue and end in perfora- tion of the peritoneal covering. The size and form of the ulceration corresponds to that of the necrotic tissue ; if an entire Pej^erian patch is necrotic, an elliptical ulcer is formed, with its long axis corresponding to that of the intestine. In the jejunum and large intestines the ulcers are usually small and round. The edges of the ulcer are sharp, tumid, and overliang the floor of the ulcer. Sometimes the ulcers are hemorrhagic. In the fourth loeelt the process of cicatrization is com- menced. Gradually the swollen edges of the ulcers sub- side, granulation-tissue springs up from their base, con- nective-tissue membrane is formed, the edges of the ulcers become united at their base, which is covered with a layer of epithelium. The gland structure is never regenerated. The cicatrix which is formed by the healing of these ulcers MOKr.ID AXATOMY. 17 is slightly depressed, and less vascular tliati the stnioinid- iiig mucous membrain'. hiiiing rh<' healing ])r()!-ess rli*- cicatrix becomes more or less ])ignii'nr('d ; these ]>igin«'nt<'d scars may be recognized years after the cicatrization has taken place. These cicati-ices seldom cause any puckering or diminution in the calibre of the intestine. In many cases the process of cicatrization does not pursue this regu- lar course ; while one portion of the ulcer is cicatrizing, the process of ulceration in another part may be extending; such long-confcinued ulceration may prolong conval'^si-, 'Hcc. and even cause death from exhaustion. I will now briefly review these intestinal changes, and if you will bear in mind the weekly order in which they occur, 3'ou will better remember them. The first thing noticed is congestion, which is most nuirked around the glands ; with this congestion the glands become changed in color. Xext, the glands become en- larged, which enlargement is due to a rapid development of cells within their structure ; these cells are for the most part lymi)hoid ; but, in addition, there are present large, round cells, with several nuclei. These large, round cells are formed not only in the glands, but in the mucous and submucous tissue adjacent to them ; consequently, the enlargement encroaches more or less upon the surrounding mucous membrane. These newly formed cells not only swell the glands and press upon each other, but they press upon the capillary vessels which furnish these structures with nutrition ; consequently, there is an interference of the circulation of the gland structure, and as a result the glands become more or less anfemic ; degenerative changes occur as the result of impaired nutrition. In some of tln^ enlarged glands the new elements become disintegrated and are absorbed, and the process ends in resolution ; in others, individual follicles soften, break down, and their cont(Mits are discharged into the intestinal caiud. and the patches acquire a reticulated appearance. >fore frequently, a necrotic process is establislu'd which causes the removal of the entire gland and its contents, leaving an ulcer with everted and perhaps overhanging 2 18 TYPHOID FZVER. edges, with tlie muscular coat of tlie intestine for its base. It is now ready for tlie cicatrizing process, and if it pro- gresses regularly, first the edge of the ulcer becomes in- verted, then the base of the ulcer is covered with new connec- tive-tissue cells, the edges become adherent to it, new con- nective-tissue cells are thrown out upon the edges, and the formation of new tissue goes on increasing until finally the process of repair is complete. These ulcers do not always run such a regular course and terminate thus favorably. If the nutrition of the glands and the surrounding tissues is so interfered with that a gangrenous ulceration is estab- lished, sloughing follows, and the gland, with the muscular and other tissues in the neighborhood of the ulcers which are the seat of cellular infiltration, is removed. In some instances the necrotic process continues to extend and in- volves the peritoneum, causing perforation of the intestines and a fatal peritonitis. These ulcers may assume a hemor- rhagic character, with a surface of a dark color. Under these circumstances they are frequently the seat of profuse hemorrhages, Avhich may destroy the life of the patient. Usually, when such accidents occur, vessels of considerable size are involved in the ulcerative process. Whenever the sloughing process is arrested, repair takes place in the man- ner already described. As I have stated, these ulcers may be developed in the jejunum, the ileum, the stomach, and the large intestines. In the lower part of the ileum, at the ileo-cjecal valve, they are usually of large size — so large that only small poi'tions of healthy mucous membrane are left between them ; in the jejunum, stomach, and large intestines they are usually round and of small size. Mesenteric Glands. — Associated with these intestinal changes, analogous changes take place in the mesenteric glands. These mesenteric changes are also most marked in the glands situated nearest the ileo-cfecal valve ; they are secondary to the changes in the intestinal glands, and are usually affected in a degree corresponding to the extent of the intestinal lesions. The glands are first congested, then there is a production of lymphoid and large cells similar to MolM'.Il) ANATOMY. 19 tliose wliicli are found in the enlarged intestinal follicles, the glands become enlarged, and are the seat of an acute celluhir hyperplasia. When the enlargement has attained its full size, tlie liyjx'raMnia diminishes, and the cellular elements begin to disintegi-ate and are absorbed. In al)()ut one-half the cases the enlargement reaches its niaxiimiiu size by the middle of the second or at the commenremeiit of the third week. TIk^ eidarged glands vary in siz(^ from that of a hazelnut to a small hen's egg. In the stage of retrogression some of the glands simply shrink and return to their normal condition; in other ghmds partial softening takes place and afterwards absorption, leaving a fibrous cicatrix. If the glands reach a very large size, absorption is incomplete, and dry, yellow, cheesy masses are left, in ■which after a time salts of lime are deposited and they be- come enclosed in a fibrous capsule. In rare instances the glands become fluid, their capsules are destroyed, and the softened masses escape into the peritoneal cavity and cause peritonitis. A calcareous condition of the mesenteric glands, like the pigmented cicatrices of the solitary and agminated glands, give evidence of a previous severe attack of typhoid fever. TlK^re is yet another pathological lesion of typhoid fever oc- curring during convalescence, concerning which I will speak — namely, a suppurative inflammation in the cellular tissue upon the surface of the body. The inflammation is not of an active type, but is accompani(^d by some redness and pain ; gradually a tumor is formed at the seat of the inflam- mation; usuall}^ this occurs where there is the greatest amount of jiressure. After a time fluctuation becomes dis- tinct, the swelling increases ; sometimes two or more of these swellings coalesce, and flnallv an immense abscess may be formed, which when opened will discharge a pint or more of pus. These abscesses are due to suppurative in- flammation in the cellular tissue of the skin. Retro-])ha- ryngeal ulcers are the result of suppurative inflnmmntion of the connective tissue. As a result of imperfect nutrition of the skin, a gangrenous inflammation of the skin may be developed, which gives rise to " bt-d-sores.'' as tln-y are 20 TYPHOID FEVER. commonly called. These are especially liable to occur in the hitter stages of a typhoid fever which has been attended by a prolonged high temperature. The slough may form over the trochanters, over the sacrum, or wherever the tis- sues have been subjected to pressure for a long time, and is a consequence of impaired nutrition of the skin. Sometimes this gangrenous process not only involves the skin, but also the subjacent cellular tissue and the muscles. Gangrene of the toes and portions of the integument which are not sub- jected to pressure is due either to thrombosis or embolism. This completes the history of the anatomical lesions of typhoid fever. In connection with this history I would call your attention to something of special importance, which I wish you would remember, namely, that typhoid fever is a specific disease ; that it has a specific pathological lesion, a catarrhal inflammation of the intestinal mucous mem- brane, attended by special follicular changes ; and though you may find present in other diseases changes closely re- sembling those w^liich I have described as the characteristic lesion of typhoid fever, yet there is no other disease in w^hicli these changes have a regular development, in which the difi'erent stages can be indicated with a degree of cer- tainty by days and w-eeks. Etiology. — \Ye very naturally pass from the considera- tion of the mor])id anatomy of typhoid fever to its etiology. According to the classification of fevers which I have adopted, it is included in the list of miasmatic-contagious fevers. Usually, it has been regarded as an endemic form of disease. There seems to be no connection between its development and destitution ; for not only does it choose its victims from the hovels of the poor, but from the dwellings of the middle classes, and from the palaces of the rich. It ma}^ occur as an isolated case, or w^hole households and neighborhoods may be stricken down with the disease. We must therefore regard the causes of its production as local and limited, and not widespread. It is possible for it to prevail as an epidemic, but it must first have been endemic. In studying the etiology of this fever, two prominent questions present themselves : ETIOLOGY. 21 F/)\H. — Is it a contagions form of disoasc? Seco/id. — Is it ever of sijontaiieous origin i The qnestion of contagion is one tliat lias been very tlioronglily discnssed. For many }'ears representative med- ical men have differed \i\Hm this ])oint. After years of carefnl investigation, I think il may be now nnhesitatingly slated that facts do not snstain theo])inioii that ty])hoid fever is ever, strictl}' speaking, a contagions disease, or tliat it is ever directl}^ transmitted from one individual to another. Persons sick with this fever are now admitted into onr general hospitals, and are placed in beds by the side of patients sick with pneumonia or any form of chronic dis- ease, without endangering the lives of such patients. This fact shows how generall}^ the j^rofession regard this disease as non-contagious. Typhoid fever is no longer restricted by quarantine regulations. All these facts tend to dispose of the question, Is it a contagious disease ? The question, Is typhoid fever of spontaneous origin ? has also been thoroughl}^ discussed, and there are strong advo- cates on both sides of the question. Some of those who believe that it may have a spontane- ous origin maintain that the poison which gives rise to it is developed b}^ the decomposition of organic matter, and that the specific character of the fever is due to the particular substances which are undergoing decomposition. Others maintain that the decomposing substance is mainly human excrement — in other words, that decomposing human excre- ment is necessary for the production of the peculiar poison which gives rise to typhoid fever. Again, others who beli (l('C()ini>()sitioii docs not ])rinuuily ori.uiiKilt; the poison, but lurnislies a I'livorablc soil for ils giowth and dcvcloiinicnt. Facts warrant us in inakini; tlie statenicnt that while on the one hand tyi)hoid fever caiuiot be regarded as a strictly contanious disease, on the other hand it is not of spontane- ous origin. It is hardly necessary for nie to revimv all the facts which have a bearing ujjou this subject. I believe any uni)reju- diced person will arrive at this conclusion from tin? careful study of them, that when typhoid fever makes its ap])ear- ance in any locality, its development is preceded by the introduction of a specific typhoid poison, which has been re]:)roduced (in most instances) in connection with decom- posing human excrement. The question now arises, What is the real nature of that poison derived from a person sick with typhoid fever, which has the power of indeiinitely rei)roducing itself outside of the liody in connection with decomposing organic matter, and thus becomes the infecting agent, when individuals are brought within its intluence ? The history of endemics of typhoid fever leads to the con- clusion that the poison is contained in the fjccal discharges of the sick. When such excrement is in a fresh condition the poison is not active ; it must go through a stage of development outside of the body. This may take place in the excrement itself, but it goes on more raj)idly and abun- dantly if the excrement is collected in privies or in earth that is already saturated with oiganic matter. In this way you can readily explain how a lyphoie comiiuinicatecl fi(.iu one jierson to another through the excrements which have undergone decomposition after their discharge. 26 TYPHOID FEVER. TJiird. — That an endemic of typhoid fever only occurs where tlie air or drinking water of the locality has become poisoned by emanations from typhoid excrements which have undergone decomposition, and that, if the fever be- comes epidemic, it is a circumscribed epidemic, and not widespread. Fourth. — That the exact nature of the typhoid-fever poi- son is still unknown. LECTURE III. TYPHOID FEVER. S>/m2')toms. I SHALL this morning commence the history of the symp- toms of ty})hoid fever. If I shouhi attempt to give you a correct picture of this disease — one perfect in all its colorings — it would occu])y too much time, and you would become so confused as to be unable to recall even the outline of the picture. After I have briefly spoken of the manner in which this disease makes its advent, I shall consider the prominent symptoms of a typical case, and then discuss in detail tliese symptoms, wiiliout special regard to the time of their oc- currence. This fever is usually insidious in its a])proach, and comes on with a certain degree of uneasiness through- out the syst<^m ; the patient feels uncomfortable, has no l^ain, l)ut feels that he is about to be sick. If the individual is in a region where the disease is prevailing, it is quite common to hear the expression, "I believe I am going to have the fever," and yet those who make such complaint will scarcely admit that they are sick. They coni])lain of a grumbling headache, more or less aching of the liml)s, " a tired feeling all over," chilly sensations, alternating with flashes of heat ; loss of ai)petite, and not unfrequeiitly nau- sea and vomiting are present. These premonitory symp- toms gradually increasing in severity, by tlie fifth or sixth day the i)atient is comiK-Ued to take to his bed. At this early period there may be a slight diarrhcra. In very mild cases the disease conies on so insidiously, and with symp- toms so mild, that the patient is often able to pursue his 28 TYPHOID FEVER. ordinary avocations, coinplaining only of an undefined in- disposition—not feeling exactly well, but not regarding himself as really sick. In very many severe cases it is im- possible for the patient to accurately fix upon the time when the fever commenced. In no case will you be able to make an early positive diagnosis. Typhoid fever may be suspected, but that is as far as you can safely go. In all cases variation in temperature is one of the most important early symptoms. Such variation in temperature in a typical case may be divided into four periods, of one week each, which correspond to the four weeks of the disease. In the first week there is a gradual and steady rise in temperature, with regular morning and evening variations. This is one of the characteristic features of the disease. If, in any case of fever, you find, while making your ther- mometrical observations, that there is a gradual rise in tem- perature, marked during the first week by regular morning and evening variations, you may be quite certain your patient has typhoid fever. This gradual rise of, and these variations in temperature are not present in every case, but when they are present they will greatly assist you in mak- ing an early diagnosis. It has been said that typhoid fever is the only disease, except double quotidian intermittent fever, that gives two full thermometrical curves within twenty-fours ; that is, two full remissions and two exacerbations. If this is true, it helps to explain certain high temperatures in the morn- ing, and aiTords valuable assistance in making a diagnosis. During the second week the variations in temperature are slight, retaining, however, the same degree of exacerbation which was reached at the end of the first week. The variations during the third week are remittent in character. During the fourth week they become intermittent, and the range of temperature in the exacerbations is lower. The variations in pulse correspond to the variations in tem- perature. During the first week the pulse gradually be- comes more and more frequent, and remains at the height SYMPTOMS. 29 rraclird at the end of tlu'liist week; lliroui;liou( Ihc second and iliird weeks ihci-c are distinct morning- and cvcnin^^ remissions; durinu; the ronrtli week it falls to its iioinial standard. On the seveiitli day, or sometimes bctwiM-n it and the twelfth day, the characteristic eruption iipp(.'ars. Al)oiit this time the licadaclie al)ates and more or less somnolence and delirium conu' on. The delirium at llrst is slight, and is only obsei'ved during the night. Day by day the patient loses liesli and strength, and becomes more and more un- conscious, and all the phenomena of the typhoid state are develoi)ed, viz., a dry blown tongue, feeble ]uilse, low mut- tering delirium, stupor, tremors, subsultus, involuntary evacuations, and the other phenomena of great prostration. If the disease is to terminate favorably the amendment is usually gradual. The first sign of improvement is a de- cided remission of the fever. During the first week there is usually some diarrhoea ; in very many instances it is pres- ent before the patient seeks the advice of the physician. It may have ceased at the time he seeks such advice. Such, in brief, are the phenomena which attend the usher- ing-in and developing stage of an ordinary case of typhoid fever ; they are, however, subject to numerous modifica- tions. Some cases of this fever are mild throughout their entire course ; some are severe at first and mild afterwards ; some are mild at first and severe afterwards ; while others are severe throughout their entire course. In the detailed study of the prominent phenomena of this disease I shall nt^t attempt to follow the order of their development, for they are subject to so many variations that such a course is imi)Ossible. In ourattem])t to analj'ze its principal symptoms I will first notice the changes which take place in the counte- nance. TiiK PiiYsKxiXOMY.— As a rule, in the milder cases, the countenance has noj^iing peculiar in its appearance ; tlie patient does not even look ill. If the disease is of a severe type, by the second week the countenance assumes a char- acteristic appearance — there is a pah^ olive, leaden look, 30 TYPHOID FEVER. the eye becomes dull and tlie conjunctiva congested, and usually there is a small, rose-colored spot in the centre of the cheeks. The face does not assume the dark mahogany color, as seen in typhus, but in the advanced stage of the fever it has more of the hectic flush of phthisis. Tongue. — The tongue will also present certain changes. From the very outset it is covered with a light, white coat, but there is nothing special in its appearance before the end of the first week ; then it may become red upon its sides and tips, and show a slight disposition to dryness in its centre. As the disease passes into its second and third weeks, the tongue becomes more heavily coated, the coat- ing becomes brown and dry, and sordes collect upon the teeth and sides of the mouth in sufficient quantities to form crusts. These crusts may become thicker and more abun- dant as the disease progresses. At any period in the course of the disease the tongue may suddenly clear off, and present a shiny red appearance, "beef-colored," as it has been called. The tongue and lips may become dry, cracked, and fissured. As the sordes are removed from the lips, tliey will often bleed ; and in certain cases, more especially in the severer forms of the disease, the entire mouth and tongue may be covered with dark-colored in- crustations. Such incrustations are seen early in connec- tion with those cases where there are extensive blood- changes : when present tlie}^ are of grave significance. As soon as convalescence is established the changes in the appearance of the tongue are very marked. One of the first indications of convalescence is a moist condition of the tongue about its edges ; gradually its entire surface be- comes moist, and by the time convalescence is fully estab- lished it is restored to its natural condition. Gastric symp toms are always more or less prominent — loss of appetite is one of the earliest sjanptoms, and nausea and vomiting are quite common during the first week of the fever. The vomited matters usually consist of a greenish fluid. When vomiting comes on late in the fever, it is due either to sub- acute gastric catarrh, or it is symptomatic of local or gen- eral peritonitis. In a large proportion of cases the thirst is SYMI'To.NfS. 31 excossivo. The lips ar<' parcliod, and in severe cases nark and Itli-'d. In some eases luniori-liage from tlie gnnis oeenrs. DiAPJiiKKA. — Altli<»n,L;li nxt invaiial'ly present, it is so frequent an attendant of this fever tiiat it is considered one of its cliaracteristie symptoms. It varies with the severity of tlie attack, the date of its coninjencement, and its dura- tion. The cliaracteristie typlioid discharges are of a yel- lowish green color, described in tlie books uTid*n- the term of "pea-soup discharges," Sometimes they are of a dark color, resembling coffee-grounds ; their reaction is alkaline. In some cases diarrhoea is present at the very outset of the disease, and continues throughout the entire course. In other cases it does not appear until the third week. The second week is the ordinary time for its appearance. When the diarrha?a appears late in the course of the disease, the discharges are more copious than when it appears earl)^ A mild diarrhoea throughout the entire course of the fever is a favorable rather than an unfavorable symptom. In mild cases diarrhoea is sometimes absent. I>rTESTiNAL Hemorrhage. — Intestinal hemorrhage is not an infrequent attendant upon typhoid fever. It occurs in about one in twenty cases, and varies in quantity from a mere trace of blood in the stools to a profuse discharge of from sixteen to eighteen ounces. The slight hemorrhages which sometimes occur early in the disease simply indicate a hemorrhagic tendency, the same as the epistaxis which is very frequently among the early symptoms. In both in- stances tlie bleeding comes from the capillaries of the mucous membrane. The more profuse hemorrhages are due to the opening of an artery in some intestinal ulcer. IIemorrhag<^s due to this cause may be sudden and profuse, and may destroy the life of the patient. The usual time for the occurrence of these profuse intestinal hemorrhages is in the latter part of the second and during the third week. These hemorrhages are usually ]ireceded by a sudden fall in temi)erature, ]ierha]>s two or thiee degrees; if then in a patient severely ill of typhoid fever a sudden fall in temperature occurs during the second or third week, 32 TYPHOID FEVER. accompanied by extreme prostration, it is very conclusive evidence that intestinal hemorrage lias occurred, although externally the hemorrhage may not have made its appear- ance. When intestinal hemorrhage occurs during the sec- ond or third week it must always be regarded as a grave symptom ; yet it is not necessarily followed by fatal results. The blood is usually fluid, rarely clotted ; generally it is of a bright red color, owing to the alkaline condition of the intestinal contents. Copious intestinal hemorrhages are more frequent in severe cases that have been attended by profuse diarrhoea. In one or two instances I hav^e had patients die of intestinal hemorrhage before any blood had been voided externally. If the patient survive a j)i"0- fuse intestinal hemorrliage, there is great danger of his dying from peritonitis. He may die unexpectedly by syncope a number of hours after a 2:)rofuse intestinal hem- orrhage. Abdominal xx^in and tenderness are not usuall}^ present at the very outset of tj^phoid fever ; generally, and almost without exception in the severer cases, by the sixth day of the disease some pain and tenderness will be present in the right iliac fossa. The pain and tenderness usually increase as the disease progresses, and in the advanced stages it is sometimes so marked that slight pressure over this region gives the patient great pain. While examining this region in order to determine the presence or absence of pain and tenderness, remember never to press the surface with the ends of the fingers, but alwa^^s make the examination with the palm of the hand ; while making the pressure watch the face, and frequently you will be able to determine by the expression of countenance whether you are, or are not, causing pain, long before an audible complaint is made by the patient. It is also important for you to bear in mind the possible occurrence of a more severe abdominal pain — namely, that pain arising from intestinal perforation. The following are the characteristic symptoms of this lesion. If in the course of a slight or severe form of this fever, or even when the disease has been latent and the diagnosis of typhoid fever SYMrTOM>'. 33 lias not boon oloar, tlio pariont should bo suddt'iily seized witli diai'ilupa. ])aiii in tlio abdoiiK'ii, au:,i;i'avat('d by pres- sure, porlKi])s at lirst localized in tlie right iliac fossa, but soon extciidint:: over the entire al)doininal cavity, attondod by symptoms of great prostration, a rapid, feeble pulse, a sunken, anxious expression of countenance, rapid tympani- tic extension of tho abdomen, nausea and vomiting, quickly followed by coldness and blueness of the extremities, and the other signs of sudden collapse, you may be almost cer- tain that ^perforation of the intestines has occurred. I have known this accident to occur when convalescence was pro- gressing ajiparently safely and satisfactorily. Few live more than thirty-six hours after the occurrence of the per- foration. Tiimpanitls is another very common symptom of typhoid fever. Usually it is not present during the first week, but by the end of the first or the commencement of the second week a fullness of the abdomen will be noticed. As the fever advances, sometimes the distention often becomes ex- treme ; this is due to a collection of gas in the large intes- tine, developed from some change in the mucous membrane, the exact nature of which we do not fully understand. We only know that sometimes the mucous membrane of this intestine very rapidly secretes gas, or allows it to generate, and that the intestine becomes distended by its accumula- tion. When once it is developed it remains until convales- cence is fully established. It is alwaj's an important diagnostic sign of this fever. In connoction with the devel- opment of the tympanitis, whon firm pressure is nuido over the right iliac fossa, a gurgling sound is produced; but gurr/liiiff in the right iliac fossa cannot by any means be 'regarded as a positive symptom of ty])hoid fever, as it may occur in any disease where there is distention of the abdo- men due to accnmulation of gas in the intestines. In ty- phoid fever, so long as tho abdomen remains tvm])anitic, no matter what the temperature and pulse of the ])atient may be, he is in more or less danger, for it shows that there are intestinal changes still in progress, and that the re]»arative processes are not complete ; this is more especially the case 34 TYPHOID FEVER. wlien the tympanitis has continued from the active period of the disease into the jDeriod of convalescence. Therefore, the presence of tympanitis during convalescence is never to be lightly regarded. These are the most important symptoms wldch are refer- able to the alimentary tract, and may be regarded as form- ing, in connection with the temperature variations, the essential part of the history of this fever. Urine. — Extended and very careful analyses of the changes in the urine of typhoid fever patients have been frequently made, without giving any very practical results. Usually during the first two weeks of the fever the urine is diminished in quantity ; after the second week it is in- creased. During the time it is diminished in quantit}^, its color is dark and its specific gravity is high ; when it is in- creased and convalescence is established, it becomes pale, and its specific gravity is lowered. The amount of urea excreted daily throughout the active period of the fever is increased. The increase is in propor- tion to the intensity of the fever, subject in some degree to the quantity and quality of the food taken. It will be greater when large quantities of strong beef-tea are taken, than when the diet consists of milk. So long as the kid- neys are able to eliminate the excess of urea, no harm re- sults ; but if the quantity exceeds their power of elimina- tion, or if their function of elimination is interfered with, uraemic symptoms will be developed, such as delirium, stupor, and coma. Albumen in the urine is only of occasional occurrence in the course of typhoid fever. When present the quantity usually is small, and it is only temporarily present. It rarely appears before the third week. Its appearance is often marked by the occurrence of cerebral symptoms. Renal epithelium and casts may or may not be present with the albumen. The sjoleen is often much enlarged, and can be felt through the abdominal wall. The enlargement" is greatest in persons under thirty years of age, and during the second week of the fever. Nervous Phenomena. — The symptoms referable to the SYMI'TOMS. 3.") noi'Yons system arc not so proiiiincnt in t3'])hoi(l as in typhus fever; 3'et tliero arc niany cases in which these symptoms phiy an inqiortaiit ])arl in its liislory. One of the luosr constant ol" this (;lassoi" syin])toins is licad- ache. In tlie majority of cases it is one of tin.' usli('iiii,L;-iii symptoms of the disease. It is present in mihl as will as in severe cases ; sometimes it is confined to tlie forelu^ad and temples, more often it extends over tlie wdiole head — not violent, but a dull, heavy pain. It usually increases in severity until the middle period of th(3 disease, certaiidy until the close of the tirst week; and generally associated with it there is intolerance of light and conjunctival injec- tion, pain in the back and limbs, and a general aching of the whole body. Somnolence is another nervous phenomenon present to a greater or less degree in all cases. In mild cases it does not appear until late, and usually is not long-continued. In the severer cases it appears early and continues until con- valescence begins ; in fatal cases it increases up to. the time when the patient passes into a state of coma. It is often interrupted by delirium. In children this symptom is especially prominent, and is very valuable as a means of diagnosis. For example, if a child complains of feeling sick, without any well-defined pain, upon inquiry you find that he has had little or no slee]) for two or three days ; gradually he passes into a state of somnolence, which at first is slight, but soon it becomes ])i-()foiind : you may infer that typhoid fever is about to be developed. Dtlir'nim is more ficcpiently jnvsent than absent in ty- phoid fever. The character of the delirium varies; the usual form is known as the '' low-muttering '' deliiiuni. This form is rather characteristic of tliis type of fever, and yet in very many cases the (Icliiinm may be violent in character, and may become maniacal to such an extent as to require physical restraint. Not unfrecpiently tyjihoid fever patients attempt to jump out^ of a window, or to in- jure themselves or their attendants in their endeavors to escape from fancied pursneis ; or rhe}^ are seized wiih the 36 TYPHOID FEVER. impression tliat tlieir attendants are their personal enemies, or that within themselves there is sometliing fearful that must be destroyed. It is very common for the minds of this class of patienta to be occupied with those things which engaged their atten- tion just prior to their illness. They imagine persons who are absent are about them, and not unfrequently call them in the most endearing tones, or denounce them with the most violent epithets. The delirium rarely comes on until the second week of the fever, and it commences and is most active at night. After it has once appeared it usually continues until con- valescence is established, and generally disappears during a sound sleep which attends the early stage of convalescence. The maniacal form of delirium in typhoid fever is usually most marked at night. During the low-muttering delirium, if the patient is asked questions, he will generally answer correctly. Muscular Prostratioist and Paralysis. — In all severe cases of typhoid fever muscular prostration is noticeable in the early stages, and increases with the progress of the fever. It is generally most marked during the third week. Where there is marked muscular paralysis, the urine and fseces are passed involuntarily, there is inability to protrude the tongue, and more or less difficulty in deglutition. These symptoms are often attended with difficulty or inability to articulate distinctly. Retention of the urine, occurring early on account of the inability of the bladder to evacuate itself, is a very unfavorable symptom ; the same is true of involuntary discharges from the bowels. Muscular Tremors. — Tremors of the hands, or tongue, or lips, are most often met with in young subjects, and in those who are addicted to the use of spirits. Severe tremors, unaccompanied by much mental disturbance, often attend extensive intestinal changes. Spasmodic movements, such as subsultus, hiccough, etc., are observed in the advanced stage of severe cases. Eigid contraction of the muscles of the neck and those of the extremities are also sometimes present in severe cases. SYMPTOMS. 37 General convulsions me oi" very rnre oecnrreneo, except in very young children, and when they occur liave no spe- cial signiiicanco. Special Skxsks. — The syini)lonis reTeral)!*' to the special senses require little more than enumeration. As regards the sense of s'ufhf, there is notliiiig wortliy oC note, except that the eye assumes a dull expression and that the pupil is dilated ; some jiatients complain of hazi- ness of vision, which is increased when they assume a sitting posture. The sense of hearing is always more or less impaired ; this is most marked about the middle period of the fever ; then it is impossible for your patient to hear ordinary con- versation — you will be obliged almost to shout in his ear. Hinging and buzzing sounds in the ears are often com- plained of in the early stage of the fever. When the loss of hearing is confined to one ear, it is generall}^ caused by ulceration of the mucous lining of the Eustachian tube, or by suppuration of the middle ear. The se)ise of taste usually is altered or perverted ; articles of food are tasteless, or have an unnatural flavor. AVhen the tongue and mouth are covered with a heavy coating of sordes, with a tremulous tongue, the patient is unable to distinguish between bitter and sweet, and swallows the most disgusting doses without complaint. Ill/prrcpsthesia is another disturbance of a special sense. The surface of the body of a typhoid fever patient may become so sensitive that lie will cry out with pain from the slightest touch. Tliis hy})ei-avsthesia may be present during the lirst week, or may not be i)i-esent until convalescence is established. It is most marked over the abdomen and lower extremities, and usually occurs in females of a hysterical tendency. It is of importance that you discriminate between cutaneous tenderness in the abdominal region, and the ten- derness of i)eritoneal inflammation. ErisTAXis. — I have already referred to this symjttom as of common occurrence in the early stage of typhoid fever. AVhen it occuis during the first week, in most cases it is of little importance, except as a diagnostic sign of this type of 38 TYPHOID FEVER, fever; when it occurs during the third week, it becomes important as an element of prognosis, as it may be suffi- ciently profuse to destroy the life of the patient. Occurring late in the disease, unless it can be promptly arrested, it always jeopardizes the life of the patient. Emaciation is perhaps more marked and rapid in this than in any other form of fever. It commences early and is progressive. By the time a patient has reached the fourth week of a typhoid fever of even moderate severity, he is usually in a condition of extreme emaciation. In this par- ticular he markedly differs from a patient ill vdth typhus fever, for in the latter case emaciation to any great extent does not occur. LECTURE IV. TYPHOID FEVER. Si/nipfoms {continued). — Differential Diagnosis. I WILL continue the history of typhoid lever, and de- scribe more in detail those 'cariations in temperature which ntteiid its development and mark its progress. As has al- read}' been stated, the temperature at the commencement of a typical case of this fever is characterized by morning remissions and evening exacerbations ; and by these regular variations often you will be able to make a diagnosis dur- ing the first week of the disease. In order to estimate the real value of these variations, it will be found convenient to divide the fever into four periods which shall correspond to the four weeks of the disease. In making your therm ometrical observation, in this as well as in all othtn- forms of fever, the thermometei may be phiced in tlie axillji?, the mouth, or tlie rectum. You must remember, however, that tlie temperature ranges al)<)ut one degree higher in the mouth and rectum than in the axilhe. I shall refer to axilhuy temperatuiv whenever I speak of temperatui-e without qualilication. Usualh' the tem])ei'ature begins to rise about noon on the first day of the development of the fever, and continues so to do until between six and eiuht o'clock in the evening:, when it reaches its niaximurii height for that day; then there is no change until midnight, when it begins to decline, and by six or eight o'clock in the morning it has reached its minimum decline, which is a degi-e<^ higher than on the morning of the preceding day. After six or eight o'clock in the morning the temperature does not vary much until 40 TYPHOID FEVEK. noon ; then it again begins to rise, and b}^ six o'clock in the evening it has reached its maximum elevation for that day, which is two degrees higher than on the evening of the preceding day. Again, at midnight it begins to fall, and by morning it has fallen a degree, Avhich leaves the maximum temperature for the day a degree higher than on the preced- ing day. Thus it rises a degree each day, with regular morning and evening variations, until the eighth day of the fever, when, in most cases, it has reached its maximum height. During the second week the temperature remains at about the same maximum degree which it has reached by the end of the first Aveek. There are morning and evening- variations of a degree or more, but the maximum of the evening exacerbation remains the same. During the third week the remission becomes more and more marked, and with it the temperature falls, while dur- ing the exacerbation the temperature retains the same stand- ard as during the second week. By the end of the third week the morning temperature during the remission will have fallen two or three degrees below the point which it had reached during the second week. By the time fha fourth loeeJc is reached, or at least by the middle of the week, the temperature becomes intermittent, and with each exacerbation it falls lower and lower, until by the end of the week the normal standard of temperature has been reached — it may fall a little below the normal standard. These are called the typical therm ometrical variations of typhoid fever, 3^et they are not always present ; besides, there are many things which will materially modify them. For instance, marked deviations from the record may be produced b}^ complications Avliich would never have been discovered but for the irregular thermometrical variations. By treatment, for a time the temperature can be very much lowered ; but, if the treatment be discontinued, it will again rise. In some cases you will be unable to ascertain the cause of the irregularity. Pulse. — The pulse is also subject to variations, which correspond very nearly with the variations in temperature, RYMI'TOMS. 41 tiiid occur not 011I3' oil diircicnt days, but at dill'ci-ciit hours on the same day. Durini;- tlie ilrst week I lie |iuls(,' Ix'coiufis iHoicaiid iiioie frequent, (111 liim- (In' second and third weeks it remains at its liei^-lit, and during the fourtli we(?k siidvS to its normal average. During the whoh^ course of thi; dis- ease it is k^ss frequent in the morning Ihaii in I he cvciiing. If, at the commencement of the fever, tiie pulse is ninety- eiglit, it gradually increases in frequency, until, by the end of the lirst week, it has reached one liundred, oronelinn- dred aiul ten per minute ; during the second week it remains at about this height ; after that time it may run as high as one hundred and twenty or one hundred and forty. Dur- ing the first and second weeks the rate of the pulse and the temperature range correspond, but after this time tiu^ i)ar- allelism ceases, the failure of heart-i)o\ver beginning to manifest itself. This failure of heart-])ower is indicated by ail increase' in the freqiieiicj^ and feebleness of the pulse, which at this rime may reach one liundred and forty per minute, and yet the tem])erature show no alarming varia- tion. A jDulse which remains for live or six consecutive days above one hundred and twenty per minute is a bad omen, for it shows extensive changes in the muscular tissue of the heart. Under these circumstances, the pulse may become in-egular and intermitting. Should these irregu- larities and intermissions occur during the third week, in most cases they are followed by death. With an irregular and intermitting i^ulse, usually, you will lind the first sound of the heart inaudible over the precordial si)ace, and this indicates that prompt and judicious means must be em- ployed to restore, if possible, the heart's normal action, and thus relieve your patient and avert a fatal issue. The severity of the fever during the lirst and second weeks of its development is, to a great extent, detf'rmined by the frequency of the ])ulse and the lieight of the tem- perature. Although delirium and extensive tympanitis are important symptoms, yet they do not determine the result ; but if your patient, during tin? lirst, or at the commence- ment of the second week of the disease, has a pulse of one hundred and twenty per minute, and a temperature of one 42 TYPHOID FEVEK. hundred and six, it is very doubtful whetlier convalescence can ever be established. You must remember that from feeble heart-power alone the pulse may increase in frequency, while the temperature is steadily falling. On the other hand, the pulse sometimes falls almost to a normal standard, while the temperature re- mains high. In either case, if these changes occur during the second or third week of the fever, they must be re- garded with susjoicion. Eruption. — We now come to the study of what is known as the " characteristic symptom " of typhoid fever, namely, the eruption. Some have claimed that the eruption should be considered as a lesion of the disease, but I prefer to class it among the symptoms. It makes its appearance between the sixth and twelfth days, dating from the commencement of the fever (not from the day the patient takes his bed, but from the time the first symptoms of the disease manifest themselves), and it is not attended by any unusual sensa- tion. It remains visible from eight to fourteen days, leaving no stain or mark on the surface after its disappearance. It consists of isolated, lenticular spots scattered more or less abundantly over the surface of any part of the body, yet usually most abundant upon the chest and abdomen. There may be only a few spots visible at a time, or it may be so profuse as to cover the body like a rash. Two or three well-defined spots of the eruption are sufficient to establish the existence of the fever. Each spot is circular in shape, and varies in diameter from a point to a line and a half, rarely reaching two lines. It is slightly elevated above the surface of the surrounding cuticle, is of a bright rose color, disappears upon slight pressure, and returns as soon as the pressure is removed. Each spot remains visible for three days, and then disappears. Sometimes, as one crop of the eruption disappears another is developed, and this may go on for eight, twelve, or fourteen days. There are many cases in which only one crop appears. As soon as one spot makes its appearance, it is well to mark it with tincture of iodine or nitrate of silver, so that you may be certain that SYMPTOMS. 43 your observations are always madf upon tlie one point. If it is a spot of typhoid erui)tion, and one croj) of (nuption is to follow another, it will disappear within three days from the time at whirh it was Hrst sei-n, and other spots will tak<' its place. It is this feature which distinguishes the typhoid eruption from that of all other fevers. The question may be asked, Is this eruption essential to the diagnosis of typhoid fever ^ Doubtless there is no question in connection with its history which has given rise to more discussion than this. As a matter of course, this question has two sides. Many observers mention that the eruption is not constant, and consequently not neces- sary for its diagnosis ; while others, equally competent, maintain that, unless the eruption be present at some period during the progress of the disease, the diagnosis of typhoid fever cannot be made with positiveness. Jenner states that he found the eruption present in one hundred and forty-eight out of one hundred and lifty-two cases. I would not say that it is possible for typhoid fever to occur without the eruption, neither would I affirm that scarlet fever ever exists without the characteristic rash of the dis- ease ; but I do say that, as regards these respective fevei-s, that if no eruption was present, I would make the diagnosis with equal hesitanc}' in the one case as in the other. The eruption is usually most marked in cases of typhoid fever which occur between the ages of ten and thirty. Be- fore ten and after thirty years it is usually not as well marked, and may be readily overlooked unless careful search is made. I have described to you the prominent symptoms which are present during the course of a ty]ti(al case of typhoid fever, and believe you will now l)e able to recognize the disease and to manage intelligently your tyi)hoid fever patients. At this point let me state to you that the tyi)hoid poison, in its operation on the human body, does not always effect the series of changes and symptoms which I have been describing. On the contrary, there are cases which run so mild a course that they can scarcely be dignilied l)y the 44 TYPHOID FEVER. name of fever; besides, there are imperfectly developed cases wliicli show a great diversity in their course, but they all can be included under two heads : First. — Mild typlioid fever, in which the symptoms are all mild. Second. — Abortim typlioid fever, in which the duration of the disease is markedly shortened, Tn the tnild type., the fever runs its regular course, but it is of low grade. The temperature rises regularly until its maximum is reached, which rarely exceeds 103° F. ; then it remains stationary for a time, generally about a week ; then a decline follows in the same manner as was noticed in the typical case. This is the regular course of these cases if left to themselves, and, as a rule, they should be left to themselves. Some of these cases are so mild that the patients are not confined to the bed, nor even to their rooms, and perhaps throughout the entire course of the disease are able to transact a certain amount of business. Such cases have been called "walking cases" of typhoid fever. The eruption appears in these cases early, is of short duration, only a few spots appear ; usually there is only one crop. Diarrhoea is also present in most cases of this class, but it is of a mild type, the discharges from the bowels apparently giving relief to the patient. In some cases the diarrhoea alternates with constipation, or consti- pation may be present throughout the entire course of the disease, and the cases go on exhibiting a varying amount of fever for from twenty to thirty days, until gradually conva- lescence is established. This class of cases, if properly managed, rarely prove fatal ; but, if improperly managed, there is great danger. For instance, if a patient walks about while he is suffering from one of these so-called mild attacks of typhoid fever, he does it at great risk to life— in other words, there should be no "walking cases" of ty- phoid fever. A patient sick with typhoid fever, however mild the type, should take to his bed and remain there until convalescence is fully established, as it is impossible to say just how extensive the changes may be that have DIFFEKEXTIAL DIAGNOSIS. 45 occiirivd in tlie intestinal track, and in tlio niiklGst ty]w of the disease tliey may be of such a iiarurc tliat very little ]>liysical exertion will cause intestinal i)eif()ration, \v]ii<-li will be followed by a fatal peritonitis. The ahortiveform of tf/pJioid fever is ushered in with all the symptoms of a typical case — headache, lassitude, pain in the limbs, nausea, etc. — and the temperature during the first week follows the regular variations of the fever. At the onset the disease has every ap})earance of a severe form of typhoid fever ; the temperature may rise as high as 105' F. or 106° F. by the end of the first wwk ; delirium is often active, and diarrhoja is present. By the end of the second week, certainly by its close, if recovery occurs, tlie fever is cut short, and a])ruptly disappears ; the temperature falls to the normal standard, and the patient passes on to a state of rapid and complete convalescence. The eruption, diarrhea, and all the urgent symptoms of the disease may be present, and yet before the end of the second w^eek the patient may have fully convalesced. That it is the typhoid poison which thus acts upon the system, and gives rise to the characteristic symptoms of typhoid fever in these abortive cases, is evidenced by the fact that at the post- mortem examinations the characteristic typhoid intestinal lesions are found, and these, taken in connection with the presence during life of the t^^phoid eruption, estab- lish the diagnosis beyond question. There can be no doubt but tliat an individual may be affected, over- whelmed, as it were, by typhoid poison, and yet not de- velop well-marked typhoid fever. So, if only a moderate amount of tj'phoid poison is introduced into the sj'stem, a mild or an abortive type of fever will be developed. The natural powers of the individual to resist the action of such poisons must always be regarded, and should be taken into consideration in the treatment of a case. Differential Diagnosis.— In a typical case, after the fever is fully developed, the diagnosis is not difficult. Tlie presence of febrile excitement, marked by evening exacerba- tions and morning rtMuissions, headache, diarrhoea, abdomi- nal tenderness, and other abdominal symj)toms, and the 46 TYPHOID FETER. ])resence of the cliaracteristic rose-colored spots, are snf- ticient for a diagnosis. In tlie mild type of the disease, or when the symptoms are developed irregularly, or during tlie first week of a typical case, the diagnosis is often difficult, and sometimes impossible. The principal diseases which are liable to be confounded with tj^Dlioid fever are typhus and relapsing fevers, typho-malarial fever, acute tuberculosis, pj^semia, septicaemia, pneumonia, and gastro-enteritis. The points of differential diagnosis between typhoid and typhus, relapsing and typho-malarial fevers, will be more apparent, and more readily comprehended, after we have studied these different forms of fever. I shall therefore not call 3^our attention to their differential diagnosis until I have given you a history of these fevers. Acute Tuberculosis. — This disease is attended by very many of the symptoms which are present in, and by some supposed to be characteristic of typhoid fever. The fever of acute tuberculosis is of a remittent type, attended by evening exacerbations and morning remissions, delirium, a dry, brown tongue, a tendency to stupor, great prostra- tion, rapid emaciation, and sometimes by a diarrhoea, with abdominal tenderness and tympanitis. All of these are among the prominent symptoms of typhoid fever ; conse- quently these two diseases are frequently mistaken the one for the other. More than once have patients in Bellevue Hospital, with the diagnosis of typhoid fever, presented at the post-mortem examination the characteristic lesions of acute tuberculosis. If, therefore, patients with acute tu- berculosis may go through a large general hospital, under the observation of diagnosticians, who certainly are not men of inferior ability, and be supposed to have t^^phoid fever, there evidently is great danger of a mistake in diag- nosis. The higher range of temperature in acute tuberculosis than in typhoid fever is one of the distinguishing character- istics of the disease. Usually, early in the progress of the disease, it reaches 106° F. or 107° F., while in typhoid fever the temperature rarely reaches 106° F., and even then in PIFFEPwENTIAI. I)IA(;XOSIS. 47 most rases not Ix-fon- the end of the st-coiul week of tlio fever, by Avliich linn' you will have been able to cleter- minc^ tlie true nature of the disease. Again, you will notice that there is no eruption, neither is there enlarge- ment of the spleen in acute tuberculosis, while both are very constant attendants of ty]»hoid fever ; yet their absence is not positive proof tliat typhoid fever does not exist. In all doubtful cases you must take into account the family history of the patient, his immediate surroundings, whether typhoid fever is prevailing at the time, and whether the patient has been exposed to tjjihoid poison. These are important points, and by a careful study of them, if yon are able to watch the case thronghout its entire course, probably you will arrive at a correct diagnosis before the end is reached. Should 3'ou see the case during the first week of the disease, rely upon the presence of the rose- colored spots for a diagnosis of typhoid fever, and you will rarely mistake it for acute tuberculosis. Pv-EMi-V AXD Septicemia.— These diseases, while devel- oping, present many S3^mptoms which resemble those of the developing stage of tyjihoid fever. In most cases you will be able readily to recognize them, as the surface of the body has a jaundiced hu«' ; there are no lenticular spots, and the febrile symptoms are irregular in their develop- ment. There are exacerbations and remissions, but their appearance and disappearance are not marked by any reg- ularity, and usually there is more tlian one exaciM-bation and remission in the twenty-four hours. Not only are the variations in temperature irregular, but the temperature reaches a high degree much sooner, and ranges higher throughout its entire course in py;i^mia and septicaMuia than in typhoid fever. In pyjcmia and septicaemia you will also have early in the disease profuse sweatings, great prostration, rapid emaciation, delirium, subsultus, tympani- tis, and diarrha?a, while in typhoid fever these do not come on until late in the disease. Besides, the history which precedes and attends the development of jiyaMuia and sep- ticaemia widely differs from that of typhoid fever. f 48 TYPHOID FEVEF.. There is a condition of septic poisoning occnsionall}" met with, resulting from the introduction into the system of septic malaria through the drinking water, which so closely resembles that Avhich is the result of typhoid poisoning that it is almost impossible to make a dLfferential diagnosis. In these cases the absence of the rose-colored spots is almost the only distinguishing feature. Pjs^eumoxia. — Pneumonia, with typhoid symptoms, is sometimes mistaken for typhoid fever. It is called in your books typliokl pneumonia. The differential diagnosis is not difScult if you remember that the pneumonia which com- plicates typhoid fever does not come on until late in the fever, and you have the regular history of typhoid fever preceding its development. On the other hand, when the tj^phoid symptoms are present from the beginning of, or come on at the end of the second stage of the pneumonia, the ph^^sical signs of the pneumonia will attend or precede the typhoid symptoms. There will be cough and the char- acteristic j)neumonic expectoration ; there will be no erup- tion, and no typical variation in temperature. If you do not see a patient who is over sixty years of age with this type of pneumonia until the second or third week of its progress, although evidences of lung consolida- tion may be present frequentl}^, it will be very difficult to decide whether the pneumonia is or is not complicating a typhoid fever, and under these circumstances of course the differential diagnosis will be very difficult. Gastro-enteritis. — In the adult this disease is quite readily distinguished from typhoid fever, as the diarrhoea and vomiting precede the febrile movement ; the fever is ir- regular in its development and progress, and the tempera- ture rarely rises higher than 103° F. In a child between two and six years of age it is very difficult to distinguish gastro-enteritis, or intestinal catarrh, as it is sometimes called, from typhoid fever. The eruption is not so promi- nent or constant a S3anptom in the child as in the adult, and with both diseases we have diarrhoea, tympanitis, and typhoid symptoms. These circumstances render many cases of this character difficult of diagnosis. When all TMKFKrj-.NTIAL DIAGNOSIS. 49 the sjniptoms precede the fever, niid you ran liave a liis- tory of tlie case, and a tlierinoinetrical recoi-d from the he- iriiiiiiiii: of the fever, ill most cases you can i-eadily make tlie diaixiiosis ; hut if you do not see the case until it lias reached the second week of its pro^rn'ss, and you have no accurate or r.'lial»le history of its development, a positive diauiiosis is impossible. 'ruiniixoi'S DisK.vsK. — Poisoning l>y trichina' has fre- quently been mistaken for typlioid fever. This condition is not unfrequently attended Ity diarrhcpa, vomitinir, and the development of other typhoid sj-mptoms ; but with poison- ing by trichinje there is almost constantly present muscular pains and (pdema of the eyelids, which will be sufficient to arrest your attention. We have, then, in poisoning by trichina?, diarrhcBa, vomiting, tympanitis, rapid emaciation, great exhaustion, a brown, dry tongue, higli temperature, and other typhoid sym2)toms ; with these you have the oedema of the face, especially of the eyelids, and the most intense muscular pains. By removing a small portion of the muscular tissue and placing it under the microscope. the trichinje can be seen, and thus you will be enabled to make a positive diagnosis. 4 LECTURE V. TYPHOID FEVER. Prognosis. — Duration. — Relapses. I HAVE already spoken to yon of tlie differential diagnosis of typlioid fever, and will now give 3^on some of the more prominent rules which should govern you in its prognosis. Peognosis. — Death may occur at any stage of this fever. A typhoid patient is not out of danger until all tympanitis, diarrhoea, and other abdominal symptoms which indicate that intestinal changes are still progressing, have disap- peared. Independent of complications the duration, type, and intensity of the febrile excitement has more to do than all the other elements in determining the prognosis in any case of typhoid fever. The height of the temperature on the eighth day determines the range of temperature that may be expected on each succeeding day. If upon that day it is not higher than 104° F. or 105° F., and has been regular in its development (independent of complications), the prog- nosis is good ; in uncomplicated cases it very rarely rises higher than the degree it has reached at that time. A pro- longed high temperature (above 105° F. ) after the first week renders the prognosis unfavorable. In mild cases, during the second week, a marked morning remission occurs, which begins early and continues until midday ; the evening exacerbation is late, and by the end of the second week there is a marked and permanent fall in the temperature. In severe cases, the opposite conditions are observed. A sudden rise in temperature, or a rapid and extreme fall at any period of the fever, is a very bad omen ; niooxosis. 51 the latter ofton pivrrdt's tln' occurrcnro of a soverc intfstiiial hi'inoiiliagc. ^^larkril variation from the typical ti'm])('ra- tiire of the diseast' indicates the existence of c()in]ilii atioiis. Sliii'ht decline, acc()nii>anicd by great fluctuation of t<'iii])t'ra- ture. during the third week, is an unfavorable symptom. The natural power of an individual to resist disease, especi- ally the effects of iirolonged high temperature, is a very important element in prognosis. The organ which is the surest indicator of such power (especially in t3^phoid fever) is the heart. If the pulse is full and regular, ])erhaps beat- ing at the rate of 110 or 115 per minute, if the cardiac im- pulse is good, and a distinct first sound can be heard, even though at the end of the second week the temperature stands as high as 106° F., the prognosis is favorable. If, however, the pulse has risen to 120 or 130 per minute, if the apex-beat is feeble or imperceptible, and the first sound of the heart is indistinct or altogether obscured, with a ten- dency to cj^anosis and pulmonary oedema, the indications are that the patient's powers of resistance are failing, and under such circumstances the prognosis must be unfavor- able. It is not so much the rapidity as the regularity, a sudden falling and a sudden rising of the pulse, that indi- cates the impending danger. The rapid rising of the pulse upon the slightest excitement is the most unfavorable indi- cation, as it shows extensive heart-failure and a rapid giving way of vital ])ower. A sudden fall of the pulse from any cause must always be regarded as an unfavorable indication. The abundance or color of the eruption does not influence the prognosis. Excessive tympanitis and severe abdominal pains are un- favorable symptoms. Severe and protracted muscular tremors, with subsultns, indicate danger. Sudden collapse during the second and third weeks of the fever is always attended with dang<»r, as it is very likely to be due to copious intestinal hemorrhages or intestinal perforation. It sometimes occurs indepen- dently of either of these causes, but nevertheless is very apt to be soon followed by a fatal result. The prognosis is alwaj's bad in persons who are very fat. 52 TYPHOID FEVER. and in those who are the subjects of gout, diseases of the kidney, or any otlier severe form of chronic disease. In all such persons, duiing the second and third weeks of the dis- ease, you must constantly be on the watch for the occur- rence of sudden collapse. Different opinions have been given as to the importance of intestinal hemorrhage in reference to prognosis. Some have regarded slight intestinal hemorrhages as beneficial, while others have regarded them as always of dangerous significance. My own experience leads me to the belief that when the hemorrhage is scanty it has little influence on the final re- sult. When it occurs before the twelfth day of the fever, it often does good by relieving the intestinal congestion. But when profuse, or even a slight hemorrhage after the twelfth day, is an unfavorable symptom and renders the prognosis unfavorable. The occurrence of the hemorrhage renders it probable that^ulceration has extended to the ves- sels beneath the transverse muscular fibres of the intestine, and such ulceration is very aj^t to go on to perforation and a fatal peritonitis. So that although the patient may sur- vive the hemorrhage, there is great danger of death from peritonitis, and this danger must always enter into your prognosis, whether the hemorrhage is slight or severe. The influence of age is very great in determining the prog- nosis in any case of tyj)hoid fever. The prognosis is much better in children than in adults. Occurring in persons over forty years of age, the prognosis is decided.ly unfavorable, even though the symptoms may not indicate a severe type of the disease. In the case of those individuals who habitually use alcoholic stimulants, whose power of resistance to high temperature is diminished, the rate of mortality is very great. The puerperal state renders your prognosis especially unfavorable. The danger to the patient is equally great, whether the fever comes on prior to delivery or during puerperal convalescence. In this fever there is greater danger to those who are guf- nioc.NOSis. 63 fi'iiiiu; from any rorni of clironic disease tliaii to those who aiv ill a healthy condition at tiie tinie of tlie attack. Wiihout delaying you longer with those conditions in the ordinary course of the disease wliicli intluence its prog- uo^^is — the most ini])ortant of wliich have been referred to under the head of synii^tonis— I will ]>ass to the considera- tion of the coini)lications which inlluence its prognosis. Thev are more numerous than those in any other disease. l\vill hr.-r l.iirlly :illude to tliose which are intimately connect(>d with, or de])endent upon, the morbid changes ordinarily incident to the disease, and afterwards speak of those which may be designated as accidental complications. The parenchymatous changes which take place in the different organs oi" the body, during the progress of this fever, necessarily intluence prognosis. For instance, the muscular degenerations of the cardiac walls and the conse- quent loss of heart-power, which favors pulmonary and other hypostatic congestions, and the diiiiinished quantity of blood sent to the various tissues of the body, interfere more or less with their nutrition. Necrotic and gangrenous processes, sometimes met with in the cellular tissues of the surface and along the line of the intestines, also the venous thrombi which so frequently develop in a protracted case of this fever, are, to a certain extent, the result of this car- diac weakness. It is apparent that the dcn-elopment of ex- tensive cardiac degenerations must render the prognosis unfavorable. Excessive cardiac weakness favors the development of blood-clots in the heart-cavities ; these may break up and cause embolism somewhere in the course of the general cir- culation, and thus lead to changes which may destroy life. Again. I nhsU nttJ jyrrf orations, one of the results of the in- testinal changes incident to the fever, render the prognosis most unfavorable. The same is true of co-plons intestinal licinorrlKKjt'S coming on after the third week of the fever, as well as of all th<.)se glandular changes which are a part of til.' naluial hi-lory of the fever, and which I liavr already described. Any of these changes may h-ad to complications which 54 TYPHOID FEVER. endanger tlie life of the patient, and conseqnently, when they occur, necessitate a guarded, if not an unfavorable prognosis. Some of the prominent accidental complications which may occur in the course of typhoid fever, but which do not belopg to its regular history, have their seat in the respira- tory organs. Slight bronchial catarrh is present in nearly every case, and can hardly be regarded as a complication. It is so much a part of the clinical history of the disease, that some have named this fever hronclilal iyplius. Tliere is another much more serious bronchial complication, namely, catarrh of the smaller bronchi, or capillary bron- chitis. This usually comes on during the second or third week of the disease, and if extensive, greatly endangers the life of the patient. If, then, during this period of the fever, you have subcrepitant rales suddenly developed over the whole of both lungs, accompanied by great dyspnoea and an abundant expectoration of stringy mucus, you are war- ranted in giving an unfavorable prognosis. Extensive oedema of the lungs occurring wdth, or inde- pendent of, capillary bronchitis and pulmonary congestion, sometimes comes on suddenly during the third week of typhoid fever, and indicates great failure of heart-jDower. The slightest indication of its occurrence should alwa3^s be regarded with suspicion. It is not unfrequently accom- panied by more or less extensive hemorrhagic infarctions of the lungs ; these depend on embolism of some of the branches of the pulmonary artery due to fragments of clots which have formed in the right side of the heart, the result of the cardiac weakness ; these often lead to gangrene of the lung. It is sometimes impossible to diagnosticate their existence during life. Pneumonia, when it complicates tyi:)hoid fever, is gener- ally latent. It comes on very insidiously, and unless you are on the watch for its development, and make frequent and careful physical examination, it will pass unrecognized. It is more frequently developed during the third and fourth wTek of the fever, and usually is catarrhal rather than croupous in character. At first only single lobules are in- rnooNosis. 55 volvcd. hilt nfttT a flinc an oiitiiv lob<» becomes consoli- dated. W'lii'ii irregulai- variations in teinjxTatuiv occnr (hiiiiig convalescence, or during the third or fourth week of the fever, there is reason to suspect the development of pneumonia. In the majority of cases tlie charaeteiistic pneumonic cough and expectoration are absent. W'litii- ever an extensive pneumonia conii)licates typhoid fever, tlic prognosis is especially unfavorable. Pleurisy does not occur so frequently, as a complication of tyjdioid fever, as does pneumonia or bi-onchitis. AVhen it does occur, the almost invariabl<' product of the inliam- matory process is pus. Usually it comes on late in the dis- ease, comes on insidiously, and is quite likel}' to ])ass un- recognized unless frequent physical examinations of the chest are ma(h^ In many instances it is really a sequela of the fever, not develo})ing until three or four weeks after the fever has run its course. Its occurri*nce must alwa3'S be re- garded as unfavorable, for a 3'ear or even longer time must elapse before recovery can take place, and even then recov- ery is doubtful. Occasionally laryngitis is a serious complication of this fever. It generally occurs in those cases where the fever lias been very protracted, and there is great prostration. Its presence is marked by sudden and very intense intlam- mation of the mucous membrane of the glottis, which is lia- ble to become oedematous, when death may suddenly occur. It may lead to ulceration of the mucous niembiane. AVlnni- ever, during any stage of a typhoid fever, the characteristic symptoms of laryngeal obstruction occur, remember the danger of oedema glottidis and of extensive laryngeal ul- ceration, and promptly resort to those means which shall relieve the unpleasant sym]»toms. and avert the danger which threatens your })atlent. P3'aMiiia maybe met wiili as a complication dui'ing con- valescence from ty})hoid fevei-, l)ut it is not of as frequent occurrenc(? as sei)ticnMiiia. Wlu-never we have septic poi- soning developed, with extensive sloughs in the intestines, the })rognosis is exceedingly unfavoiabje. Acute gastric catarrh is another complication of this fever, 56 TYPHOID FEVER. the possible occurrence of which must enter into your prog- nosis. A patient may have reached his fourth week, and be rapidly convalescing, his desire for food returning ; you endeavor to hasten his recovery by increasing the quantity of food taken, or by allowing him to partake freely of such articles of food as are difficult of digestion. The result of this overcrowding, or of imprudence in diet, is irritation and inflammation of the enfeebled gastric mucous mem- brance. Vomiting of a stringy mucus occurs, which by its prostrating effects endangers or destroys the life of your already enfeebled patient. I would impress you with the importance of exercising the greatest care in regard to the diet of patients convalescing from typhoid fever. They should be restricted to milk and nutritious broths in mode- rate quantity until all danger from this complication shall have passed. Disturbances of nerve-function have been considered un- der the head of symptoms, but, not unfrequently, certain brain and nerve lesions are developed which cannot be classed under that head. Cerebral oedema may complicate a typhoid fever during its third week, and give rise to symptoms of a grave char- acter. A decided enfeebling of the mental powers and a tendency to stupor announces it occurrence. Hemorrhagic extravasations on the surface and into the substance of the brain, the result of degeneration of the walls of the cerebral vessels, occasionally occurs during the height of the fever. If the effusion is moderate, no marked symptoms are developed ; but if a considerable extravasa- tion takes place, it gives rise to symj^toms of cerebral com- pression. Meningeal inflammation is a rare complication. The occurrence of any of these complications in any case renders the prognosis unfavorable. You must remember tliat during the second or third week of the fever certain cerebral disturbances may occur, which seem to indicate the existence of some one of these compli- cations, when really no cerebral lesion exists. Usually, these are present in patients who have had a continuously PKOGNOSIS. 57 liigl] teniperatare ; in favorable cases they disappear after a few days. These liave been referred to under the head of symptoms. You will encounter various other disturbances of the nervous system, such as hemiplegia, paraplegia, etc., which may simulate those due to lesions of nerve-centres, or local forms of pai-alysis and aufcsthesia, which seem to h>i con- lined to individual nerves ; but as these functional disturb- ances do not depend upon any anatomical changes, the prognosis in such cases is good. Those changes in the kidney due to the parenchymatous degeneration which usually attends this fever, have been already noticed ; but occasionally nephritis is developed as a sequela. The urine becomes scanty, is loaded with albu- men, and contains blood and casts ; the face and extremities become (Edematous, and death may occur from uraemia. The occurrence of this complication necessarily renders the prognosis bad. In a few instances under my observation, severe catarrh of the bladder has developed during convalescence, greatly complicating the case ; in one instance the cystitis was accompanied by pj^elitis. Snppurative inflammation of the cellular tissue of the bod^-, or cellulitis, (.^specially of the surface, often compli- cates convalescence, and in some cases causes death. It is most liable to develop in tliose parts which havt' been sub- jected to long-continued pressure. Occasionally it is met with in the pharynx and along the line of the lymphatics Accompanving these cellular inflammations, or occurring independently of them, not unfrequently gangrenous inflam- mations of the integument occur, giving rise to what has been called bed-sores. These gangrenous processes are most frequently developed at those points which have been sub- jected to the greatest pressure, on account of the position of the ])atient in bed, such as the sacrum, nates, heels, and shoulder-blades, etc. In the simplest form of bed-sores there is only a superficial loss of substance ; in more severe cases the subcutaneous cellular tissue is involved; and in the worst cases the muscles and fibrous tissues. I have met 58 TYPHOID FEVER. with cases where the slough had involved the connective tissue and muscles, and laid bare the bony tissue. A considerable number of typhoid patients who have lived through the fever, die either from the exhausting effects of these bed-sores, or from the septic poisoning re- sulting therefrom. The possible occurrence of these complications must enter into the pi'ognosis in every severe case, and the earlier they make their appearance the greater the danger. We have now completed the list of principal complica- tions which are to modify your prognosis in any case of typhoid fever. Before leaving the subject, I will say a word in regard to the duration and mode of termination of this fever. DuKATioisr. — Its average duration is from three to four weeks ; it may terminate in death or recovery at an earlier date. A typical case extends over a period of four weeks. The period of invasion lasts from one to five days. The period of glandular enlargement continues until about the fourteenth day. The period of ulceration extends from the twelfth or fourteenth day to sometimes between the twenty- first and twenty-eighth. When the fever is protracted be- yond the middle of the fourth week, in most instances this is due to some complication, or to an extension of the in- testinal ulceration. The period of greatest danger is at the close of the third week. Death rarely occurs before the fourteenth day. The prominent direct causes of death are : First, Toxcemia ; Second, Asthenia; Third, Suppression of the excretory function of the kidneys; Fourth, Hyper- cemia and oadenia of the lungs ; Fifth, Intestinal hemor- rhage ; Sixth, Exhaustive diarrhoea ; SeventJi, Intestinal perforation ; Eighth, Peritonitis, with or loithout intesti- nal perforation. In nearly all cases the failure of heart- power is directly or indirectly the cause of death. In no case can convalescence be said to be fairly established until the temperature remains normal for two successive evenings. Its termination, like its commencement, is gradual, and it is not marked by any critical evacuation or day of crisis. Helapses. — After typhoid fever has run its course, and RELAPSES. 50 after the patient is entirely fre»' from fever, quite frequiMitly we have a new (l»'vel()i)nit'nt of tlu' fever ; these iu*\v dt'vrlop- nieiits air callt'd relai)SfS. Tlifir eourse corresi)oii(ls with that (>r iIk' primary attack, only they are of shortt-r dura- tion. Tlie tt'iupt-raturt' rises more rapidly, the <'rui)tioii \r- a})})eais, the s})lr('n cnlariifs, tiir iiitrstinal and ahdominal symjitoiiis rciiii II. and all the I'loiiiiiK'nt sym})toiiis ol" the primary fever arc rajiidly dcvclojii'd. As a rule, tin- it'la))se is mild.'r than llif jirimary attack. If it tcnninates fatally, the })()st luoittin t'xaiiiiiiation shows, in addition to the eicatrizin^H- intestinal ulcers of the primary attack, the re- cent intestinal chani;-es of the relapse. The lesions of the relapse, although of the same character as those of the pri- mary attack, are less extensive. It is very difficult to give a satisfactory exi)lanation of these relapses. Some claim that they are the result of cer- tain plans of treatment, esi)ecially the cold-water ])lan. This assertion lacks proof. Again, others hold that all re- lapses depend upon a new infection. Perhaps this is pos- sible if the patient remain in the same locality and has the same surroundings as when he had the primary attack ; but how shall we explain relapses in those who are removed from all the sources of the primary infection^ Another explanation offered is that a part of the typhoid poison has remained in the system, undeveloped during the ])rimary attack, and that some time after this has passed the poison reproduces itself and sets up a second fever. A more recent theory is, that the typhoid poison thrown off in the faeces of the patient is reabsorbed and causes the rela])se. Unquestionably, it is possible for ht^althy glands to l)ecome inoculated by sloughs thrown off from those lirst affected. In many cases it is impossible to account for the occur- rence of the relapse, and all of these explanations as to the cause in any case are more or less unsatisfactory. In those cases which have come under my own observa- tion, I liave noticed that the s])lenic eidargeUK-nt which has existed during the course of the fever does not subside with its decline; ami that the tenderness along the line of the 60 TYPHOID FEVER. intestines, especially in the right iliac region, continues during the j)fii'iod between the original attack and the re- lapse. In some instances, apparently, the relapse has been brought on by indiscretion in diet, or by injudicious exer- cise on the part of the convalescent patient. Occasionally relapses have occurred when great care had been taken against any indiscretion or over-exertion. There is little doubt but that relapses are of much more frequent occurrence in those cases that are treated with cathartics during the first week of the fever, than in those where cathartics are not emplo^^ed. LECTURE VI. TYPHOID FEVER. Treatment. Before speaking in detail of the treatment of typhoid fever, I will say a few words concerning its prevention. If the modern theory (which I have already givon yon) of its etiology be accepted, the qnestion naturally arises, cannot the typhoid poison be prevented from entering our dwellings, or polluting our driidving- water ? Facts prove almost conclusively that ty]ihoid fever is never of spontaneous origin. Should it occur in tlu' locality where you may reside, if possible find out its origin. If no case has ever before occurred in the locality, endeavor to ascertain the manner in which the t3qihoid poison has been introduced. If it is already endemic, limit the disease to the iirst few cases by a most thorough disinfection, and remove all those surroundings which favor the reproduction of the typhoid poison. If the theory is correct, that typhoid fever is depcnih-nt upon a poison contained in the excrements of a typhoid patient, then the poison should be destroyed as soon as it is discharged from the body. For tliis purpose, the intes- tinal discharges should be received into a porcelain bpd-])an, the bottom of whicli should be covered with a thin layer of powdered sulphate of iron ; immediately after the discliarge, crude muriatic acid, equal in quantity to one-third of the f{ccal mass, should be poured over it. Never emi)ty the discharges of a tyi)hoid patient (no matter how tlioroughly 62 TYPHOID FEVER. they may have been disinfected) into the privy or water- closet used by the family. Trenches should be dug for their reception, and new trenches should be opened every few days ; the greatest care should be taken that these trenches are not so situated that drainage from them can contaminate wells or springs which furnish drinking-water. All under-clothing or bed-clothing that may have become soiled by the discharges from the bowels, should be imme- diately immersed in chlorine water, and thoroughly boiled within twenty-four hours. This procedure will certainly destroy the infective i^ower of the typhoid poison contained in the intestinal discharges, and in the majority of instances you will prevent the spread of the fever. Repeated observation shows that when one member of a family has typhoid fever, not unfrequently it is developed in every other member. This spread of the disease can be prevented, unless there is some local cause for its develojD- ment which cannot be reached. When its origin is not apparent, the wells, springs, and all the sources from whence water is derived for drinking and cooking purposes should be carefully and thoroughly inspected. Care must be taken that the waste-pipes from wells and springs do not pass directly into cesspools or sewers, and thus become a means for the conveyance of impure gases into the springs and wells. The greatest care must also be exercised in regard to home drains and sewer-pipes, that they shall be free from leakage and obstruction, and that all water-closets, sinks, and other openings into them be provided with suitable traps. When unpleasant odors are constantly present in dwell- ings, especially in sleeping apartments, disinfectants should be employed, and the house be thoroughly ventilated. When it may be necessaiy to open drains and cesspools in a dwelling for purposes of repair or cleansing, the same precautions should be exercised; these are especially of importance during the summer and autumn. In conclusion, let me impress upon you this fact, that when typhoid fever is carried from the sick to the healthy, the evacuations are the chief, if not the only means of con- TKKATM?:\T. 03 tamination ; consequontly, tlio iinporfanro of thnronuMily disinftH-tiiiu; tlic cxcnMin'iits of tyitlioid patients sliould always bo home in mind. In tliis coniiiMrion the question naturally arises, can we not counteract or neutralize the effects of tlie fevei- ])()ison after it has <;ain''(l admission into the system, ami thus prevent the develo]unent of typhoid fever? To acc()m])lisli this, at one time blood letting was resorted to ; but at the presi'Ut day few i)ractitioners would venture to suggest such a plan of treatment, and few patients could be found willing to submit to it. Plmetics were given on th«« sup- ])osition that the fever-poison acted primarily u])on the mucous membrane of the stomach, and that the offending af'-ent nii<'-ht be removed by their early administration, and thus its absori)tion into the system prevent<'d. As it has been proved that the typhoid poison can be introduced into the system thnnigh other channcds than the stomach, and as experience has shown that emetics have not the power to prevent the development of ty])lioid fever, their use has been abandoned. Diaphoretics have also been eruployed ; but there is not the slightest proof that typhoid or any fever-poison was ever removed from the system by sweating. A patient with some of the premonitory symptoms of fever may sweat, be relieved, and at once r<'cover, but such a patient has not received the typhoid poison into his system, and was not, as is sometimes said, " threateued with typhoid fever.'' Notwithstanding the bold afRrmation of the author of the cold affusion ])lan of treatment, that if it were resorted to before the third day of the disease, it would invariably arrest its development, it has failed to stand the test of practical experience. More recently, sulphate of ([uinine, administered in large doses, has been thought to have the power of arresting the development of ty]ihoid fever in the same way that it arrests malarial fever, l)y its anti-periodic power: but there is no evidence that it has any such power, and as a prophy- lactic remed}' it has been aband(uied. I might goon almost in'l"finit.*ly "iiiim''rating measures 64 TYPHOID FEVEK. wMcli have been resorted to for preventing the develop- ment of this fever ; but after the poison has once gained entrance into the system, no means have as yet been dis- covered by which it can be counteracted or neutralized so as to prevent the development of the disease. The duty of the physician is to guide the disease, so far as he may be able, to a favorable issue, and prevent injury to organs essential to life, keeping in mind that a certain definite period must elapse before this result can be accomplished. Before entering into a detailed account of the treatment to be pursued in the management of a case of typhoid fever, I will say a few words in reference to the arrange- ment of the sick-room of fever patients. Though often overlooked, this is a matter of no inconsiderable impor- tance, not only as regards the comfort of the patient, but it has much to do with the successful issue of the case. It is of the greatest importance that a properly qualified nurse be selected ; one who has had experience in the care of fever patients is to be preferred. In the next place, the patient should be placed in a large and well-ventilated apartment. All furniture should be removed from the sick- room, except those articles which are necessary for the com- fort of the patient and the convenience of the attendants. Remove the carpets from the floor, place your patient in a bed of moderate size in the centre of the room, and let there be free ventilation during both day and night. The temperature of the apartment (if possible) should be kept below 60° F. The bed and body linen of the patient should be changed daily, and at once be removed from the sick-room and placed in a weak solution of chloride of sodium ; especially is this important if the patient is having frequent discharges from the bowels. The apartment should be kept perfectly quiet, the light subdued, and only the attendants should be al- lowed in the room. These preliminary arrangements having been made, we will suppose we have in charge a patient with a mild type of typhoid fever. All medicinal interference in such a case is unnecessary. The treatment resolves itself into the TlIKATMKNr. 0;") arrangement of the sick-room and ])roper diet ; milk is i»ie- fe ruble, //7///.S' are not to he allowed hi ((n if case. In the miklest case this care in diet is important, and the patient shonkl be kept in bed nntil convahiscence is fnlly estab- lislied. This should be insisted H])on in the mild as well as the severe cases. As I liave already stated, the temptMature in a mild type of this fever rarely rises above lo:f F. ; therefore there is no necessity for resorting to antipyretic measures ; frequent sponging of the surface with cold or tepid water, as is most agreeable to the patient, will be found of service. By far the larger number of cases of this fever are of a more severe type, and though in your treatment you must be guided by the circumstances which attend each indi- vidual case, usually you will be obliged to resort to more decided measures. Remember that there are no specifics for this disease ; all of those which have been proposed and employed have either fallen into disuse, or are resorted to only as aids in general treatment. Typhoid fever is a disease that has certain stages to pass through, limited only by days and weeks. There is great doubt whether the physician can shorten its duration by a single day, but experience warrants the belief that many lives may be saved by remedial measures used at the proper time, and combint'd with Judicious hygienic management. There are critical periods in this disease ; bf ])r<'])art'd bv knowledge and judgment to carry your ])atient (if possible) safely through them. Umpit'stionably one of the most important things to be accomplishfd is the reduction of temperature, or rather the keeping of the temperature below a certain standard. P.lood-h'tting. em»4ics, dia]>hon'tics. cathartics, chlorine water, and mineral a<'ids hav.- all b.'.>n resorted to in order to reduce temperature. The last two agents were supposed to reduce temperature by neutrali/ing the typhoid poison. At the ])resent day 1 think there is no intelligent physician who imagines he can neutralize the typhoid poison, and thus reduce temperature, while only a few years ago these ag'-iiN were supposed to ]»oss.'ss such 66 TYPHOID FEVER. power, and were very extensively employed for such a purpose by some intelligent physicians. The agents which more recently have been employed for this purpose, namely, sulphate of quinine and cold applica- tions to the surface, are powerful agents in reducing the tem- perature and lessening the severity of the disease ; but they can never shorten its duration, and if you employ them, ex- pecting this result, you will be greatly disappointed. It is claimed by many very distinguished observers of the jjres- ent day that the parenchymatous degenerations of the dif- ferent organs and tissues of the body, which are found in those who die of typhoid fever, are due to the prolonged high temperature which is present during the course of this disease ; but as yet there are no facts to prove this asser- tion, for the same parenchymatous changes are found in the bodies of those who have died of diseases, the course of which was not marked by high temperature, and did not extend over a period of more than forty-eight hours. So far as we are able, to determine by analogy upon what these parenchymatous changes depend, we are led to believe that the s]3ecific poison of the disease has more to do with their development than the high rate of temperature. One thing must be apparent to every clinical observer : that the injurious effects of a prolonged high temperature are early and most markedly shown by disturbances of the cerebro- spinal system. It is still an unsettled question whether these disturbances are due to the primary changes in the constituents of the blood, which always accompany a high range of temperature, or to the direct effects of the high temperature on the nerve centres. Whichever view we accept or adopt, the employment of those means which have the power of safely reducing tem- perature is indicated, and when judiciously used they have much to do with the safety of the patient. All those means which have been employed for the reduction of temperature are included under the general term of antipyretics, and the treatment of disease by the use of these agents has received the name of antipyretic treatment. TUKA'I'MKXT. (57 I'liqiiostioiKihly tlir iiiosl cflicieiit and rdiaMr i>\' I lie aiiti])vi-i'lic an'cnts ai-i" I he cxlci-iial apjilicatioii of cold liy incaiis of hallis. ))a('ks, and cll'ii^ioiis, and tin- iiihTnal atlininistrafioii of llic snlplialc of (|uiiiiii('. TIh' (luiiiiiir is not adniinisd'ivd lo ])i(i(luct' an^' sjx'cilic acLion njion llu; ty))li(>id fever jxiison, hnl is employed for its ant ipy relic [)()\ver. Tliciv are other anti])yi'etic afz;ents besides these two, but tln\v are of so little importance that it is necessary to give (hell) (.nly a ])assing notice after we shall have con- sidered these two imjiortant ones. At the ]iresent time the opinion prevails, to a great ex- tent, that the ap])lication of cold to the surface is the gn^at antij^yretic in the treatment of fever. This is no new teacliing. Long ago Dr. Currie recommended the applica- tion of cold to the surface of the body for the purpose of i-apidly i-educing temperature, and proved that it had such an effect ; j^et it was never very geneially practised, and soon fell into disuse, as there was nothing reliable to guide one in its application. As we now have the thermometer to guide us in its application, more recently it has been resorted to with considerable success. I will give you some general rules, which may be of ser- vice to you in the use of this antipyretic in the treatment of ty]ihoid fever. As soon as the axillary temperature in the evening rises above 103° F., place the patient in a water-bath having a temperature of 70° F. or 80° F., and gradually lower that temperature by the addition of cold watei- or ice, until the temperature of the i)alienl begins to fall. Vmu may lie compelled to lower the tempei-atuie of the l>ath to do F. before the temperature of the ]iatient is alTected ; but the lowering of the bod}^ temperature must be acconi]ilislied i)y the lowering of the tem])eiature of the bath, taking can^ that the latter does not fall below 60° F. When the tem- perature begins to fall, renew your thermonietrical observa- tions every two or thr<*e minutes. While the baths are being used, the ti'm])ei;itiiie must betaken ])y ]»lacing the thermometer in the rectum. If it falls ra])idly — that is, two or three degrees in live or six minutes — as soon as the 68 TYPHOID FEVEK, fall has reached 103° F. remove your patient from the bath ; if it falls slowly, as soon as it reaches 101° F. he should be removed and imnn^diately placed in bed. Never keep the patient in the bath until the temperature shall have reached the normal standard ; should you do so, he may pass from a condition of fever into a state of collapse, as the tempera- ture continues to fall for some time after his removal from the bath. While in the bath, cold should be applied to the head by means of a sponge wet in cold water or by an ice-bag. The cold pack is much less effective than the bath ; but if the patient is too feeble to be moved, it may be employed with benelit. You should wrap the patient in a sheet wrung out of tepid water, and over this sheet apply one wrung out of cold water. The latter may be removed as often as it becomes warmed ; its application and removal may be con- tinued until the desired fall in temperature shall be obtained. In severe cases, during the first and second weeks, you Avill lind that after the temperature has been reduced by the application of cold to the surface, it will begin slowly to rise until it reaches its former height. Usually one to three hours will elapse before it begins to rise, and from two to six before it reaches its former height. You will then be obliged to repeat the baths or packs, and to con- tinue their use, both day and night, from three to six times during the twenty-four hours, if you expect to keep the temperature below 103° F., and accomplish anything by this plan of treatment. My experience in the use of cold applications leads me to believe that unless you are able to maintain a low range of temperature after four or five baths, you gain very little by their continuance. In other words, if, after using the baths for twenty-four hours, the temperature of your patient rapidly rises to the same or a higher degree than it was before their use was commenced, you will obtain little or no benefit from their continuance unless you can introduce some other agent which shall maintain the low temperature reached by the bath. I am also convinced that, after the second week of typhoid fever, cold baths should not be employed to reduce temperature, for by their continuous use after that period they may do THE ATM K NT. GO great liann. Tlu^ condition of a lyplioid ])ati(>nt diiriiif^ tiie first and second week of I lie frvcr is veiy d lift 'rent from tiiat during tlie thinl and fourth weelv. Durini:; this latter ])eri()d tliere is great danger of colhi]t>r afirr a cold batli, and in several instances I am confident that }>ulmonary coni}>lications have l)een the result. In a few instaiiirs the teniix'ial uie can In- very rapidly jdwcrcd 1)\- ilif a|t]iliralion of ice-hags to the abdomen. The rajtidity with which the tem])erature can be reduced iisuallj' (h'j)ends ujion the severity of the i'l'vci-. In some cases, whrn the patient is; placed in the cold bath, the temjx'rature will immt'diatdy begin to fall ; in other cases there will be a gradual reduc- tion of temperature as the water is made cooler. In ceiiain severe cases, you may keep a patient in a bath of the teuj- perature of C()° F. for the space of half an liour without the temperature falling a degree. These cases are exceed- ingly grave in character, and you sliould use the bath with great care. Finally, let me impress upion 3'ou tliat in t3'phoid fever, in order to reduce the tem])erature, 3'oii must not indiscrim- inately apply cold to the surface of the body. Perhaps there is no remedial agent wliicJt requires greater care and judg- ment in its use ; yet doubtless, when judiciously employed, the lives of many typhoid patients may be saved, and it is equally certain that when injudiciously employed, many lives may be destroyed. If you use the cold baths in con- junction witli other means for reducing temperature (con- cerning which I will s])eak at my next lecture), I am con- fident you will accomplish much ; but if you rely oidy \\\)0\\ the baths, in the majority of instances you will be disap- pointed in the result. At the present time it seems to me, that by some the benefit and ])Ower of cold baths in the treatment of ty})hoid fever have been overrated. The general condition of your patient and the stage of the fever must be considered ; also the effects of the tiist few baths must be car<»fully noted. Should a paticMit's temperature range at 1(>4' F. or l(>o° F., there is no positive evidence that you must resort to a cold bath, or that a c(»ld bath is the best agent to be em- 70 TYPHOID FEVER. ployed for its reduction. Again, if the patient after the second or third bath is more quiet, has less delirium (if delirium previously existed), if his breathing becomes easy and natural, if the heart' s action is more regular and for- cible, and he falls asleep and perspires, there can be no ques- tion in regard to the beneficial effects of the bath. If, on the other hand, the bath is followed by feebler heart's ac- tion, by dusky cheeks, by rapid respiration, and by cold- ness of the extremities, from which condition the patient rallies slowly and imperfectly, you may be certain that, however high the temperature may range, you will do harm by continuing the baths. When the extremities are cold, or there is profuse hemorrhage from the bowels, or Avhen, from any cause, there is great feebleness of the heart's ac- tion, and especially in the case of aged persons, cold baths are contraindicated. Cold compresses or ice-bags applied to the abdomen, in addition to their beneficial effect on the intestinal changes which constitute such an important element in the history of tills fever, often have great power in reducing the gen- eral heat of the body, I have also in some instances found the body temperature rapidly lowered by injections of ice- water into the rectum. Care must be exercised that the cold injections are not administered too rapidly or in too large quantities. Although this mode of abstracting heat and the lowering of the body temperature is never so effective as by baths and packs, still it has this advantage, that no such compen- sating increase in the production of heat follows the use of the cold injections as follows the cooling of the external surface by the baths. In many cases the extreme obstinacy of the fever, which resists the most systematic use of cold, as well as the fact that some patients cannot bear a sufficiently frequent repe- tition of them to effect the desired result, or that there may be contra-indications to their use, necessitates the employ- ment of other means for the reduction of the body temper- ature. To these I shall invite your attention at my next lecture. LECTURE VII. TYPHOID FEVEll. Treatment {continued). We liave already considered the antipyretic power of cold api)lications in the treatment of typhoid fever, and I will now oall your attention to the antipyretic power of the i>uli)liate of quinine. When quinine is employed as an antipj^retic, it must be given in large doses ; the administration of two grains every two hours, or a larger quantity administered in divided doses within a period of twenty-four hours, will not act as an antipyretic ; but thirty or forty grains must be adminis- tered within a ])eriod of two hours. If the stomaeli is irritable, and you fear that a large dose will produee vomiting, teu grains may be given every half hour until the desired quantity has V)ee'n administered. Usually from four to six hours after the antipyretic dose has been taken, the fall in temi)erature will l)egin, and in about twelve hours it will reach its minimum height ; then it will remain stationary from twelve to twenty-four hours. After the tem])erature has once been reduced by the (piinine, its administration may be discontinued until the tempera- ture shall again rise to 105° F. As a rule, the tem})erature rarely ranges as high as ])eroi-e the (piinine was administered. This mode of administering quinine in antij)yretic doses to fever patients rarely jiroduces any s^^mptoni of cincho- nism, other than a tr.insient deafness after the first dose. In a large numb.-r of eases the temjierature can be kept 72 TYPHOID FEVEK. below 103° F. by tlie sulphate of quinine ; but in very severe cases it will be advisable, and sometimes it will be absolutely necessary, to employ not only the quinine, but at the same time the cold baths. My rule is, after I have reduced the temperature to 101° F., or 102° F., by a cold bath, to administer an antipyretic dose of quinine, and thus delay the recurring rise of temperature. While the cold bath more rapidly reduces temperature, the effect of the quinine is more lasting ; consequently, by making use of both of these reliable antipyretics during the first two Aveeks, you will be able to control the temperature during that time. After this period it is not safe to resort to cold baths ; but when the temperature rises above 103° F., oc- casionally you may use the cold pack in connection with antipyretic doses of quinine. If, during the third and fourth weeks, you fail to reduce the temperature by these means, administer during the twenty-four hours from ten to twenty grains of powdered digitalis— unless the pulse is very frequent and irregular— when its use is contra-in- dicated. As an antipyretic, digitalis should be adminis- tered only when quinine is given. It seems to increase the antipyretic power of the quinine, but has little or no power when administered alone. The use of all these antipyretic remedies must be per sisted in until the desired end— the reduction of tempera- ture—is accomplished ; but the peculiarities of each patient must be studied, and these agents must be so administered as to suit each individual case. You cannot trust to the judgment of nurses and attend- ants, but you must determine for yourself what are the requirements in each case. The satisfactory results obtained by the systematic use of these remedies Justifies their employment ; but the exact rules which are to govern one in their use, as to manner and time, can only be determined by experience. All careful observers are aware that great danger attends prolonged high temperature ; but it is still an unsettled question whether this danger is due to parenchymatous changes in the different organs, which some claim are the TUKATMKXT. t.i result of tho liigli tcinix'nitiiri', <>i' to (listuibnnc(> of tlu* nerve centres from the isiinu' caiLsc Wlialcver may Ix' tlie final settlement of the qiu'stion, the bendieial results which follow the antii)yreti(^ treatment of frvcrs are gcnnally admitted ; and my advice to each oin' of you is, at the outset of your ])r<)fessi()nal career to Miakr yourself perfectly familiar with the use of these most imiioitant and reliable antipyretics. If you can kee]) tli<' tem]>eiat me of your jKiticnt at about 103° F. during the tirst two weeks of the fever, you have accomplished the Jlrst and ])erliaps the most im})ortant thing in the treatment of this disease. To^iiixls the end of the second, or during the third week, sometinu'S etii'lier, sometimes later, signs of failure of heart, power begin to manifest themselves; the pulse becomes feeble and irregular ; at times the surface is cool and moist ; the patient complains of a sense of exhaustion, perhaps is unable to turn in bed ; the tongue assumes a dry, brown appearance, and the necessity of supporting the patient becomes apparent. This will bring you to the second im- portant question in the treatment of this fever, namely, 2c7iat means shall he employed to sustain heart powei\ or, as is sometimes said, the vital powers of the patient? When a i)atient, during tin; second or thii'd week of the disease, dies from cai)illary bronchitis, pulmonary oedema, or suddenly passes into a state of conui, failure of heart power is the real cause of death. In those cases in which, during the early part of the fever, you have been comj)elled to resort to a vigorous anti- pyretic treatment, during the third week, although the temperature may not rise higher than ]oi F.. th«' ])ulse frequently becomes extremely ferble, and reach<'S 140 per minute, the first sound of the ln'art becomes inaudible, muscular tremors, dry tongue, and all tiie phenomena which indicate failure of vital power are })resent. Under such circumstances the use of stimulants seems to be urgently demanded. There are a few sim])le rules wiiieh may guide you in the administration of stimulants in this fever. 74 TYPHOID FEVER. Plrst. — They should never be administered indiscrimi- nately — that is, never give a patient stimulants simply be- cause he has typhoid fever. Second. — When there is reasonable doubt as to the pro- priety of giving or withholding stimulants, it is safer to withhold them, at least until the signs which indicate their use become more marked. Third. — In every case, but especially when stimulants are not clearly indicated, watch carefully the effect of the first few doses. There are few whose experience in the treatment of typhoid fever is such as to enable them to positively determine, from the appearance of the patient, when the administration of stimulants should be com- menced. Should you commence the administration of stimulants, it is necessary to see your patient every two hours, and note carefully the effect produced. If you find the tongue becoming dry, the patient more restless, the delirium more active, the temperature ranging higher, and the pulse more and more rapid, you may be certain that stimulants are contra-indicated. If, on the other hand, the pulse becomes fuller and more regular, if the first sound of the heart is more distinctly heard, or, if it has been absent, it has re- turned, if the restlessness and delirium are less marked, the tongue more moist and the patient more intelligent, you may be certain that the time for the administration of stim- ulants has arrived. When you have commenced their use, it is of the greatest importance that you administer them at stated intervals, especially during the night. In a severe case of typhoid fever, a free administration of stimulants, just at a critical period (which may not last more than twenty-four hours), will often be followed by a refreshing sleep, and your patient may rapidly pass from an apparently hopeless condition to one of convalescence. The tliird important thing to be accomplished in the management of typhoid fever patients is the maintenance of nutrition. You must bear in mind that the primary and principal effects of the typhoid poison are manifested in the changes which take place in the lymphatics of the gastro- TKKATMKNT. /•> intestinal tract. Expt'iiriicf has tau<:;lit us that th<' cnfee- bI«*in»Mit of tht' (lint'stivc and assiiiiihitivc ])()\vi'rs, duo to thcst^ ulauduhir chaiiLCt's. whicli air luaiiirt'st from the Vfiy coniiUfiicciiK'iit of thi' ['<-vr\\ irn(h'is thi' dig«'stiun of solid food iiii))ossil)lt'. and for :i lon.^ tiino it, lias bcm the nilf of the profession to uUow typhoid fever patients only rupiid food. There lias been, and still is, gn^at diversity of opinion in regard to the special articles of diet In-st suited to this class of patients. Most medical writers and i)ractitioners claim that beef-tea is the proi)er diet for fever ]>ati»'nrs ; coiisf- quently it is the rule to pour into these enfeebled stomachs a decoction of beef in such quantities as a healthy stomach could hardly tolerate, and which, in itself, has little or no nutritive element. Others claim that gruels are far superior to animal broths, and advocate the feeding of fever patients with grurl made of barley and other farinaceous substances, to the exclusion of every other article of diet ; yet gruels furnish few ele- ments essential to the nourishment of a physical organiza- tion struggling against a subtle poison, and rapidlj' wasting with a burning fever, and starvation is the necessary result of a restriction to gruel diet. There is no disease in whicli a waste of all the tissu<'s of the body goes on so ra])idly as in typhoid fever ; and milk is an article of diet which furnishes the elements of nutri- tion necessary to repair this ia]»id waste, and there arc not the objections to its use which there are against animal broths and gruels. Although there have been, and still arc, in some quarters, strong objections against its use as an aiti- cle of diet in fevers, recently it has been regarded with more favor, and those who have had most extended oi)i)or- tunitics for testing its nutritive qualities have come to regard it as the only article nH diet required by tyjthoid patients. In it we not only find all the elements required for re]iairing tin* rapidly wasting tissues, but they are in a condition to be mo>t readily assimilated by the enfeebled digestive ap- paratus. In Older to make the milk more digestible, it may b<.' di- 76 TYPHOID FEVER. luted with lime-water. The lime-water is an antiseptic, and allays irritability of the stomach and intestines. The quan- tity of milk is not limited ; the patient may take all his stomach will digest — usually patients will take from four to six quarts in the twenty-four hours. After the patient has passed into the fourth week of the disease, you may find it necessary to administer cream and the yolk of eggs in connection with the milk. Having considered the three most important things to be accomplished in the general management of tyjohoid fever, I now come to the treatment of the accidents of the disease. DiARRiKEA. — I have told you that diarrhoea is one of the common symptoms of this fever ; but it is one of which medical writers have taken sj^ecial notice, and for the relief of which different means have been employed. Let us for a moment notice the chain of phenomena of which diarrhoea is a link. The poison which produces this fever unquestionably has a specific action upon the intes- tinal glands and lymphatics. It is here that we find the characteristic lesions of the disease, and it is scarcely ques- tioned that the typhoid poison, to a great extent, gains entrance to the system through these glands and lymphat- ics, and here produces the primary irritation. Following the irritation and inflammation of the follicles, other por- tions of the mucous membrane become involved, and we have a catarrhal inflammation of the mucous membrane of the intestinal tract. The necessary consequence of this is a diarrhoeal discharge. Is this diarrhoea to eliminate the fever poison? Certainly not. It is simply an indication that these intestinal changes are going on ; it is not due to the elimination of the typhoid fever poison, but to the inflammation which the fever poison has excited in the intestinal glands, and the subsequent intestinal catarrh. When the diarrhoea is present in the earlier period of the disease, it is better to let it alone. The question may be asked, will it not exhaust the patient '\ During the earlier period of the fever (the first and second week) the danger is very slight. It has been proposed to treat this diarrhoea, which makes its appearance early in the disease, with alka- TIIKATMKXT. 77 lie?!, bi^mntli, p<']isin, etc II is chiimt'd, if those roni<'(li«'s beadiuiiiistfrcd, di:inh«i'a can !»<• luwcntrd. or, if it alnnidy exists, tliat it can be controlled. Tln^oreticiilly, I sw no reason for cmiiloying alkaline ivinedi(>s, for tin- dian-liovil dischar<;-es aiv always strongly alkaline, and, from clinical observation. I am convinced that bismuth, j)epsin, etc., have little or no effect eitlier in (lontrollin^ th(^ diarrhd'a or in ])ivventinn: the intestinal changes which ])roducc it. When diarrlura commiMices lair in the disease (diirinf; the latter part of the third, or during the fourth wcM'k of the fever), it is of a very different character from that which occurs during the first and second weeks. Ulcera- tion of the intestinal glands, and perhaps sloughing, has been establi<;hed, and, in addition to the extensive local changes, there is a septic element Avhich enters into the causation of the diarrhoea at this stage. Besides, the in- creased peristaltic action of the intestines, which attends the diarrhoea, favors an extension of the inflammatory ])ro- cesses to the peritoneum, especially that portion which covers the intestine, which corresponds to Peyer's patches. In view of these facts, the diarrhoea should be arrested or held in check. For the accomplishment of this, there is but one remedy which can be relied upon— that is, opium. My experience is against the use of astringents. If o])ium will not arrest it, you may expect little aid from astringents combined with o])ium as they are usually administeivd. The use of opium is objected to by some, who claim that it diminishes the power of the heart's action; bur in this disease, when administered in small doses, it seems to me to increase rather than diminish the heart-power. It is ac- knowledged that 0])ium, more tlian any other drug, arrests the peristaltic action of the intestines ; and that is what we wish to accomplish when diarrlupa is jtrescnt during the third and fourth week of typhoid fever. Tymiwxitis. — You will recollect that the tympanitis, which is sometimes so troubh-.some a symptom in t3i)hoid lever, is due to gaseous distention of the intestines. Some assert that this gaseous accumulation is due to ft-rmentative processes going on in the inr''-.tin''< : consequently that the 78 TYPHOID FEVER. use of antiseptic remedies is indicated, sncli as muriatic acid, chlorate of potash, pepsin, etc. When this has proved a distressing symptom, I have usually found relief to be obtained by the application of turpentine stupes to tlie ab- domen. Some claim that if turpentine be administered internally, from the beginning to the end of typhoid fever, that tj^mpanitis and the intestinal changes which lead to it and to the diarrhcea are much less severe. I am confident that the turpentine treatment, as it is called, does not have the controlling influence over this fever which has been claimed for it ; but I am also certain that it is our most reliable agent for the relief of the tympanitis. Intestinal Hemorrhage. — Hemorrhage from the bow- els in tjT-phoid fever (as I have already stated) is a serious accident, and mn,y cause death by producing a fatal ex- haustion. When it occurs earl 3^ in the fever, usuall}^ it requires no treatment ; but when it occurs during the third or fourth week, or after convalescence is apparently fully established, it must be arrested as promptly as possible. The occurrence of severe intestinal hemorrhages may sometimes be prevented by keeping the patient in bed. A typhoid fever patient should not be allowed to get out of bed from the beginning of the attack until convalescence is fully established. Especically is this of importance if the case is a severe one, and attended by symptoms that indi- cate extensive intestinal lesions. When hemorrhage from the intestines does occur during the third or fourth week of the fever, at once semi-narcotize your patient by the administration of opium in small doses at short intervals. Absolute rest of the body must be in- sisted on, the patient must not be turned on the side or moved in bed, and an ice-bag should be applied over the abdomen. I doubt if any good results can be accomplished by the use of astringents, either by enemata or by the mouth, as it is not known that they even reach the seat of the hemorrhage, although gallic acid and the persulphate of iron are usually recommended in cases of intestinal hem- orrhage occurring in typhoid fever. If the hemorrhage is TltKATMKN'T. 7'J profiiso, if niny bo nocossary to k»'<'p your jjatlt'iit undtT tlie iiitliit'iicc of the o])ium for :i \v('«'k or ten days ; in sucli cases tho internal use of turpentine in connection willi the oj)iuiu will be found of service. Peritomtis. — When perforation of the intestine occurs, the case may be regarded as hopeless ; death takes place usually witliin twenty-four hours: death occurs as the result of geiu-ral ])eritonitis ; no plan of treatment avails anything. If the ]ieritonitis occurs without perforation, from the extension of the inflammatory process from the intestinal ulcers to the ])eritoneuni, by bringing your patient rapidly into a state of semi-narcotism and holding him there for live or six days, you may prevent the ex- tension of the peritonitis and thus save life. Such a case you are to treat in every respect as one of localized perito- nitis. After recoveiy from an intestinal hemorrhage or a local- ized peritonitis in typhoid fever, be exceedingly careful about the administration of cathartics or enemata ; either may jeopardize the life of your patient. The bowels will move spontaneously after a time, even though the use of opium be continued, and no harm will follow should two or three weeks pass without a movement from them. When the stomach is irritable, the hy}>odermic injection of morphine is preferable to opium administered by the mouth. This is given in sufficiently large quantities to paralyze the peristaltic movement of the intestines. Bkoxciiitis. — I have aheady stated that catarrh of the larger bronchial tubes is ])resent in all severe cases of tyi)hoid fever. Xo sptvial treatment is required for its management ; but. if tlie bronchitis becomes cajullary, great relief will be obtained from the ap]>lication of dry cups to the chest and the internal administration of car- bonate of ammonia. Vapor inhalations will also be found of service in severe cases. Pneumonia. — The pneumonia which complicates typlioid fever in nearly every case is lobular in character. The signs which indicate its occurrence are sudden rise of tem- perature, increased frequency of respiiation, and the physi- 80 TYPHOID FEVEK. cal signs of localized pulmonary consolidation ; congh and expectoration are rarely present. Its occurrence is always an indication tliat stimulants should be administered. If they are being administered, they should be increased in quantit}^ To prevent or relieve tlie hypostatic congestion of other portions of the lung, which frequently accompanies pneumonic development, the heart-power must be increased, and the position of the patient changed. Laryi^^gitis. — For the relief of the laryngitis which occa- sionally complicates typhoid fever, a small blister may be applied on either side below the angle of the Jaw, and the whole neck enveloped in a poultice. If these measures fail, and suffocation appears imminent, tracheotomy should be resorted to without delay. Subacute gastric catarrh, occurring as a complication during convalescence from the fever, can only be managed successfully by giving the stomach rest as far as possi- ble, restricting the diet to a single tablespoonful of milk at a time, and applying hot fomentations over the epigas- trium. Bed-sores. — The severer forms of bed-sores are the most intractable complications we have to combat. Fortunately, the severer forms are much less frequently met with under the more recent plan of treatment ; and, if they do occur, they are superficial and limited to small spots. Scrupulous cleanliness is one of the principal means for preventing their development. So long as there are no erosions, the parts should be frequently bathed in spirits of camphor, and the points of attack should be relieved from all pres- sure. If the sores penetrate the integument, they should be frequently washed with a weak solution of carbolic acid, or brushed over with equal parts of balsam peru and balsam copaiva and afterwards covered with dry lint or lint covered with vaseline. The most unfavorable cases are those in which the point of pressure caused by the weight of the body becomes gan- grenous. In such cases, by some a continuous warm bath is recommended. As soon as sloughing takes place, and ■rilKATMKXT. 81 tlu' ]»;uts scpunitc, tlu^v slu)iiM Ix' drcsst'd witli lint siitii luted with bals^aiii ul* ]K'ni and caiholic acid. As has been already stated, dianluL'a is usually })r»'S(!UL in the early i)eri()d of this fever; but sometimes there is e<»nsti})atioii. The ijuestion arises, is tlie adnuuistration of cathartics ever admissible in typhoid fever i If so, what cathartic shall be employed i There is great diversity of o])ini<)ii ui>()ii these points. One recommends the adminis- tration of rliui)arb, another advises alkaline cathartics, and another would give calomel. Quite diverse views are still held in regard to what the answer to this question should be. liecently, certain observers of extended experience have claimed that there is sufficient reason for the belief that a portion of the typhoid poison lodged in tlie alimentary tract may be expelled by the timely administration of cathartics, and thus the severity of the fever be mitigated and its duration shortened. Recent German writers claim that calomel, concerning the favorable action of which in this fever so much has been said and written, acts beneficially only as a cathartic. Those who favor the administiation of cathar- tics recommend their use uuunly during the first week of the disease. On the other hand, eqnall}' competent observers maintain that the intestinal changes are augmented, and rendered more extensive by the action of cathartics ; that the normal course of the fever is interfered with ; and that in a largt^ proportion of cases where intestinal and jxMitoncal compli- cations occur, hypercatharsis has been induced at an early period of the fever by the administration of cathartics for the purpose of shortening its duration. My own experience leads me to exercise the greatest caution in the administra- tion of cathartics in an}' stage of this fever. I am conlident that the routine practice of administering purgative medi- cines in tlie early stage of typhoid fever can only be fol- lowed by a threefold injury : i'V/'.sY. — The patient is weakened. Second. — The local intestinal lesions aiv increased. Tliird. — Perforating peritonitis is more liable to occur. 82 TYPHOID FEVER. The administration of cathartics as an oliminative pro- cedure has neither reason nor experience to sustain it. Before speaking of the management of the convalescence of typhoid fever, I will make a few general remarks on the use of anodynes for the relief of certain troublesome ner- vous phenomena. I have stated to you that among the earliest, most fre- quent, and often most prominent nervous symptoms in this fever is headache, but it is seldom very violent or of long continuance. Should it be severe, not readily relieved by fomenting the forehead and temples with warm water, or should it give place to active delirium, and other severe nervous disturb- ances, the question presents itself, shall anodynes be administered ? If you decide to use them, the most reliable of this class of remedies is opium. Usually, the condition of the pupil of the eye will serve to indicate to us whether opium shall or shall not be administered. A contracted or "pin-hole" pupil maybe considered to contra-indicate its use, though there are exceiD- tional cases in which opium acts favorably, notwithstanding this condition of the pupil. Opium should be given with great caution whenever signs of cyanosis are present. In all cases of typhoid fever, it is safer to administer opium in small and repeated doses than to venture upon the administration of one large dose. There are other anodynes which you will sometimes find of service, such as hyoscyamus, chloral, and the bromides. I would caution you against administering too large doses of chloral ; the desired effect can generally be produced by ten or fifteen grains. If the first dose fails to relieve, a sec- ond may be administered at the expiration of two hours. This remedy is said to have a special value in quieting the active delirium, which is sometimes so troublesome, but my own experience in its use has not been favorable. When anodynes have failed to give relief to typhoid fever patients, who have been delirious aud somnolent for days, they will sometimes become quiet and fall asleep immedi- ately after the free administration of stimulants. Those TUKATMKXT. 8;} ('asi>s in w hicli | In- nervous symptoms iirc din- to an an.-rmic condition of tiic hiain, associafcd with a ufak lirmt and a tlaggiiii;- riicnlation. ar(> mosf lik<'ly to Ix' iK'nclilfd hy tin; use of stimulants. In iliosr cjisrs in wliidi sul)sultus becomes vory maikrd mid tlici-c is a gcufral tn-nioi', jacti- tation, and rcstlcssiit'ss, 1 Ikuc seen most lia})])y ellrcts jiro- duced by the use of liyjuxlcrmic injections of sulpliuiic etlier. 1 \\(»uld use, as an average (|ii;iiiiiiy. fom- diiiclims given in injections of one drachm eacli, in dill'erent ])laces. Tile sanu' watcid'ul care sliould l)e tal-ten of a ty])hoid fev<'r ]iatient during convalescence as dui-ing tlie active j)eriod of tlie fever. Tlie numl)er of tyjdioid patients who die duiing convales- ceiu'e is ])roportionally large. Frequently this is due to the fact tliat tlie })hysician has laid down no sti-ict rules to be observed as to diet and ex(^rcise, and frequently from the non-observance of such rulers when tliey liave been given. The diet of fever patients during this period sliould be carefully watched. Allow your patient to eat frecpieiitly, but only small quantities of food should be taken at a time, so that the gastric juice secreted by the enfeebled stomach may be sufficient for its complete digestion. All indigesti- ble articles of food, and those which fuinisli a large amount of waste, slnmld be stiictly forbidden. An ap])arently insignilicant disturbance of tlie stomach, a slight vonnting, or a moderate diarrha?a occurring during the period of con- valescence sliould be regarded as dangei'ous, for any ones of these may induce a subacutt^ gastritis, or lead to intestinal ])erforation and a fatal ])i'ritonitis. It is o])vious that while the intestinal ulcers are healing, much misciiief may be done by imjnoper diet. Notwithstanding the cravings of the ]Kitient's a])petite, the diet must be restricted to such articles as milk, cream, gruels, jellies, and aninuil broths. Solid food must be strictly forbidden, especially meats, vegetables, and fruits. Tf diarrh(pa is ]u-esent duiing convalescence it is far safer to restrict the patient to milk and cream. All exercise, exce])t simply walking around the sick-room, should be proliibited. I have had iiatieiits con\alescing from tyjthoid fever sink 84 TYPHOID FEVER. rapidly after a long ride, or after indulging in some violent and fatiguing physical exercise. It is of the greatest impor- tance that this class of patients should keep in the recum- bent or semi-recumbent posture until the cicatrization of the intestinal ulcers is completed, which in some instances does not take place for two or three weeks after convales- cence is w^ell established. If convalescence is slow, small doses of quinine, iron, and cod-liver oil are of service. They should be given after the patient has taken food. When, during the period of convalescence, diarrhoea is persistent, the patient should be kept in bed, and some of the vegetable astringents, such as catechu, hgematoxylon, may be employed. In many cases it is important that you should take the evening temperature for at least two weeks after the com- mencement of convalescence, for by its range you will be able the more accurately to determine the exact condition of your patient. When convalescence is delayed, so that at the end of four or five weeks the patient has not regained strength, change of air is indicated. LECTURE VIII. YELLOW FEVER. Morh id Anatomy. — Etiology. — Symptoms. TIII^? morning I will commence the history of the second in the list of miasmatic-contagions fevers, namely, Yellow Fever, This fever has received its name from a yellow discolora- tion of the skin, which is a part of its clinical history. The term, yellow fever ^ has been generally adopted b}' American, English, French, and German writers, and it is not necessary- to mention the long list of obsolete names which have been applied to this disease by different writers, ^MoUBiD AxATOMY. — We find tliat the anatomical changes whicli take place in the diffen-nt organs and tissues of tlie body during the course of this fever, in some respects are similar to those which occur in miasmatic and contagious fevers, allying the disease more or less nearly to eacli of these classes of fever. Althougli these different types of fever have many points of resemblance in their anatomical lesions, as well as in their general history, each has its own distinguishing char- acteristics which mark it as a distinct and specific disease. The characteristic lesion (if we may so call it) of yellow fever is to be found in the liver. This organ is not much increased in size, but there is a striking and uniform change in its color, Sometini'*^ it i^ of the color of fresh butter, 86 YELLOW FEVEE. sometimes of a mustard color, and sometimes tlie color of coffee and milk, or cliocolate color. In most instances this change occurs throughout the entire organ ; occasionally, it is confined to one lobe, or to a small portion of a lobe. With this change in color there is a diminution in the quan- tity of blood in the liver, so that it contains less blood than normal. It has a dry appearance, is softer than norma], breaking down readily on firm pressure. When a section is placed under the microscope, it will be seen that there has been infiltration of the hepatic cells with oil-globules. In fact, all of the liver cells are more or less filled with oil-glob- ules. Sometimes the change is a granular one, the nuclei of the cells have disappeared, or become obscured ; in other instances, the entire liver cells have filled with large oil-glob- ules, but the form of the cells has not changed. This change lias received the name of acute fatty degen- eration. In its gross appearance, as well as in its minute anatomical changes, the liver resembles the fatty degenera- tion of the liver of rum-drinkers. Besides this, there is no change of any importance observed in the liver in yellow fever, except it may be slight extravasations of blood upon its surface, rarely in its substance. Mucous Membrats^e-s. — You will find the mucous mem- brane of the intestinal track, as also that of the larynx, the seat of a more or less severe acute catarrh. The vessels of the mucous surfaces, especially the veins, will present a turgid appearance ; and so intense is the h^^perpemia that at points they will present a varicose appearance. If there is a uniform congestion throughout the entire extent of the intestinal track, you will notice here and there little blood extravasations or ecchymotic spots. The whole track con- tains a greater or less quantity of fluid blood. Frequently the mucous membrane of the stomach is found thickened, reddened, and softened, sometimes with quite extensive blood extravasations. The contents of the stomach corre- spond to matters vomited during life, which I shall more fully describe under the head of symptoms. Heart. — The heart is soft and flabby, ligliter in color than normal, and will be found to have undergone degen- MolMUl) ANATOMY. 87 pvativf clKiiiufS similar to tliosc wliicli take jOacc in ils imiscular tissue in typhoid fi'Vfi-. Tlicsc dianL^cs iimloiiht- »'(lly do not depend nium lii-li l«iiiiieral ni-i-, for a very lii^i;h renii>eiature is laicly ])resent in yellow fever. The normal outline df the heart is lost, and it breaks down readily on lirm prosure. The more severe the f.v.-i-. ami the lon,ii:er ils duration, the more extensive will lie the parenchymatous deueneratioii. The ])ericardium usually contains one oi' i uo ounces of blood-staiin'fl sei'uin. Par- tially ori;ani/,ed clots are found in tlie heart cavities ; these often e.xleiid for some distance into tlh' vc^ssels. The}' are the residt of a slowing- of the circulation from feel)leness of the heart })ower, and, in most instances, are J'ormed just prior to death, although they are not tlie cause of death. Lungs, — Usually the lungs are the seat of hemorrhagic infarctions. In fact, you will rarely make ati auto})sy ui)on one who has died of yellow fever without hndiiig iid'arctions in the lungs, and sometimes they w^ill be quite numerous. Diffused pulmonary apoplexies often occur, wdiicli may in- volve a large portion of a lobe. Under such circumstances the lung tissue will be broken down and occupied by large blood-clots. Spots of ecchymosis will also be found under the pulmonary and costal pleura. KiDXEVs. — The kidneys are always more or less increased in size. This increase is due to swelling of the cortical sub- stance, which is the seat of a more or less extensive fatty metamorphosis. It is a true parenchymatous nephritis, in which the fatty stage is very rapidly reached. You will find the uriniferous tubules crowded with oil-globules ; in some places the tubes are denuded of epithelium ; in other places they are filled with broken-down e])itlielium, which is undergoing a fatty and granular change. The pelvis of the kidneys is frequently tln^ seat of acute catarrh, and evi- dences of catarrhal iiiHammation may be found along tin; ureters and in the blad present decaying animal and vegetable matter. l-'or tli'- ]>i-oduc- tion of the nuasm which causes malarial fevers vegetable decomposition is sufficient, but for the development of yellow fever, both animal and vegetable decomposition is necessary. A high temi)erature is necessary to its develop- ment. The average temperature for the twenty-four hours must be above 77° F. The period of the 3'ear during which yellow^ fever prevails depends upon climate and temperature. In the United States, it has usually appeared in July or August, and dis- appeared upon the first frost. The great epidemic of yellow fever in New York City, in 1795, began early in August, and disappeared about the middle of Octo- ber. Undoubtedly, this fever is indigenous in certain locali- ties. There are certain seaports along our southern coasts, and certain islands of the sea, wdiere it is developed when- ever the necessary atmospheric conditions are present. Especially is it a disease of hot climates, and, in localities that are subject to it, it is more likely to prevail in very waini and wet than in cold and dry seasons. It ma}^ be endemic or epidemic. Sporadic cases are of rare occur- rence, even in localities where it is indigenous. Some races more than others are subjects of this fever. The African race is most exem])t from it. A prolonged residence in a district where yellow fever is indigenous renders an individual less liable to contract the fever. Possibly a person may become acclimated to the 90 YELLOW FEVER. disease. Having once liad the disease is a partial, tliongli not complete, ])iotection against a second attack. North-westerly winds seem to arrest, while south-easterly winds seem to favor its development. In other words, when south-easterly winds are prevailing, the epidemic spreads and increases in severity, while, if the wind changes to the north- w^est, its progress is arrested. Whenever the ttnnperature falls below the freezing point, no matter how pestiferous a region may have been, nothing more need be feared from the spread of the disease. These are some of the conditions which are necessary for the development and spread or arrestation of yellow fever. Now, the question arises, What is the nature of the poison that produces the fever \ Is it a miasm or a conta- gion ? There can be no question but that it is a poison in many respects similar to that of typhoid fever, which can be conveyed in some way from one individual to another, or rather that, when certain atmospheric conditions are present in connection with animal and vegetable decom- position, the introduction of the specific yellow fever poison is followed by its rapid reproduction. When it has been so reproduced, it may be received into the human system and give rise to morbid processes, attended by certain clin- ical phenomena wdiicli are characteristic of this disease. Thus far chemical and microscopical research has afforded no positive information in regard to the nature of the yel- low fever poison, but there can be no question as to the existence of such a distinct and specific poison, and it w-ould seem, from the conditions necessary to its develop- ment and the manner of its conveyance, that it is in some respects of the nature of a miasm, and in other respects that of a contagion. You may have yellow fever, remit- tent fever, and typhoid fever, all prevailing at the same time in a locality, yet each of these three diseases will run its individual course, and no one will lapse into another. The question now comes to us. Is ydlow fever contagi- ous ? There are three leading doctrines upon this point. First— "TliQ doctiine of unqualified contagion, which t:ti(»i,ositioii. to which must be added the speciilc yellow-fever ])oison l^efore the fever can be ])ropagated from the sick to the healthy. While the advocates of the doctrine of non contagion are 92 YELLOW FEVER. positive as to tlie non-contagious character of yellow fever, they are eqiiall}^ certain that it is a portable disease, that is, tliat it can be conveyed from one locality to another by means of clothing, merchandise, and in tlie holds of vessels. They also believe, when yellow fever poison is thus intro- duced into healthy localities which are suited by tempera- ture and the presence of animal and vegetable decomposition to its reproduction, that it rapidly and repeatedly repro- duces itself, and in this way epidemics of yellow fever may be developed in localities which are usually free from the disease. Consequently, it is a disease which should be guarded against in any seaport by a vigorous quarantine. How long yellow fever poison may retain its vitality is not 3^et positively determined, but that the period is a very long one tliere can be no question. One may visit a locality where yellow fever is prevailing and remain in it for a considerable time, and not convey the i^oison in the clothing beyond the boundaries of the district where the disease is prevailing. In order to the con- veyance of the poison bej^ond these limits, it is necessary that the clothing become so saturated with the poison that it will not become neutralized when exposed to the air of a non-infected district. I have briefly stated to you all of the important well- ascertained facts that bear upon this vexed question. In conclusion, it may be stated that with the written history of the disease before one, there is not sufficient evidence to lead to the acceptance either of the doctrine of contagion, or of contingent contagion. It seems to me there need be no fear of contracting the disease by visiting those sick with yellow fever in a yellow fever district, unless such visits are ver}^ much prolonged. The poison of yellow fever, as met with in the holds of vessels, sometimes is so concentrated that a very short exposure is sufficient to overwhelm the nervous system, and give rise to ver}^ urgent nervous phenomena, which are soon followed by the development of the fever, and from such exposure it is possible to convey the poison in the clothing. The length of the period of intubation varies from twelve SYMPTOMS. 93 lioui'S to four or live days; it is claiiucd by some lliaf tliis ])eri()d of iiiciihalioii ma}' «'Xtriid over a jK'riod of srvcral wet'ks. Wlicii tlic cxposiiic is foilou-cd in u few lioiiis by the lever, llicycllow fever ])oisoii must necessarily b(; very coneeiitrated. Symptoms.- — Tiie de\ cloiiuienl of yellow fexci' may or mav not be preceded by ])remonitoiy sym])loms, such as head- ache, pain in- the limbs, and loss of ai)i)etile. If these symj)- toms are ])resent, they are l\v no means characteiistic of the lever. In nearly e\('ry inslance the disease is nslien^d in b}^ a distinct chill ; in no disease, unless it may ])e i)uer- peral fever, is a chill so invarial)ly an nshei'ini^ in symi)tom as in yellow fever. While aj»i»arently in th(? most perfect health, while at work, or even while aslee]), jK^tients will be seized with a slight or severe chill, and immediately be- come seriously ill, taking their beds in the most disheart- ened manner. You will remember that I stated, to you that there were both mild and severe types of typhoid fever, and that tliey differed only in degree, not in kind ; so also is the case in yellow fever, and you must remember this fact when con- sidering the symptoms of this fever. The outline of the clinical histor}^ is very nearly the same in a mild as in a severe type of the fever. Following the (hill or rigor which usliers in the attack, tliere is supra- orbital headache, pains in the back and limbs, which are especially severe in the calves of the legs. The counte- nance is flushed, the conjunctiva congested ; the eye has a ])(.'culiar lustre and a staling look. Tlie temperature rises rapidly, and reaches 102° F. within a few liours after the chill. The temperature in yellow fever varies very much in dilTcnvnt cases. In sonu^ cases it never rises above lOS" F., while in some severe e])idemics it has ])een recoi'ded as high as 110° F. Such a teni]»erature is veiy seldom reached. By the end of the second day ihe 1iiii]m laiure nsuall}' reaches its maximum heigln, which larely is higher tlijin lo.")' F. In this countiy. according to i-ecoids made, the temperature lias rarely risen highei- I hail jol !•'. Tlii< fever is not characterized by >o high a range of temperature as is 94 YELLOW FEVER. mot Avitli in almost all the otlier varieties of fever. From the second to the fourth day the temperature variations are slight, and do not amount to distinct remissions. By the fourth day, if not before, the temperature falls very rap- idly, so that in twelve hours the normal standard may be reached ; usually, however, it does not fall below 100° F. This fall constitutes a distinct remission. This period of remission may last from a few hours to two or three days, after which time the temperature again rises, and rapidly reaches 104° F., or even rises higher ; then it remains sta- tionary from twenty-four to forty-eight hours, after which time it falls to the normal standard, where it remains until convalescence is established. In accordance with the temperature variations, the dis- ease may be divided into three stages : a first stage, or stage of invasion ; a second stage, or stage of remission ; and a third stage, or stage of exacerbation. Some writers have divided the disease into a febrile stage, or stage of exacerbation, a passive stage, or stage of remission, and a stage of collapse. LECTURE IX. YELLOW FEVER. Sf/??iploms {continued). — Differential Diagnosis. — Proff- nos is. — Treatm ent. This morning I would invite your attention to the farther study of tlie symptoms of yellow fever, I have statt^d to you tliat in the iiiMJority of instances this fever is usliered in l)y a distinct chill ; usually, this is not prolonged ; follow- ing rlit' <'hill there is a rapid rise in tem])crature, wliich, by the third or fourth day, reaches its maximum height, from 103^ F. to 107" F. This rise in temperatur<> may be accom- panied by dryness of the surface, or the surface of the body may be bathed in a profuse ])erspirati()n. Sometimes, aft<'r the chill has subsided, there is an unnatural coldness of the surface, and there seems to have been Jio rise in tem- perature, but the thermometer in the rectum registers 104° F. or 105° F. PuLSK. — The pulse in yellow fever is never accelerated in proportion to the rise in temperature. It rarely becomes as frequent as in other forms of continued fever, seldom reaching more than 110 beats per minute. In quite severe cases it may only reach loo, and in the milder cases it may not be accelerated more than live or six beats. It has a peculiar character ; many writers term it a "g:\seous ])uls(\" It is easih' compressed and has an uncertain volume and cliaracter. This peculiarity of pulse is an element of diller- ential diagnosis. 00 YELLOW FEVER. Eye. — The eye is suffused, and the conjunctiva becomes congested quite early in the disease. The appearance of the countenance in severe cases has almost uniformly been regarded as diagnostic of this disease. The eyes are red and watery, and the conjunctivae are so intensely congested that the eyes resemble two balls of fire, while the face has a dusky, deathly hue ; these give to the countenance a re- markable expression of dejection and distress. Tongue. — The tongue is early covered with a thick white coating, except at its tip and edges, which are red, and in fatal cases, towards the close of life, sometimes the tongue becomes dry, brown, cracked, and fissured, resembling the tongue of typhoid fever. There is loss of appetite, and from the very onset of the disease there is more or less nausea and vomiting. YoMiTiNG. — Nausea and vomiting may be regarded as among the most constant and characteristic symptoms of 3^ellow fever. They come on soon after the chill, and con- tinue throughout the entire course of the fever. At first the matters vomited are simply the contents of the stomach, then they become yellowish or greenish in color, are fluid, and have an alkaline reaction. There is nothing about the matters vomited that is characteristic of yellow fever. If the vomiting subsides without any other changes in their character, it is quite evident that the case is going on to recovery. In the fatal cases the vomiting continues un- til a few hours previous to death, and in some cases until the hour of death. In a large proportion of these cases there is finally developed the striking and well-known hIacTc vomit, wliich has been regarded as characteristic of this fever, and which by some is supposed to occur only in this disease. This peculiar vomiting ma}^ occur upon the second or third day of the fever, but more commonly it does not come on until thirty-six or forty-eight hours pre- vious to death, or not until the day of death. It undoubt- edly occurs more frequently in yellow fever than in any otlier disease, but it difl'ers in none of its constituents from a similar material which is sometimes vomited in other diseases. A microscopical examination of the black vomit SYMPTOMS. 1)7 sItows it to ronsist of ])i<;iiii'iit. iiKittii- in tin- rorm of llip- graiuilt's, aerature rapidly falls, so that in twelve hours it may reach its normal standard. In the majority of in- stances it does not fall below 100° F., and there is no dis- tinct intermission, but a decided remission. The pain in the head and back now subsides, the patient is in every way very much improved, and you may consider him con- valescing. Yet, in a day or two, there may" be a return of all the febrile and other distressing symptoms which were present in the early period of the fever ; after these have continued for twenty-four or forty-eight hours, usually convalescence is established ; especially is this the case when recovery is to take place as soon as the remission is established. In such cases, with the remission, the pain in the epigastrium, the vomiting, and the yellow discoloration of the skin all begin to subside. The patient is now able to take nourishment, and with the occurrence of these symp- toms, if the surface has btM»n dry, a slight moisture ap})ears, and the patient soon passes into a state of convalescence. On the other hand, the vomiting maj' continue, and the black vomit appear; the distress and burning in the epigas- trium may become more and more severe ; there is greater restlessness, tossing, and agitation; the albumen in the urine is more abundant ; the urine becomes more and more scanty, until tinall}^ complete su])pression occurs, and coma and death follow. Some epidemics are marked l»y a ]»redoniinaiice of one class of symptoms and some hy the predominance of an- other class, so that it is difficult to give a history of this fever which shall accord with all its different modes of de- 100 YELLOW FEVER. velopment. Consequently, there have been many varieties of yellow fever described, such as the comatose, the algid, etc. Strictly speaking, these so-called varieties are simply variations in the clinical manifestation of the disease pro- duced by the degree of poisoning, and by some peculiarity in the atmospheric conditions under which it prevails. Some epidemics are much more fatal than others, and the ratio of mortality is much less during the latter part than during the early part of an epidemic. At the present time, there seems to be little question but that the immediate cause of death in all severe epidemics of yellow fever is due to uremia. The yellow fever first produces its changes in the blood, which leads to such glandular changes, especially of the kidneys, as arrest glandular functions, and a secondary blood-poisoning is the result. Some writers have described a j)eriod of collapse. It is true that a condition of collapse not unfrequently occurs, but it is nothing more than a period of commencing death. Differential Diagnosis. — Yellow fever has been con- founded with malarial fever, relapsing fever, and with acute atrophy of the liver. Under ordinar}' circumstances the diagnosis of yellow fever is not difficult, yet there are cer- tain types of malarial fever which are especially liable to be mistaken for it. Some writers have even gone so far as to maintain that the so-called bilious-remittent is only a modification of yel- low fever. At the present day, it has been fully established that each is a distinct type of fever. The following are the points of differential diagnosis between them : First. — The character of the prevailing disease, the re- gion in which it prevails, and the manner of its endemic or epidemic development. Yellow fever prevails in seaports, remittent fever in inland towns. Yellow fever is, remit- tent fever is not portable. Second. — The difference in the manner of invasion of the two diseases, the difference in the range of temperature, the projectile character of the vomiting in yellow fever, and its non-projectile character in remittent, the peculiar character DIl'FKKKN riAL DTACN'OSIS. KM of l)iilst' in yellow t'i'vcr, as well as ilic almost characteris- tic oxi)n'Ssi(Hi of tlic coiiutciiaMcc, is quite sullicieiit to dis- tiii(' of remittent fever. Then the difference in the aiiatoinical ch:inires, and in tlie elVect of quinine in the two diseases is veiy st^ikini,^ There is a yellow discoloration of the skin in l>oth diseases. but it appears earlier and is more intense in yellow than in remittent ftn-er. The presence of an enhnp'd si)leen would lead to the diaf^nosis of remittent rather than yellow fever. Helapshig Femr. — At the first appearance of this dis- ease in a new locality it may l)e confounded witli yellow fever. You will be led to a correct diagnosis by study- ing the etiological relations of the two diseases. Relaps- ing ferer i.9, yellow fever is not, propagated by contagion. Then, the almost tyjiical range of temperature in relapsing fever furnishes a marked distinction between it and yellow fever. In the former if yellow discoloration of the skin is developed, it does not come on until late, generally not until the relapse. An enlarged spleen is the rule in relaps- ing, and the exception in yellow fever. Hemorrhage from the mucous surfaces may occur iu both these types of fever, and there can be little question but that the blood-changes are very similar in kind, but not in degree, in these two forms of fever. During the past two years, in the wards of Bellevue Hospital, in two instances, has acute yellow atro- pliy of the liver been mistaken for yellow fever. If an accurate history of the cases could have been obtained, doubtless the mistake in diagnosis would not have been made. In yellow atrophy of the liver, as well as in yellow fever, there is jaundice with fever, and vomiting of a black mate- rial accompanied by suppression of urine ; but the liistory of the devel()]iment of the two diseases and the gradual but steady diminution in the siz«> of the liver in yellow atro])hy, while in yellow fever the organ rather increases than dimin- ishes in si/e. is sufficient for a diagnosis. The difficulties which attend the dilFerential diagnosis of yellow fever aie often very great ; in fact, sometimes it is impossible to make a i)Ositive diagnosis. For example, some 102 YELLOW FEVER. of the crew of a ship coming from an infected port become jaundiced, have hemorrhage from the mucous surfaces, ac- companied by fever of a remittent type ; if these patients have previously suffered from intermittent fever, attended by an enhirgement of the spleen, it will be almost impossible in the earlier cases to decide between so-called bilions-re- mittent and yellow fever. Prognosis. — The average duration of yellow fever is six daj^s ; sometimes it destroys life in three days. The prog- nosis greatly varies in different epidemics. The highest recorded ratio of mortality which I have been able to find is one death in every three cases. Some writers have claimed that more than one-half the cases are fatal, but upon a careful examination of statistics I find they give no such percentage of death. In some epidemics the fever is of so mild a type that only a very few cases terminate fatally, perhaps one in fifteen or twenty. A consideration of the following conditions is of impor- tance in making our prognosis : The severity of the invasion of the fever. The intensity of the febrile excitement. The early appearance of the yellow tinge of the skin and the intensity of the jaundice. The greater the severity of the period of invasion, the higher the range of temperature ; the deeper the jaundice, and the greater the amount of albumen in the urine, the more unfavorable is the prognosis. If the quantity of albu- men diminishes, the patient is advancing toward recovery ; if it increases, a fatal termination is indicated. The elements of a favorable and unfavorable prognosis may be briefly stated. The fai^orahle symptoms are a slow pulse, a slight rise in temperature, a quiet stomach. Streaks of blood during the latter stage of the fever are not regarded as indicating danger, especially if the blood-corpnscles are entire. Al- buminous urine without casts is not of serious import. Under all circumstances, a copious secretion of urine must be regarded as a favorable symptom. A recent residence in a temperate climate will enter very largely into the chances of recovery from 3^ellow fever. PROGNOSIS. 103 Tlu^ tcnfawrahle synrptoms are: a higli temporal uiv, a red toiiixiK'. nil irritable stoiiiacli, intense i)ain in tin? liead, scanty urine, containinu- albninen and casts, black vomit, a faltering articulation, and dilliculty in jirotruding tlu.^ tongue. A streak of blood in the early vomit indi<'ates great danger, especially if the blood-globules are l)roken down. The intensity of tin- jaundice, and ihefact that the ])atieiit has rec«Mitly suiTered i'roiuan attack of yellow IVver, render the ])rognosis unfavorable. In a large number of cases you will lind great difficulty in giving a positive prognosis. The presence of the "black vomit" and an entire suppression of urine render a case almost liopeless, as lias already been stated. Recovery after the occurrence of "black vomit" is more frequent than after suppression of urine. In mild and in severe cases the period of convalescence is in proportion to the duration of tlie disease. In some cases it is not fully established until two weeks after the cessation of the febrile symptoms. Complete recovery does not take place in some cases until five or six months after the commencement of convalescence. There are no certain sequelae of yellow fever. Cellulitis and abscesses are spoken of by some writers, but they are by no means constant. Tkeat3[ENT. — Before considering in detail the treatment of yellow fever, I would say a few words concerning its prophylaxis. The ])rophy]actic measures for tlie most part are included under the general head of quarantine regula- tions. It is possible by strict quarantine to prevent the introduction of j'ellow fever into any district or seaport where it is not indigenous. It is not necessary that I should enter upon a discussion of those quarantine regulations wliich have been found most successful in ])reventing the introduction of this disease; tlu'se come rather within the province of State medicine. If you lind yourself in a re- gion visited by an epidemic of yellow fever, you may escape it by removing ])ey()nd the limits of the iid'fi-ted district. If you are compelled to remain within tin- limiis wlnrc tlif epidemic is prevailing, avoid ever\"thing which is regarded 104 YELLOW FEVER. as a predisposing cause of the disease. Under sueli circum- stances most observers regard tlie sulpliate of quinine, taken daily in moderate doses, as a proplij-lactic agent. The details of the treatment to be employed when the disease has once established itself are very unsatisfactory ; perhaps there is no disease the treatment of which is more unsatisfactory. Medical men widely differ as to the most effectual means to be employed in controlling or mitigating the severity of the fever. Physicians in India, and Ameri- can physicians who have come in contact with this fever, treat it very differently. Within the past few years there has been a marked change in the views of American physi- cians in regard to its treatment. The remedial agents which have been most extensively used are mercurials, bleeding, stimulants, and quinine. It is very difficult to accurately estimate the relative value of these different agents, for this reason, there are certain forms of this fever in which no treatment avails anything, the patient receives his death-blow at the very onset of the fever. On the other hand, there are forms of so mild a type that the patient is almost certain to recover. Hence the great uncertainty which attends any plan of treatment, and the nnreliableness of statistics in regard to its effects. Under all plans of treatment there are many deaths and many recoveries. I have already alluded to the four leading plans of treatment which have been resorted to for the management of this fever, namely, the mercurial, the blood- letting, the stimulant, and quinine plan. The plan now most generally adopted is the expectant, or, as it is called by some, the diaphoretic. At one time blood-letting was very extensively practised in the treatment of yellow fever, one hundred and eighty ounces of blood have been drawn from the temporal artery at a single bleeding. The most experienced and intelligent physicians, with the largest opportunities for observation, have abandoned this plan of treatment, which fact is suf- ficient argument against it. The same is true of the mer- curial plan of treatment ; now mercury is onl}' employed as a cathartic at the very commencement of the fever. / TUKAT.MKNT. 105 Till' stiiuulatiiiu; plan of treatment has also iallen into dis- ivi>ntt'. It was found that the ailniinistration of sliunilants during the active period of the fever was not followed by good results. xVgain, our nn)st competent observers unhesitatingly de- clare that quinine has no controlling power over the fever. Let us i)ause a moment and consider what are the indica- tions as to treatment. The great danger in yellow fever is that tin- kidm ys will fail to ])erform their function. What more sensible plan of treatment than that which contem])lates relieving the kidneys from excessive work ? Here is an opportunity for the use of diaphoretics, and a certain amount of cathartic medicine, not to use them to such an extent as to produce exhaustion, but so far as to afford as much relief as possible to the kidneys. At the commencement of the attack counter-irritation over the region of the kidneys is undoubtedly of great service. The plan of treatment now most generally recommended and adopted is, as soon as a patient is taken with yellow fever, in addition to the application of counter-irritants over the region of the kidneys, to administer ten grains of calomel combined with ten grains of quinine. Why the quinine is added to the calomel I do not know. Keep up a moderate dia])lioresis. At the same time administer lime-water and milk, which is said to have greater control over the nausea and vomiting than any other means which have been em- plo3'ed. It has been recommended that the surface should be bathed with some alkaline lotion, on the theory that alka- lines applied to the surface have a controlling influence over the vomiting. There are no reliable facts to sustain this theory. In severe cases, during the fever, there is usually nausea, great restlessness, with tossing and rolling of the head. In order to quiet this uneasiness and jactitation some liave pro- posed tlie use of chlorodine, otliers the administration of chloroform, but all have i)rotested against the use of opium, 106 YELLOW FEVER. because of tlie kidney lesions, insisting that by the use of opium in any form we ran the risk of causing additional disturbance of the function of the kidneys. I regard this restlessness to a great extent as due to the effect produced upon the nerve centres by the urea in the circulation, and believe that all these nervous manifesta- tions can best be controlled by the hypodermic use of the sulphate of morphine. Perhaps it may be worthy of mention that a physician living in the West Indies has recently quite successfully treated cases of yellow fever by administration of carbolic acid in doses of one and a half to two grains every two hours. It is claimed that the carbolic acid given in this way arrests the changes in the blood produced by the yel- low fever poison. I should question very much if carbolic acid has any such power. As the course of this fever is very rapid, it is of the utmost importance to sustain the vital powers as far as possible till the morbid processes come to an end. This is always diffi- cult on account of the great irritability of the stomach— but as soon as the stomach is in a condition to receive food, you must endeavor to improve the composition of the blood by a most nutritious diet, combined with wine, quinine, and iron. MALARIAL FEVERS. LECTURE X. MALAIHAL FEVERS. Introduction. When I began the liistoiy of fevers, you will remember that I divided tliem into three general classes, namely, the contagious, the malarial, and the miasmatic-contagious. This morning I commence the history of those which are included under the head of malarial fevers. I pursue this course for the reason that I believe you will be better pre- pared to study contagious fevers after you shall have become familiar with the malarial. The different varieties of malarial fever are like difl'erent branches of the same tree; they have many things in common, yet dilftn- from each other so widely in the phenomena which attend tlirir development, that they may be regarded as distinct dis- eases. They have a common origin in a poison which has received the name of miasm. All varieties of these fevers depend upon one and the same poison, which is subject to certain variations in quan- tity. The concentration of this poison determines the severity and, to a certain extent, the type of the fever. It is possible to arrange the different types in a progressive scale, from the mildest to the most severe, beginning with the simple intermittent and passing on to the most severe type of pernicious fever. Tiie extent of the morbid pro- cesses, and the ra])idity with which they are developed, depend upon tlie intensity of the malaiial ])()is()ii. tlie length of time the individual has been uikI-t its iiiUiience, 110 MALARIAL FEVERS. and, to some extent, "apon individual idiosyncrasies. Many tlieoiies liave been advanced as to the nature of this miasm or malarial poison. By some it is regarded as gaseous in its nature ; others believe it to be a living vegetable organ- ism ; and, again, others think it is a specific poison, having no tangible, chemical, or microscopical constituents. No one of these theories, nor of the many others which at different times have been advanced, have been sustained either by facts or by reliable chemical or microscopical analysis. Thus far we have no positive knowledge in regard to its true nature, but we do know something of the cir- cumstances which are necessary for its production and the laws which regulate its development. J^irst. — There must be a certain amount of vegetable matter, either on the surface or in the substance of the soil, where the malarial poison is generated. It is not necessary that the quantity be large, but a certain amount is a neces- sity. Second. — A certain amount of moisture must be on the surface or in the substance of the soil ; it need not be excessive ; but some is indispensable. Third. — A certain average degree of temperature is neces- sary for its production. It cannot be developed below an average temperature of 58° F. for the twenty -four hours, and will not prevail as an epidemic unless the average tem- perature ranges as high as 65° F. for the twenty-four hours. In regions where these fevers prevail, their type, form, and intensity, to a great degree, depend upon the height of the temperature. As a rule, malarial fevers are endemic, rarely extending over large sections of country in the form of an epidemic. I will repeat, three things are known to be necessary to the development of miasm or malarial poison, namely : t7ie presence of decomposing organic matter., a certain amount of moisture., and a certain arierage range of temperature. We also have some knowledge concerning the regions in which malarial fevers are most likel}^ to prevail, and which seem most favorable to the development of malarial poison. First. — Marshes are especially favorable to the develop T\Ti:oi>rrTrox. Ill ment of tliis ])oison, mikI mwy i^onorate it for nn indfli- nito period. The Ponliin^ iiiiirslies litivc Ixmmi iruiliuial for more tlmii two tliousaiul years. Yet all marshes are not malarial ; their power to ireiierate the malarial poison varies with the amount of water the}' contain. Where there is an abnndaiu-e of water, malarial fevers are rare; when they are covered only l>y a thin sheet of water, and are exposed to the direct rays of the sun, malarial poison will abound. Marshes that have dried nj) are especially favoi-iMe to tile develojmient of this poison, yet as soon as heavy rains sul)merge the previously j^arched surface, the power to generate the poison is for a time diminished or entirely arrested. Scattered here and there over our own continent are districts which have been malarial ever since the white man has held possession of them ; whether such was the case in earlier times, our history is too uncertain for ns to de- termine. As a rule, salt-water marshes are especially free from malaria, but when salt and fresh water become mixed in the marsh, as, for instance, on the New Jersey Hats, you liave the most favorable conditions of marsh for its abun- dant dtn-elopment. Those marshes resting on a sul)stratum of sand are far less malarial than those resting on lime- stone, clay, or mud. There are marshes in the higher latitude of our own and other States which often, during the heat of summer, be- come dry, yet no malarial poison is generated (although during the day the thermometer may reach 00° F. ) ; for this reason, that during the night the atmosjtheric temper- ature falls below 50° F. There are some quite extensive marslies in which a])par- ently every condition for the development of malaria exists, and yet none is generated. We cannot account for this fact, unless we accept tlie theory that the ozone which is claimed to be present in such marshes arrests or pi-events its generation. "Damp bottom-lands" that are exposed to an annual overflow, such as are found along the scuithern shon'S of 112 MALARIAL FEVERS. the Mississippi River, are as fruitful as swampy regions in tlie generation of this poison. Second. — Another condition which seems to favor the development of malaria is the upheaval of new alluvial soils, such as obtain when new lands are first brought under cultivation. This same state of things also occurs throughout the middle and southern portions of this State, and in the ISTew England States. Where railroad excavations are made, malarial fever is very frequently developed. In this city, while the so-called " Fourth avenue im- provements" were being made, the entire region along the avenue was rendered highly malarious by the excava- tions. Such excavations bring decomposing vegetable matters to the surface ; these, under the intiuence of heat and moisture, generate miasm. The fact that fevers of this type appear in regions pre- viously free from them, as soon as these conditions favor- able to their development exist, is confirmed by the testi- mony of many careful observers. TJiird. — Regions otherwise non-malarial may have ma- larial poison brought to them by the waters of rivers w^hich ' have their source in, or flow through, malarial districts. Examples of this kind are found along the banks of our Western rivers, where are developed some of. the most per- nicious types of this fever ; while in places only a short distance from these rivers it is unknown. This can be accounted for, if we accept the theory that malarial poison has been transmitted through waters having their source in, or running through, malarial districts. Fourth. — Non-malarial regions may be rendered malarial from poison transmitted by the wind. There has been considerable discussion as to whether this poison can be transmitted in such a manner, and if it can be, to what distance. I find no reliable account of its trans- mission over a greater distance than four and three-quarter miles. Malarial fever broke out in the crew of a ship, which was anchored Just four and three-quarter miles from shore where T^rnoDurTiox. 11 :i this f(>vor was provailiiii:;. No cases wcn^ on boaid wlwn tlio anchor was cast, nor did any of the crew <;o on siioiv. So long as the wind blew from th«; sliij) towards shore, tli(? crew remained wrll. l)iit wlim the wind cliaiiLred its direc- tion and hlew from llie shore Inwards tlie slii]), witliin six days from tlie time of cliange, cases of well-developed malarial fever ajipeared on board. This seenied to prove conclnsively that the fever was bronght to the ship })y the wind. The wind may also carry malarial i)oison up ahmg the sides of mountains, to an elevation of one thousand feet; some writers say no liigher than six hundred feet. American writers give no account of its being earned higher than six hundred feet, while some German writers give well authenticated cases, which show that it must have been carried to the height of one thousand feet. I have thus far called your attention to some of the more im])ortant conditions which are necessary to, or seem to favor, the development of this malarial poison. You have seen that certain of these conditions are absoluti'ly neces- sary for its production. I have also noticed most of the conditions which render its development more active. I will now ])riefly consider some of the circumstances whicli are inimical to its production. First. — Hif/h latitude. In this country malarial poison is not generated in higher latitude than that of Quebec. The limit of its development is 03'' north latitude, and 57° south latitude. Between these two parallels of latitude, both on the eastern and western hemispheres, malarial fevers may be developed ; the nearer the ajjproach t(j the equator, the more severe the type. They do not prevail over the entire region embraced between these ])arallels of latitude, but it is possible for them to be developed at any point where the altitude is not too great. Second. — High elcration is another condition inimical to its development. As a rule (as I have already stated), it is not generated above an elevation of one thousand ft.'et a])ove sea level. There are, however, some reniaikable excejitions ro this 8 114 JIALAKIAL FEVERS. rule. We find recorded cases of malarial fever wliicli have been developed upon plateaus among the Pyrenees, at an altitude of o, 000 feet. I have already referred to the fact that malarial poison is much more readily developed in marshes which have a cla}'" or lime-stone bottom, than in those which have a sandy or porous substratum. Among the Pj^renees, there is a marsh which has a clay bottom, and there malarial poison is developed which is very per- sistent. Tltird. — Drainage is another means which diminishes, and in certain conformations of soil entirely destroys mala- rial generation. In the majority of marshes, this generation can be arrested or prevented by free drainage. Yet there are marshes upon which millions have been expended in drainage, which still remain pestiferous. Perhaps it is possible to clrain the Jersey flats so as to render them non-malarial in their character, but it is hardly probable that this change can be effected, for they have a clay bottom, and contain both salt and fresh water, conditions which I have stated are most favorable to malarial genera- tion. Years of labor and large expenditures of mone}^ have been bestowed upon the Pontine marshes to render them non-malarial, yet they are as pestiferous as they were two thousand years ago. Fourth. — Cold is a powerful agent in arresting malarial generation. I care not how jDestiferous a region may have been, if only for one night the temperature fall below the freezing point, nothing more need be feared in that region from malaria, until the average temperature shall have again reached 60° F. This law holds in all malarial districts. In these districts, after the temperature has fallen below the freezing point, persons may have the fever, but it is the result of previous poisoning. Again, the generation is less rapid and the poison is less virulent during the day than at night. This is the uniform testimony of those who have seen most of, and written most on malarial diseases. It is also almost universally conceded that malarial districts are most pestiferous during months when the atmosphere is hot and dry, with little or TX'iiionuc-rroN'. 115 no wind, osporially wlicn iliis state of atmospli.-iv lias been pit'cedcd by lonir, heavy laiiis, and thai tin* vinili'iicc of tlio poison is greatly diminished as soon as fresh, strong winds rlear tlie atnios])lu*re. 1 have called yonr attenlion to tlie most prominent laws which seem to govern the jtroduction of this jxiisoii, as also T have endeavored to bring befori? you thos(? conditions which i'avoi-, as well as (hose which hinder or prevent its development. The ([n(>stion now arises, ITow does malarial poison gain enhance into the human bod}' i The most reasonable view is that this is effected through the res])ired air. Certain facts seem to show that it may- be introduced through the intestinal ti'act with the food and water. There stnMns to be scarcely a d()ul)t but that it ma}' be taken into tlie stonuich with foul drinking-water. Accejiting this view, in certain localities it has come to be tlu^ practice to add whiskey to the drinking-water to de- stroy the ])oison, but there is no reason for the belief that whiskey has any such power. When this })()ison has once been introduced into the cir- culation, it undoubtedl}' has the power of reproducing it- self, hence the entire system is affected. From this fact, which must be regarded as well established, those who regard this poison as a living organism, claim that these organisms may reproduce themselves indefinitely, but their existence has never yet been demonstrated. It has also been claimed that certain races are mon^ exem])t than others fi'oiu malarial fever, also that there ai-e idiosynciasies of constitution wlii<'li i-ender ceitaiii individuals exempt from diseases of this ty})e, for in (li>liicts where these fevers ]»re- vail there are persons who never have the fever. It seems to me that this exemption, both in races and individuals, is duo to the greater physical })ower of the individual, which enables him to resist these noxious atino- s})heric influences. In a district where malarial inlluencrs j)i'evail, the weak and anaunic are the most liable to be attacked, and tdl those influences which tend to lower vitiilily, and to I'lnhi- feel)l(! the powers of resistance, must be regarde(l as sp-'cial ju-edis- 116 MALARIAL FEVERS. posing causes. A strong man may resist for a long time, while the old man and the child very quickly succumb to the influence of the poison. Women are more suscep- tible than men to its influence. You can no more account for the fact that one person can take in large doses of mala- rial poison without being eft'ected by it, while another is affected by a very small quantity, than you can account for the fact that one individual can take large quantities of alcoholic stimulants without showing any signs of intoxica- tion, while a very small quantity will intoxicate another individual, supposing, in both instances, the individuals to have apparently an equally vigorous constitution. Some claim that wdien an individual has been poisoned with malaria, complete recovery never takes place ; others claim that even with the worst cases recovery is possible. My own experience leads me to believe that when an individual has once sufl'ered from malarial poisoning, he is much more susceptible than one who has never been so poisoned. For instance, an individual suffers from one or more attacks of intermittent fever, and then removes from a malarial dis- trict, if that person again enters a malarial region, he is much more likely to suffer from malarial fever, however slight the poisoning may be, than if he had never suffered from its effects. Some unknown physical change has taken place which renders him a fit subject for malarial manifesta- tions upon the slightest exposure. This brings us to the doctrine of the latency of malarial poison in the human body. This is an interesting and at the same time a very obscure subject. That there is a period of incubation, or rather that a cer- tain time elapses between the exposure and the develop- ment of malarial fever, seems to be a settled question. For, often a long, always a short period elapses before new- comers in malarial districts have their first attack of the fever ; sometimes the poison remains latent until after they have removed from the district. It is on this basis, the latency of the malarial poison, that the relapses can be accounted for, which occur in those who, having lived in a malarial district, remove and remain in a non- malarial one. INTltonUCTIOX. 117 Tliis it'awalci'iiiii-- of tlu^ iii:il:iii:il j)(>is()ii may (Ifjiciid upon a varict}- of causes, sudi as takiiii,^ cold, ovor-futiguc, sud- den changes of tenii)eratui(', etc., etc. \Vhetlier an individual who lias once been tlioroughly l)oisoned with malaria can <'ver become entirely fre*^ from its influence, is still an unsettled (juestion. From my own observation, 1 am convinced that it is im- possible to bring (Mie wholly from under tlie influence of the poison while lie remains in a malarial district, though he ma}^ become exempt from its influence (witliout the re- awakening causes already mentioned, taking cold, etc., etc.), if he remains beyond the malarial belt. Undoubtedly, you have often heard it stated that an individual may become so acclimated as to resist malarial influences, and live for a long time in a malarial district without suffering any evil effects from it. There can be no question but that those living in such districts suffer less from the acute manifestations of the poisoning than do new-comers. But the truth is, those changes, which we call chronic malarial affections, are constantly going on in those who are supposed to be acclimated. The comparison still holds good in reference to those addicted to the use of alcohol. We might say, tluy are becoming acclimated to its use. The fli-st dose a person takes may make him drunk, but after a time repeated and larger doses fail to produce this effect. Malaria acts like any other i)oison : after a time the system reaclu.'s a certain degree of tolerance. This toh'iance of malaria, or immunity from its manifes- tations, amounts to nothing more than the accommodation of the system to its prevailing influence. Let the acclimated })erson, as he is called, be taken sick with any active form of disease, such as diphtheria or pneumonia, and it usually- proves fatal, not that there is anything unusually severe in the di])htlieria or ]>neu- monia which brings about the fatal termination, but death is due to the fact that the system is charged with malarial poison. 118 MALARIAL FEVERS. Tliere is anotlier point in tliis connection concerning which I wish to say a few words. It has been clahned by very intelligent and careful ob- servers that phthisical developments are prevented by malarial poisoning. After having carefully investigated this subject, I am convinced that the eifect of the poison on the human organization is to predispose it to phthisical developments. The milder climate and the less frequent changes in temperature in the malarial regions accounts for the fact that there is less phthisis in those regions than in the cold, non-malarial regions. The malarial districts in the northern portion of the temperate zone have the highest death rate from phthisis. If we accept the fact that the larger number of cases of phthisis are catarrhal in their origin, and that catarrhal pneumonia is more likely to be developed in those who are broken down from the pro- longed influence of malarial poisoning, you will be prepared to understand how chronic malarial iDoisoning predisposes to phthisis. In quite a number of instances I have traced the beginning of phthisical development to this cause. There are many other j)oints of interest closely connected with this subject of malarial poisoning, but which have no special connection with the class of diseases which we are about to study. LECTURE XI. SIMPLE INTERMITTEXT FEVER. Morhtd Anatomy. — Etiology. — Sy77i2)to///s. — Differential Diofjuosis. — Prognosis. — Treatment. I iiAVK spoken of tlie origin of inal:iiiul fever, and of cer- tain known facts concerning the development of the mala- rial poison, and to-day will commence the history of this class of fevers. First in order is simple intermittent fever. Like typhoid fever, simj^le intermittent fever is met with in all i)arts of the world, althongh the region of its develop- ment may be said to be limited by 63° north latitude and 57^ south latitude. Within these parallels it is the more ]n-evalent the nearer you approach the equator. MoKHiD Anatomy. — The anatomical changes wliicli take place in this fever are few and require only a passing notice. In regard to the blood-clianges we are without any reliable chemical or micr()Sco])ical data. We iind none of those changes in the blood u liicli are present in the more severe forms of infectious disi-asc, neither do we find those which are jnvsent in tin* jx'niicious ty])e of mahirial fever, such as pigmentation and inaik'-d (liniiiiiitioii in ihe red globules. IL' th»' ft'ver has continued for a long time tln-re may be slijiht diminution in tlie number of the red globules and a decrease in the iibriu <.r tlx' blood; but these changes, to a great extent, are due to the high temi)t'i;i(ure which attends its paioxysms. The only constant jjatlioloixical lesion of sinijdi' iiiti-nnii fi'iii fever is congestion of i li.' intfi-ual or- gans. Tht,' s]»l('eu and liver are always more or less en- 120 SIMPLE INTERMITTENT FEVER. larged, but the enlargement is due to simple liypersemia ; no structural changes occur in these organs until the inter- mittent paroxysms have been often repeated, and the mala- rial poisoning has been of long duration. There is also more or less hypenemia of the kidneys and the mucous membrane of the intestines, but it is not attended by any signs of gastric or intestinal catarrh. As yet no one has been able to prove that any structural change takes place either in the nerve tissue or in any other tissue of the body ; nor from the structural or functional disturbances that oc- cur during the fever, has any one been able to find a satis- factory answer to the question, why it is a paroxysmal and not a continued fever 1 By some German writers it is claimed that during a paroxysm of the fever white blood- globules are very rapidly developed ; but the question arises, how is this to be demonstrated 1 I have never seen a post- mortem examination on one who had died during a simple intermittent paroxysm, and have never heard of such a death unless the patient had some intercurrent disease. As I have already stated, all the appreciable lesions of simple intermittent are those of hypersemia. Etiology. — At my last lecture this subject w^as brought to your notice. All agree that simple intermittent fever is due to malarial poisoning, and that the poison is introduced into tlie body either through the lungs or through the in- testinal tract. Whatever tends to depress the mental or physical powers of an individual renders him more susceptible to malarial influences, and consequently these depressing influences must be regarded as predisposing causes. Among these may be included intemperance, exposure to night air, exces- sive fatigue, bad hygiene, and a long list of like debilitating causes. Symptoms. — This fever is a paroxysmal disease, of differ- ent types, according to the period of time between the par- oxysms. The Ji7^st, and most common, is the quotidian type, in which the paroxysm occurs every day, and there is an in- terval of twenty-four hours between the paroxysms. SVMI'T(»\[^. 121 Seco7if1, yow liavc tlic h rliim t \ jw, in wliicli (hi- ]):ir()X- ysm occurs every tliird day, with an iiiti-ival of l'oity-ti;^ht hours Ix'twciMi lilt' })aroxysMis. 7V///V/, 3()U liavf tlic (/muliiii type, in which the piirox- ysiu occurs ever}' fourth ai()xysm occurs in the morning, in the tertian it occurs about noon, while in the quartan it occurs in the afternoon or evening. The dura- tion (jf the paroxysm varies with the ty])e of the frvcr. In the quotidian it lasts fiom eight to tr sliiiv- elled, but becomes red, swollen, iind turgid, and tlifie is a recession of the blood from the central organs to the sur- face of tlie body. That the temperature is elevattnl can be ascertaiUL'd sim])ly by laying the hand upon the surfac. If, however, you })lace the thcrmonit'tcr in the axilla, in most cases you will Iind the temperature has reached 1UG° or 107° F. The thirst is very much increased. The comfortable sensation which the patient experienced while i)assing from the cold to tlie hot stage has given way to great restlessness and uneasiness, the patient tossing from side to side, with face Hushed, and eyes red and liery. Sometimes herpetic vesicles appear about the mouth. The heat and thirst be- come intense, the tongue becomes dry, the carotids pulsate, the radial pulse becomes firmer and more rapid than in the cold stage, and nausea is now a marked symptom. It may have been present in the cold stage, but in the hot stage nausea and vomiting become the pronnnent sym])toms. As a rule the symptoms of this stage last from half an liour to two hours. In exceptional cases they may continue for a much longer time. As I have already stated, the ordinarj' duration of a paroxysm of a quotidian intermittent is from eight to ten hours; that of a tertian, from six to eight hours ; and that of a quartan, from four to six hours. It is possible, especially in those forms of malarial feviM- in which the poisoning is intense, for the hot stage of a cpio- tidian to continue twelve hours. There is no condition in which, for the time, you have more intense fever than in the hot stage of intermittent fever. The urine, which, during the cold stage, was abundant and of pale color, now be- comes highl}^ colored and scanty. Not unfrequently it is almost suppressed during the hot stage. Comi)lete sup- pression of urine occurs only in the pernicious type of the disease. When the fever has continued for a longer or shorter time, a slight moisture ai)pears upon the forehead which gradually spreads over the entire liody, and the pa- tient becomes bathed in a profuse perspiration. lie is now in the sweatinfj staff e. Sweating Stage. — As this stage comes on the former 12-i SIMPLE IXTEKMITTENT FEVER. restlessness and uneasiness passes away, and a feeling of comfort comes to the patient as the perspiration makes its appearance. The temperature rapidly falls ; the pulse rap- idly diminishes in frequency and force ; the pulsation of the carotids ceases ; the face assumes its normal appear- ance ; the congestion of the conjunctiva disappears ; and the patient rapidly passes from a high state of fever into one in which he falls asleep, and awakens after a period ranging from one to three hours, with a sense of exhaustion. Interval. — During the interval between the paroxysms at first the patient may feel perfectly well, but if there is a frequent repetition of the paroxysms, there will very soon be a marked loss of vitality ; he becomes pale and feeble, and all the symptoms of malarial cachexia are present. There will be more or less of a jaundiced hue to the skin, enlargement of the spleen and liver, and pigmentation of the tissues. It is true that many paroxysms of simple in- termittent may occur before any such general disturbance of the health of the patient manifests itself ; yet, in the in- terval between the paroxj^sms, we cannot call the patient's condition one of perfect health. Usually, in the quotidian type, the day previous to the development of the first paroxysm, unnoticed by the pa- tient, there is a • slight rise in temperature, perhaps from 99i° F, to 103° F. At the same time he experiences a sense of lassitude, and is disinclined to make any exertion, either mental or physical. The temperature commences to rise in the morning, and by noon it has reached its maximum height ; then it begins to fall, and by evening it may have fallen to nearly its normal standard. Thus the course of the temperature is quite characteristic, and may be summed up as a rapid ascent, a short and intense stationary period, and critical defervescences constituting the paroxysms, with a perfectly normal temperature in the interval. The fol- lowing day another rise in temperature will be noticed ; now the rise does not occur in the morning, but after mid- day, perhaps so late as in the evening. Usually in the quotidian type of intermittent fever tlie highest tempera- ture is reached a little earlier each da}" ; if it is reached a TUFFKni.XTIAT. DrAdXOSIS. 125 little later, you may Ix' (■•■rtaiii that the ffvcr is briiii; iiiod- ilied or ooiitrollnl by tn'atiuciit. Wf liave wliat ar<' ralh'd anticipalhuj and pontpaninij jtaroxysnis. When iIk' i»ai-- oxysin comes on a little earlier each day, it is called mificipddiHj. and indicates that the fever is not bt'in^ controlled; when il conies on at a later hour eacli day in indicates the ("ever is being cont lolled. :iiid is called a ])ost- l)onini:; intermittent. The ty])es of intermittent fever which occur most fre- quently in temperate climates are the quotidian and the tertian. With us the quotidian is most frequent. In those who liave suffered rej^eatedly from intermittent fever, the disease is liable to ruu an irregular course, th<» pai-oxysms occurring on irregular days, and with irregular intervals. In children this fever shows certain deviations from the ordinary course. The paroxysms may be ushered in by convulsions, or by a period of stupor. Children rarely liave the distinct chill. After a period varying from ten minutes to hair an lioui-, we have the hot stage of regular intermit- tent fever coming on, with all its attendant phenomena. The intermissions are rarel}^ complete. The child loses his appetite and flesh, becomes irritable, and has a pale, waxen look, and suffers from gastric and inti-stinal disturbances, and the intermittent very soon lapses inlso a remittent. Differential Diagnosis. — The differential diagnosis of simple intermitte!it fever is never very difficult. There are only two diseases which are liable to be mistaken for it, namely, remittent fever and pya?mia. It is readily dis- tinguished from remittent fever, for in remittent fever there is never a comi)lete intei-mission. whereas in intermittent there is always a period in which there is no fever. A care- ful thermometrical observation for twenty-four hours settles all question in regard to it. In remittent, tin' temperature, when at its lowest point during tlie remission, is on«' oi- two degrees higher than normal, while in intermittent the tem- perature reaches the normal standard during the intermis- sion. There is also a r<>gidar development of the paroxysm in intermittent, which does not oc'-ur in remittenf. In lemit- 126 SIMPLE INTERMITTENT FEVER. tent usually you have but one chill, while in intermittent a chill precedes each paroxysm of fever. Tlie diagnosis between intermittent fever and pyaemia is also readily established. In pyemia, there is no complete intermission in the fever and no regularity in the time of its occurrence, or in the severity of the paroxysms. In both diseases you have chills, fever, and sweats, but in py?emia the chill is short ; rapid shivering is followed by a prolonged and very high fever, and this is followed by profuse sweat- ing. The sweating of intermittent is never so profuse as that of pyaemia, and in the latter disease there is no regularity in the development of the phenomena, while in intermittent, the nature of the paroxysms, and the time of their occur- rence, can be predicted with great certainty. The principal element in the clinical history of pyaemia is a steady, high temperature, without any intermission. When the sweat- ing comes on the temperature may fall one or two degrees, but it never approaches the normal standard, and there is never a distinct intermission. It is much more difficult to make a differential diagnosis between pyaemia and remittent fever than between pyaemia and intermittent. Hereafter this will be more fully con- sidered. The same thing may be said in regard to the hectic fever of phthisis. Prognosis.— The prognosis in simple intermittent fever is good. If continued for only a short time, there will be no tissue changes to prejudice the life of the patient. The possibility of the development of malarial cachexia must enter into the prognosis. When this occurs the case is more than one of simple intermittent fever ; there is en- larged spleen, enlarged liver, and pigmentation of tissues. Treatment. — The treatment of intermittent fever is di- vided into that for the paroxysm and that for the interval. The treatment for the paroxysm, in most cases, is simply to render the patient as comfortable as possible while passing through its various stages. At one time it was proposed to tourniquet the limbs, so as to prevent congestion of internal organs, and thus arrest the paroxysms. Again, it has been proposed to apply cold to the surface TKKAI MKNT. \'27 of tho body, foi- flic ])urj)()sr of <;lving a sliock (o tlic iu'V-> vous sysli'iu. ;iii(l in tluir niaiiiH'i- to .-n-i-cst llic ])ar()xysni. To :icc()iiii)lis|i iliis. l)y covcriiii;- (he siiirnrc of tlic })ody with siii;i]ii-ms, in ordrr lo iiriinh- llic ciiliiinfuis siiifaci?, lias also hiM'ii ))i-o](o-.'(l. Soiiif lia\c claiiiit'cl tli;il if an in- dividual is lifcMiulit fully undri- tin- inllnrnci; of alcohol tii.' regular (li'V.Iojmicnt of ;i paroxysm can be ])n'vented. Again, it has hci-n (•hununl that opium, given in full doses at the usual linic foi' the recurrence of the paroxysm, lias power to ])revent it. Experience does not lead me to accept any of tliese state- ments. It is true that, in some instances, a sudden shock to the nervous system may prevent tlie developin<'nt of an intermittent paroxysm when thi' ])aroxysms have* Ix'come a liabit. If there is anytliing in the entire list of means (eitlier re- medial or hygienic), tliat I have named, which has i)ower to prevent the full development of a paroxysm, it is o})iuin. When this is adniinisterrd liypodermically, early in tlie> cold, stage, it will diminish the severity of tlie cold and hot stages. Whether, in the treatment of the milder forms of intermittent fever, the combination of oiuuin with ([uinine is advisable, is still an unanswei'ed question, thougn it seems to me that in such cases much comfort can be alTorded, and the patient be much h'ss injuriously affected, by the parox- ysm, if opium be administered in moderate doses. Patients with intermittent fever should be kepi in bed during the entire paroxysm, however mild it may be. During the cold stage, cover them with l)laid':ets, surround them with bottles of hot water, and let them drink freely of hot water. All tliese means will hasten the hot stage of the disease. Bui-ing the hot stage, the extra clothing and ex- ternal heat should be gradually removed, and cold instead of hot drinks should be administered. 1 f nausea and vomit- ing are present in this stage, you will lind that oi>iuiii. ad- ministered hypodermically, alTords great relief. When the patient reaches the sweating stage, h-t him alone; within a few hours lif will l)e cnliicly ivjicved, and in a state of convalescence. The question now aiises. What 128 SIMPLE inteemitte:n^t fever. treatment sliall we adopt during the interval to prevent t1ie occurrence of another paroxysm ? If possible to prevent it, never allow a patient to have a second intermittent par- oxysm ; for if the s^'stem once becomes accustomed to these paroxysms, they will be repeated upon the slightest provo- cation. You will frequently find this to be the case with persons who for a long time have not been subjected to malarial influence, and yet upon the least nervous excite- ment or fatigue will have a paroxysm. Let me impress upon you to prevent, if possible, the occurrence of a second paroxysm of intermittent fever. The great remedy at this time is the sulphate of quinine. Skilf all}" used, it is all-powerful to accomplish this result. How and why it arrests the development of these parox- ysms I do not know. We simply know the fact. Our knowledge of its antiperiodic power is purely empirical. There is much difference of opinion as to the mode in which it should be administered. In commencing the treatment of a case of intermittent fever, after the occurrence of the first paroxysm it is always safe to assume that the fever is of the quotidian type. At least thirty grains of quinine should be administered between the termination of the one paroxysm and the hour when another is to be expected. The first dose of ten grains should be given towards the close of the sweat- ing stage, and twenty grains about two hours before the time of the expected paroxysm. If possible, give the qui- nine in solution. If there should be sufficient irritability of the stomach to cause the rejection of the quinine, it may be administered hypodermically, or by enema. Three grains administered hypodermically has about the same antiperi- odic power as ten grains administered by the stomach. If you succeed in preventing the occurrence of a second par- oxysm you have accomj)lished much for your patient. Having prevented the occurrence of a second paroxysm, it is important that a moderate degree of cinchonism should be maintained for a number of days, by the daily adminis- tration of quinine in moderate doses. About two hours before the time of daj^ at which the first paroxysm occurred, from ten to fifteen grains of quinine should be daily admin- TUKATMENT. 129 istercd. You iiiii>l not now piTiuit yoiii- jtMiifnl lo jtass en- tirely i'roiii iiinlcryoiir olist'ivalioii. Direct him lovisil yoii one numth from tin- (// f/n'/irsl paroxi/sin^ for, alt liou^li he may not have had a IVesh iiiahiiial exjxjsure, there will he a stroni; ti'iidcncy at I ids tiiuc lo a re})etitioii of the parox- ysm, and it is of importance tliat your ])atient at tluit time sliould he amiin l)rou,i;]it fully undei' llie inlluence of the c[uinine. If it is p(.)ssibh» for jour patient to remove from a malarial district you will be almost certain to })reveiit a seeoiid paroxysm. If, however, you do not see your ])ati<'nt in his first par- oxj'sm, and lie lives in a malarial district, sulphate of qui- nine, administered in tlie manner I have just recommended, may only prevent for a time the return of the })aroxysm, and even complete cinchonisni may fail to control it. You should now very carefully examine the case, in order to as- certain if there is not some condition present which inter- feres with the antiperiodic action of the quinine, such as hepatic or splenic hyper^emia. AVhen careful percussion shows that the liver and sple<'n are increased in size, even after the administration of full doses of quinine, you will often find that the administration of full doses of calomel with the quinine will increase the antiperiodic power of the latter, and thus diminish the jxTcussion area of these organs. Occasionally, when full doses of quinine combined with calomel have failed to prevent a recurrence of a paroxysm, I have noticed an unusual excitement attending- its devel- opment, and believing from this circumstance that, owing to individual idiosyncrasies, the malarial ])oison had a more than usiuil irritating effect \\\)o\\ the nervous sj'stem, I have accomplished the desired result by administering full doses of opium with the quinine. In fact, if the i)alient is of a highly sensitive, nervous oigani/ation, f neverallow a second paroxysm to jiass without administering a full dose of 0})ium before the time when its return is t(^ be ex- pected. In all those cases which are called obstinate, ascer- tain why you have failed to c(»ntrol the disease by the use of quinine. 130 SIMPLE INTERMITTENT FEVER. I rarely have administered arsenic in simple intermittent fever. If I fail to control the fever with quinine, aft(.n' I have reduced splenic and hepatic congestion, controlled nervous irritability, and increased nutrition by the adminis- tration of iron and the moderate use of stimulants, I never succeed with arsenic. In some of the chronic forms of mala- rial manifestation, I have found arsenic of great service, but never in simj)le intermittent fever. Other means employed in the treatment of this fever will be spoken of in connection with pernicious fever. Masked Intermittent. — In this connection I would in- vite your attention for a few moments to a form of inter- mittent fever, which by some writers has been designated masJced intermittent fever. For example, to-day a patient has a regular intermittent paroxj^sm, but to-morrow, instead of its recurrence, perhaps, he suffers from the most intense neuralgia. This neuralgia ma}^ have its seat in the inter- costal or in the sciatic nerve, or perhaps more frequently in the frontal portion of the ophthalmic branch of the tri- gemini nerve. Some one nerve becomes involved and no other seems to be affected. In some cases, an intense hemicrania takes the place of the paroxysm. As a rule, these neuralgias have distinct intermissions, and so come to be regarded as masked forms of intermittent fever. Instead of a neuralgia, your patient may have an attack of asthma, or an attack of indigestion. During the past year I have seen several cases of intermittent dyspepsia. The patient, after having had one or two distinct intermittent fever paroxysms, or perhaps only a slight chill, fever, and sweat, has suffered severely from indigestion, colicky pain in the bowels, and symptoms resembling those of perito- nitis. Diarrhoea, dj^senter}^, and sometimes h^ematuria and apparent suppression of urine, may take the place of a dis- tinct intermittent fever paroxysm. Again, your patient may have a single well-defined chill, or even two chills followed by most intense hemicrania, and then have no more for a long time, but sooner or later TREATMENT. I'M hv will liavf a wcll-ilrlincd iiitninil N'lil )):ir()X3'siii wliidi will i-cvt'al the n-al iiaLuiv (d" the discasr. Soiiictiim-s I his roi-iu of iiitcriiiittt'nt fever instead ol" beintr :i t|ii"iidiaiK a Icrtiaii, or a .luaitaii. may be one in which the paioxvsius are developed every sixUi or seventJi day. 1 niiuht rereryoii lo other types of this fever, which we nii^^ht ♦•all masked iiiiermii lent, Imi which in their develojmient do not i)re.sent the regular ])heiiomena (jf a fully developed paroxysm. LECTURE XII. SIMPLE REMITTENT FEVER. Morbid Anatomy. — Etiology. — Symptoms. — Differential Diagnos is . — Prognos is . This morning I shall commence the history of Simple Remittent Fever, the second in my list of malarial fevers. This is a co7itinued fever, with diurnal exacerbations. It is known by different names, such as Southern, AVestern, African, Continued, Bilious, Acclimative, and Remittent Fever, The term, Remittent Fever, is more generally accepted, and the one which I shall adopt. Morbid Anatomy. — In many respects, the anatomical lesions of remittent fever resemble those of intermittent fever, yet there are certain points of difference with which it is important that you should become familiar. These differences are rather in degree than in kind. Unquestionably, both these types of fever are the result of malarial poisoning ; therefore, we may exj^ect the same diminution of the red globules and the same changes in the fibrin of the blood in remittent that we have noticed in pro- longed intermittents. Yet there are other changes in the blood, which we usually find present in the former, that are of quite rare occurrence in the latter, namely, the pres- ence of free pigment-granules. These pigment-granules are met with in some of the pernicious forms of intermit- tent fever ; but, in all cases of well-developed remittent fever, they are present at some time during the progress of :M()i;iun axatomv. 1^-^ the disease. This j)iuiii('iilati()ii is due to tli-' li.-iMn.'iloidiii wliicli lias ils (>riL;iii in liu' liMMiio,ii;l()l)iii wliicli has Ix'cii liberated froiu ihe bhxxl-coi-pusch'S williiii I hi' lilood-vcssels, and Mh'ii (h'Vch>iH'd in ihr licpioi- san,i;-iiiMis. This coloring matter may remain eiili.-r wilhiii the hlo()d-coi'i)iis(d(*s, which, after a time, become hansronii'd into ])igment- irranules, or i-emain free in ihe lliiid iiortioii of th«'bh)od. or inliltiale tlie adjacent cells and tissues. ll may be transformed into granular or ciystalline li;ematoidin. Till' s/>Jv('n is not so nnudi eidarged in n'lnittent as in inteiiuittent fever, and the increasi^ in size seems to be of a diU'erent natur(\ The enlargement is evidently the result of congestion, and the organ sometimes presents very nearly the sanui a})i)t>arance as it ]iresents in typhoid fever, except that there is more pigmentation i)resent, which is rarely present in a typhoid spleen. There are also structural lesions found in the liver, in the stomach, and in the intestines, which are not i)resent in intermittent fever. The liver is not very much increased in size, and, in color, is of a bronze hue. The princii)al change is in color, which is uniform throughout its entire substance. This varies in degree in different types of the disease, and in different cases of the same type. The peculiar color is due to pigmentation of the liver tissues, and varies according to the amount of pigment deposited. Pigmentation may occur in other tissues of the body, but not to the same extent as in the liver. On a microscopical examination of the liver tissue, pigment is found through- out its entire structure — not onl}' in the hepatic cells, but in the nu-lei of these cells and in the walls of the blood- vessels. This discoloration is of such uniform occurrence that it has been recognized in different countries and by different writers as the characteristic ])athological lesion of remittent fever. Consequently you will hud in your books that the *■'' bronzed lire/''' is spoken of as the ciiaracteristic lesion of this fever. Occasionally you may have the same ])athologi- cal lesion in inl'Tinit h'lil ami pi'rnicious fevr. but this is so seldom, and ils presence is so coii->taiit in iciiiillfnt fevei*. 134 SIMPLE EEMITTENT FEVER. that if 3^011 meet with it at an autopsy yon may venture n])on the diagnosis of remittent fever. Stomach. — You will find the mucous membrane of the stomach more or less congested, thickened, and softened. In this respect the disease is somewhat allied to typhoid fever. You will find similar changes also in the mucous membrane of the intestines ; it is more or less congested, and presents very much the appearance seen when a mod- erately severe catarrhal inflammation is present. The Peye- rian patches are usually enlarged, and quite frequently present the "shaven beard" appearance. In some cases there are ulcerations, not, however, as extensive or of the same nature as the ulcerative processes of typhoid fever. The mesenteric glands are not enlarged, and there is none of that granular infiltration in the glands so noticeable in typhoid fever. There is only a simple hypersemia, entirely due to a catarrhal inflammation. Thus you notice in tak- ing up the history of each of these fevers, that while each one is a distinct disease, we find many things that are com- mon to all of them. There is in all some pathological change which seems to link them together. The same changes may occur in the muscular tissues of the body, which are met with in typhus and in typhoid fever, and they are claimed by some to be the result of prolonged high temperature ; yet in remittent fever the temperature rises higher than in t3^phoid, while these mus- cular degenerations are of rare occurrence, and less exten- sive when present. The more we stud}^ these fevers the more disposed, it seems to me, will we be to attribute these granular degenerations to something besides high temper- ature. The most important characteristic change, and perhaps the only one, in all malarial fevers, is the change which takes place in the blood-globules. Etiology. — The great predisposing and exciting cause of this fever is malarial poisoning. There can be no question but that the same malarial poison which gives rise to inter- mittent fever can produce a remittent fever. In other words, we have remittent passing into intermittent fever, T'.TIOI.OCV. i:>.') and int(>rniitt('nt passing info nMnitf()dv, but tln'iv is LiriH'ial (..Idiicss ovci' the iSiiri'act' ol' til.' Ixxh at tilt' vriy coiiiint'iM-cmriit of the cliilly sensation. Aerain, tlu'iv is iioi that tiviiiuli»iisiicss and sliakin^^ of tlii> body, ntMtlior dial clialt.'iinu- of tli.' Iccih, wliicli is so frc- qucntly (wpcrii'iiccd in intriniii iriii 1V\.'|-. In a few words, til.' cliill of ivniitlrnt is not so severe as tliat of intiTniittent fever. As soon as the tcrat iiii' coiniuences to rise, the })nlse is incn'as.'d in fiviiucncy, and perhaps reaches 100 or 120 beats to tin' ininutt'. The face becomes Unshed, but not so intensely tbished as in the second stage of intermittent fever. The eyes are usually suffused, and the conjunctiva is somewhat congested. The patient is restless, tossing in bed, in the vain search of an easy posture. As the hot stage ad^•an(■rs, nausea and vomiting are always present, and the sense of oppression in the epigastrium increases, which is not relieved by vomiting. In making a diagnosis, remember that this disease is ushered in by a c/f/II, followed by afcrrr, which is accom- panied by nausea, vomiting, and gnnit distress in the epi- gastrium. We have nausea and vomiting oecurring in intermittent fever, but it is not so persistent and distivssing in character as the nausea and vomiting of ivmittrnt. Again, there is not the same amount of ])ain in the epigastrium, for in the febrile stage of remitttMit fever the patient suffers from it to such an extent that quite commonly it is the only thing of which he complains. Before this, thei-e has been a sen-.' of oppression and perhaps pain in the epigastrium, but during tiiis period the e])igastric distress is very great, and is often accom- ])anied by the most extreme tenderness upon ])ressure. The material first vomited sim])ly consists of the contents of the stomach, next follows tin' vomiting <>f n gri'enish matter, and finally, in severe cases, even of simple remittent fever, 138 SIMPLE EEMITTEIS^T FEVER. YOU iTicay have a slight amount of black vomit. This resembles the black vomit of j^ellow fever. The quantity of fluid vomited is greater than the quantity taken into the stomach. Yomiting of stringy mucus tinged with green is always present in remittent fever. Sometimes the patient's stomach rejects everything taken into it, and the vomiting is accom- panied by terrible distress in tlie stomach, pain in the head, and general disturbance of the system. At the commencement of the fever, usually, the bowels are constipated. The symptoms thus described go on increasing in severity for ten or twelve hours, then you will notice a slight amount of pei'spiration upon the forehead. In a short time, it ex- tends over the entire bod}^, not profuse, but a slight moist- ure upon the surface. With the perspiration will be a fall of one or two degrees in temperature, and a fall of ten or twenty beats in the minute rate of the pulse. The thirst will diminish, the vomiting grow less, there may now be ability to retain fluids taken into the stomach, and the patient falls into a quiet, refreshing sleep, and is relieved from all the severer symptoms of the paroxysm. If, how- ever, you will place the thermometer in the axilla, you will And that evidences of fever still exist, and although there has been a marked decline in temperature, it does not reach the normal standard. At no time is there a complete in- terruption; the fever is continuous. This is termed the period of remission. At the same time on the following day all the active febrile sjanptoms return, increased in severity, the range of temperature is higher, the gastric disturbance is more marked and severe, the countenance assumes an anxious expression, and all the symptoms are more severe. This return of the severe febrile symptoms constitutes what is called the exacerbation, and the period between the time when the fever abates and the development of the ex- acerbation is called the period of remission. Remissions and exacerbations are the characteristic symptoms of a remittent fever when it is fully developed, at which time a morning SYMPTOMS. I'AO remission is tlu- rule, tli()u,i!;li tlio tiiiic of the first paroxysm vai-ics. If the cxaccrbiitioii l)i'i:iMs :it noon, it will usually decline about midniu-liL :iii(l lln' nmission will last until about noon the next iluy. In vt-ry severe cases there may be a double exact^bation, one at noon, the otlier at mid- night, the remissions being in tin' t-vcning and morning. The second exacerbation is similar to tin- jtiinmiy in its attendant phrnomena, except that it is niort* seven' and of longer duration, ends in a h'ss profuse perspiration, and tlie remission is not so well marked as the first. On the third day, at about the same houi-, or a little earlier, we again have the exacerbation, which has a still longer duration, is of greater severity, and is followed b}' a more incomplete remission. If the disease goes on from day to day, the remission becomes less and less dis- tinct, and the case becomes dangerous just in proportion as it loses its ])arox3'smal character. By tli(; end of the first week the remission can no longer be detected, and the fin'er becomes a continued fever, without any marked daily vari- ation in temperature or pulse. As the remissions become less and less distinct, with each returning exacerbation the tongue becomes more and more parched, sordes collect "upon the teeth, the countenance becomes dull and heavy, distress and pain in the e])igastrium continues, and is ac- companied by tenderness, although the senses of the patient are so dulled that he may scarcely complain of it ; the vomiting is not so constant, and is of a less distressing character ; constipation, which was probably present at the commencement of the fever, has now given way to diar- rhopal discharges, which are usually of a brownish color. With the diarrhopa there is some fulness of the abdomen, and some local tympanitis. The pulse is increased in fre- quency, and has p<'rhaps leached 120 or 130, is small, thready, and feeble, whih^ at the onset of the diseases it was full and compressible. The patient slips down in the bed, picks at the Ix^d-clothes ; there is subsultus and diiriculry in deglutition, and the tongue is protruded with difliculty, as in the severer forms of typhoid fever. In other words, the patient has passed into a condition closely resembling 140 SIMPLE REMITTENT FEVER. tliat of 0110 wlio lias entered tlie tliird week of a typlioid fevei-, with tliis exception, there is no eruption. The diarrlia^a, abdominal disturbance and tympanitis, and often the tenderness over the ileo-cfRcal region, the typhoid tongue, and the low muttering delirium, closely allies this stage of simple remittent fever to typlioid fever ; but the absence of the rose-colored spots and the typical range of temperature of typhoid fever are sufficient to dis- tinguish it from that fever. After these typhoid symptoms have continued a week or ten days, if the case is to terminate in recovery, remissions recur and become more and more distinct, until finally there is no exacerbation, and the patient passes into a state of convalescence. If, however, a fatal termination is to take place, the remissions will not recur, but the typhoid symptoms will become more marked, and the patient will finally die from exhaustion or from complications. Of all the symptoms which attend simple remittent fever, nausea and vomiting are the most constant and the most distress- ing. I have seen patients, after the temperature had fallen to its normal standard, suffer for weeks from gastric dis- turbance, attended by more or less jaundice. If, in the progress of a remittent fever, the exacerbation occurs a little earlier each day, then treatment is not con- trolling it, but the disease is gaining ground ; the fever is then said to be anticipating, and you may be almost cer- tain that the disease is j)assing from a distinct remittent to a continued remittent. If, on the other hand, the exacerbation occurs a little later each day, the fever is said to be postponing, and you may be sure that you are controlling it, and that, as the remissions become longer, the exacerbations will become shorter and less severe, until the patient reaches complete convalescence. The thermometer will indicate to what ex- tent the disease is being controlled. This is the history of what may be regarded as simple re- mittent fever. It begins with a chill, is followed by distinct exacerbations and remissions, and, if not controlled by treatment, becomes a continued fever ; then, after a week. SYMPTOMS. 141 perluips a longer time, the remissions recur again until con- valeseenee is established, or tlu' tyi)hoi(l sym])l()ms Ix-coiue more marked, the remissions do not recur, and (h'ath ensues. If a simple remittent fever is jtiotracted, the typhoid syn4)toms whieh are develoj)ed do not stamj) it with a typh(.)id character; they are such symptoms as are liable to occur in any acute, infectious disease. Bilious J{i:mittkxt Feveu. — In a c(' ilic Stn;i!:(M»n-(Jfii('i-;il in tlml (l(']>:ii-|m('iil (iiiiiiiiic wiis iiiliiiiiiis- trvrd at (lill'crtMif jx'iiods in the coiii'sc of tli(> fever. I'lioid symptoms are manifesting tliemselves, stimulants may br demanded. Even large doses of stimidaiits may b«' re([uired to sustain the ])atient while lie is ])assing through this ])eriod of the disease. Remittent f«*ver is not, like typhoid fcvrr, a disease of davs or weeks. In its seveii'r forms, no time .should be 148 PEKNTCIOUS FEVER. lost while waiting for tlie action of cathartics or other remedial agents which are supposed to be of importance, but you should at once commence the administration of quinine. When the disease has reached its second or third week, and there is no evidence that the patient is passing on towards recovery, you must commence a second time the administration of large doses of quinine ; in this way you may arrest the progress of the fever. If, after a second cin- chonism is produced, the fever is not arrested, you must again omit for a few days the administration of quinine ; then repeat the large doses a third time. It is much better to proceed in this way with the remedy than to keep your patient in a continued state of cinchonism. It is not neces- sary to enumerate the long list of drugs which at different times have been proposed as specifics in this fever, all of which, by common consent, are now regarded as far less re- liable than quinine. The important thing is to know liow and when to administer quinine. There are certain palliative measures which it is some- times important to employ. If the exacerbations are very intense, the headache very severe, and the restlessness or other febrile symptoms are not relieved by full doses of quinine, you may resort to the use of cold for its antipy- retic effect, the same as in typhoid fever. Frequently, in mild cases, sponging the surface with tepid water is not only grateful to the patient, but it has a controlling influence over the fever. If vomiting is constant, severe, and exhausting, hypodermics of morphine will be found of service. As in typhoid, the treatment of this fever is ex^Dectaut, save in the use of quinine. PERNICIOUS MALARIAL FEVER. I now pass to the next in my list of malarial fevers, which I shall describe under the term of pernicious fever. This form of fever has received other names, at different times and in different localities. It has been called congestive MOKl'.ID AX ATOMY. 149 feter, anient fever, tropical t//p7wtdfcrer, and pernicious ferer. I have adopted tli.- latter iiaiur. for it seems to uic to be not only the most appi()i)riate, but the one wliich at the l)ivs('nt time is most f;:eneially adopted. It is true tliat in the majority of cases tliere is more or less congestion of the internal organs, and sometimes the patient is overwhelmed by these congestions, but in a large number of cases no such congestions exist, and under such circumstances the desig- nation pernicious is mostly to be preferred. It is the most severe and dangerous form of malarial fever. It may be intermittent or remittent in character, and may assume any of the types of periodical fever, but the quotidian and tertian types are the most common. Sometimes its pernicious character is clearly marked at the onset of the fever, during the first paroxysm ; at other times it comes on insidiously, and its pernicious character is not suspected until after the occurrence of two or three paroxysms. There are several well-marked and distinct varieties of pernicious fever — the most common and most im])ortant of which are the comatose, the delirious, the alffid, and the f/as'fro-euteric. Almost every locality where pernicious fever prevails gives to the fever some distinctive pecu- liarity. Pernicious fever not infrequently appears as an e])idemic, although sporadic cases are met with in those regions where simple intermittent and remittent fevers prevail. 1 have seen six Avell-marked cases of i)ernicious fever in this city during the past year. MouRiD Anatomy. — The anatomical lesions of pernicious fever are similar in kind to those found in sim])le intermit- tent and remittent fevers, but they dilTer very much in degree. For instance, you will find similar blood-changes, the most striking of which is the presence of free pigment in the blood. But the pigmentation is more abundant, and the pigment material may be in the form of granules, or in the form of plates, or it may even have a cellular outline. The abundance of the pigment, and the extent of the pig- 150 PERNICIOUS FEVER. mentation will vary according to the severity of the fever But in all cases there is some free pigment in the blood. This pigment is not often present in the blood in simple intermittent, unless the fever has been prolonged, and in simple remittent it is never as abundant as in pernicious fever. The other changes in the different organs and tissues of the body are very similar in character to those to which I have already referred in connection with the morbid anat- omy of intermittent and remittent fever. As the varieties in tyjDe of this fever are as numerous as the localities in which they occur, and as the type in any locality may change with every succeeding year — that is, the type of one year may be very unlike that of the preced- ing or following year — you see that it is very difficult even to classif}^ its different forms. The slight variations which are met with in the patho- logical lesions of the different varieties, are still more diffi- cult of description and classification. For instance, there is one variety which is characterized by a tendency to coma, called the comatose varieti/ ; another is characterized by a tendency to a peculiar form of delirium, termed the delirious variety; still another which is characterized by a marble-like coldness of the surface, called the algid variety ; again, we have one which is characterized by vomiting and purging, or choleraic symptoms, termed the g astro-enteric variety ; then one in which there is acute jaundice, termed the icteric variety ; then one in which there are profuse hemorrhages, termed the liemorrhaglc variety, and still another in which there is profuse diapho- resis, termed the colliquative variety. These are the more common varieties of pernicious fever. There are still others of such rare occurrence that it is hardly necessary that I should mention them, as they are slight variations due to local causes. ]N"one of these are distinct fevers, but different types of the same fever. As in scarlatina, measles, and small-pox, we have differ- ent names assigned to different types of the same disease, so all these forms of pernicious fever are simplj'^ different MoKHID AXATOMY. IHl manifestations of one and thr saiur fever, duo to cm' and tlie same eause, naint'ly, malarial ])oisoning. You will find the post-mortem a|)i)earances in j).! nifiouyi fever varyinii; with the intensity of the malarial infection, and tlie ])eculiar atmospheric conditions under which the lever is developed. In some instances there will be evidences of intense eni;-orgement of the blood-vessels of the brain, and tlie entire brain sul)stance will be more or less thoroughly stained with ]iigment material. In others, minute blood-extravasa- tions will be found scattered here and there throughout the substance of organs. Small blood-extravasations into the spinal cord, accompanied by more or less pigmentation, is very apt during life to be attended by tetanic spasms. In persons dying of pernicious fever after the third attack, I have found all the organs of the body pigmented. Sometimes you will find intense engoi-gement of the liver, that is, the most marked post-mortem changes will be found in that organ, and the amount of pigmentation present will correspond with the inti^nsity of the congestion. With intense engorgement of the organ there are usually blood- extravasations. Occasionally, infarctions occupy the spleen, around which there will be a mass of puljjy mat(^rial. The spleen is more frequently found softened in this form of malarial fever than in those forms already described. Although enlarged, it is usually softened and of a darker color than normal. It is sometimes so soft that it closely resembles the spleen of typhoid fever, and is merely a pul])y bloody mass, though in size it is larger than in typhoid fever. If not softi-ned it may have infarctions scattered tlirough its substance. Marked pigmi'Utation of the tissues of the])ody, <-orresi)ond- ing in anu)unt with the peculiar symi)toms present during life, a tendency to enlargement and softening of the spleen, enlargement of the liver with deeper pigmentation than is seen in any other organ of the body, are among the more common })athological lesions of this form of fever. It is unnecessary to d«'scribe in detail that enlargement of the ca])illaiy vessels which occurs as a necessary result of this 152 PEENICIOUS FEVER. intense engorgement. Sometimes tlie kidneys and tlie lungs are the seat ol' this intense hypersemia, as the result of which the functions of these organs are more or less extensively interfered witli. Etiology. — The exciting and predisposing causes of per- nicious fever differ from those of the simpler forms of mala- rial fever only in degree, not in kind, but a higher range of temperature is requisite for the development of pernicious fever. It prevails only in those localities where the average range of temperature, for a time, reaches 65° F. Sympto:hs. — Pernicious fever may commence abruptly, but generally the premonitory symptoms which mark its development do not differ from those which mark the de- velopment of simple intermittent and remittent fever. In most varieties the attack commences with a chill, which is unusually severe and prolonged. In many cases you will have a distinct malarial paroxysm of either the intermit- tent or remittent type, and the pernicious character of the fever is engrafted upon it. In other words, you may have the attack commencing with a distinct intermittent fever paroxysm of the quotidian type, but rarely more than two of these intermittent paroxysms will occur before it assumes the pernicious type, if it is to become a pernicious fever; or you may have a remittent fever with a distinct exacerbation and remission, which may go on for four or five days before its pernicious character will be developed. The milder form either gradually passes from a simple intermittent into a pernicious fever by a progressive increase in the severity of the symptoms, or a single paroxysm of not unusual severity is suddenly followed by a pernicious one ; this latter seldom proves fatal, unless it has been repeated for the second or third time. Again, you ma}^ have a distinct chill followed b}^ a condition that you will at once recognize as one of the varieties of pernicious fever. The ushering-in sj^mptoms will always vary with the type of disease which is about to be developed. I sliall not attempt to describe the phenomena that attend all these different varieties, but will only speak of those SYMPTOMS. inn most commonly mot with, mid (Ictnil rlioir ju-oiiiincut ;iiiiclly into a state of coma. In these two diseases the condition of the pupil varies. In meningitis, wlien the patient reaches complete coma, the ]nipil will be dilated, while in the comatose variety of ])ernicious fever the pupil may be contracted, dilated, or normal. The gastro-enteric and cold or algid variety of pernicious fever closely resembles cholera. It nitiy be distinguished from it by the chai-acter of the primary discharges. You may reach a time in pernicious fever when the discharges will verj' closely resemble those of cholera ; but they have been preceded by one or two blood}* discharges. Then in cholera you will have albumen in the urine, the occurrence of which is comparatively rare in pernicious fever. Then in cholera there are the peculiar surroundings of the patient, the prevalence of cholera in the locality, etc. Yet, in a recent endemic of choleraic-]iernicious fever which prevailed along the banks of the lower Mississippi, many prominent ])hy- sicians maintained that it was an epidemic of Asiatic cholera. When the endemic is at its height it is almost im- possible to make a differential diagnosis between the two diseases from the clinical history of the cases ; but, when you take the early history of the endemic, at which time the cases at theii" commencement were marked by distinct intermittent or remittent paroxysms, then the true charac- ter of the disease is very readily determined. If in any given case there is still a question whether it is or is not one of pernicious fever, this can be determined with posi- tiveness by placing some of the patient's blood under the microscope, when, if the case be one of pernicious fever, the blood will be found to contain pigment. The icteric variety of pernicious fever, which often, in many of its ]>hen()meiia, so closely resembles yellow fever, may be distinguished from it not oidy l)y the history of its development, but by tlie fact that when it ])revails as an endemic, those are seized with the f»n'er who have been longest under the iulhienceof malarial poison, when-as new- comers are not usually attacked; in yellow fever districts new-comers are almost certain to contract the disease. 11 162 PERNICIOUS FEVEE. Then the jaundice of yellow fever appears late in the dis- ease, while tlie jaundice of this form of pernicious fever comes on early, even before the chill passes away. Again, bloody urine is frequently present in this type of pernicious fever, while in yellow fever h^ematuria rarely occurs with- out the accompanying evidences of nephritic inflammation. It is hardly necessary for me, under the head of differen- tial diagnosis, to speak of all the different varieties of per- nicious fever, for there is one thing — the presence of free pigment in the blood— which settles the question of diag- nosis in difficult cases ; this is present in nearly every severe case in any form of pernicious fever. Whenever any of these types of pernicious fever prevail in the region where you are located, you will soon become familiar with their peculiar phenomena, and thus be able to make an early diagnosis. You must bear in mind that, though you have become familiar with one variety of this fever, you are by no means prepared to make an early diagnosis of any other variety, for the algid and comatose varieties differ as widely in the phenomena which attend their development as though they were distinct diseases and did not depend uj)on the same poison. Progistosis. — In all varieties of pernicious fever the prog- nosis is unfavorable. Unless you are able to control the disease before the occurrence of the second paroxysm, usu- ally the case will terminate fatally. In all cases the prog- nosis will depend, to a great degree, upon the character of the prevailing endemic or epidemic, as also upon the stage of the epidemic, for the ratio of mortality is always greater during the early period of an epidemic than during its decline. During the latter part of an epidemic you may tliink you are managing your cases better because fewer patients die, while the good results are due to the fact that the epidemic is on the decline. All observers agree that the prognosis is better in every variety of per- nicious fever if there are distinct intermissions, however short may be their duration. If the paroxysm does not last more than twelve hours, and terminates in a distinct remission, the prognosis is far better than when one parox- PROGNOSIS. 1 0:^ Ysni follows aiiotlirr wiilioiit :iiiy dislinct remission. If tlu* ])aroxysius air incrrasirii;' in st'V<'rify and diirafioii, iIk- ])atK'Ut is liable to die in tlif third or fourth itaroxysni. Unquestionably the most favorable cases are those of the tertian tyjM'. Those varieties in which the cases most fre- quently terminate fatall}' are the gastro-enteric and the algid ; those in which the cases are most likel}^ to recover are the comatose and delirious. In every case the prognosis is very much inlluenccd by the age and condition of the patient, and by the presence or absence of complications. The mortality is greatest among the very young and very old, and among the intemperate. Patients with pernicious fever may die suddenly during a paroxvsm, or the paroxysms may be prolonged and run into each other, and the patient ma}^ finally pass into a typhoid or collapsed condition. In every variety of pernicious fever you may be aided in making a prognosis by remembering what I am about to state. If the second or third paroxysm is not attended by signs of intense visceral congestion, if it declines with profuse warm sweats, if it has been preceded by distinct intervals, if the urine is free and the appetite early returns, you may safel}' prognosticate a speed}' recovery. On the other hand, if the second or third ])aroxysm is protracted and accompa- nied by great anxiety and restlessness, with active delirium and a tendency to coma, with coldness of the surface ; if there is intense })ain in the epigastrium, with tingling of the surface, and scanty and high-colored mine ; if there is pro- fuse vomiting and ])urging, bleeding at the nose and cold, colliquative sweats; if the i)ulse becomes small and feeble, or the radial pulse is imperceptible, the danger is very great, and a fatal issue is almost certain, either imnied-iately or in the fourth or fifth paroxysm. Sometimes severe and fatal djsentery comes on at the end of a paroxysm ; at other times, as the ])aroxvsm subsides, the fever assumes a tj'phoid tyi)e, and, after a ])eriod of continued fever ranging from ten to twelve days, it terminates fatally. Tke.vtment.— The expectant plan of treatment, which has 164 PEENICIOUS FEVER. been proposed for the management of some of the forms of fever wiiicli have engaged our attention, cannot be practised in the treatment of pernicious fevers. The ahirming symp- toms crowd upon one another with great rapidity, and it is only by prompt and vigorous measures that in the severe forms of tlie disease you will be able to rescue your patient from impending death. The issue of life or death often hangs upon a single lionr. Some have proposed, before administering the only spe- cific which we possess capable of controlling this disease, to produce free purgation by the administration of cathar- tics ; others to bleed and freely vomit the patients. If the case is one of the gastro-enteric variety, emetics and purga- tives are certainly very plainly contra-indicated. It is now a well established fact that in all varieties of pernicious fever patients do not bear depletion. In India, where the most severe forms of pernicious fever prevail, the English surgeons are very positive in their testimony upon this point. All forms of depletion have been abandoned in the India service. Although stimulating enemas and friction to the surface may act as aids in the management of the algid and deliri- ous varieties, they must not be relied upon for any control- ling influence which they may have over the disease. Those who have had the most extended opportunities for testing the different remedies and plans of treatment which have been em^^loyed in the management of this fever, are united in the opinion that quinine and opium are the only agents which can be relied upon for controlling every variety. In the treatment of this fever my own experience is not extended ; consequently, I am compelled to give you the teachings of those who have written upon this fever. So far as I have been able to arrive at conclusions from my readings, as well as from my limited experience in the treatment of this disease, I am convinced that in the major- ity of cases, b}^ the use of opium and quinine hjq^oderini- cally, we may hope to control it, and thus save the life of our patient. TREATMENT. 165 Til fact, (lie liyjxxlcrinir use of tlicsc dru^s lias iiiaiiuii- latftl u iK'w t'la ill its (icatiiiciit, I'ur in a lar^r ])i())>(»rli()ii of the severer forms it is iiii])()ssible to ^ft tli<' full ell'cct of eillicrof these iciiicdirs hy iIk' oidiiiaiy iu«l IkhIs (»r fln-ii' adiiiiiiistnition, (lie usual avniues for tin -jr in hod net Idh into the sj'stt'iu Ix'ini;; closed. The soliitiiiii of (luinine, coimiioiily fiuitioyrd hy the Enu-lisli surucoiis for this i)iir])os(>, is made by addiiiii; one hundred and lifty grains of (quinine and lil'ty dioijs of di- hite li\-droi-liI()iic acid to four ounces of watt-r, and then eva])oratin^i^ the solution to two ounces. Of this, thirty drops may lie administered at each injection. Some add carbolic acid to a solution of (|uiniii.' in dihilr suljihuric acid ; the carbolic acid is addi-tl to j)reveiit abscess at the point where the injection is introduced. The formula for this solution is as follows : ^. Quinia di-ul])liatis (rrs. 1. Acid sulphurici iiL. v. Acid cai'bolici iil. ij. Aqua3 destillat 3 i. M. Thirty minims is the qnantity nsually administered at each hypodermic injection ; it represents between three and four grains of quinine. T have recently used the following: IJ. (^hiinia sulpli 3 i, Hydrolnomic acid 3 ij. Aquae destillat 3 \ i. M. Thirty minims contain four grains of quinine. Whatever solution you may use, administer from live to seven grains of ([uiniiie every hour until the ])aroxysm has passed, then continue its use in three grain doses every four hours. With the quinine of the first liyjiodcrniic iiijecti(»n admin- ister one-fourth of agrain of mori»liia. The inor})liine slmnld be administered with each dose of quinim* until the j.atient 166 PERNICIOUS FEVER. is brought fully under its influence, witliout regard to tlie stage of the paroxysm. During the past few years a remedy known as " War- burg's Tincture" has been quite extensively employed in the treatment of pernicious fever by the India sui-geons. AVhen this remedy was first employed, its ingredients were unknown, and on this account it was not generally made use of by the profession. All those who used it claimed that it more successfully controlled the fever than opium and quinine, or any other remedy that had hitherto been employed. The results claimed for it were really astonish- ing. Recently, the formula for making this tincture has been published in the London Lancet. I will give it as pub- lished. Formula. Warburg' s Tincture. 1^. Aloes (Socotr.) librom, Rad. rhei (East India), Sem. Angelica, Confect. Damocratis, ana uncias quatuor, Had. Helenis (s. Enulse), Croci sativi, Sem. Foeniculi, Cret. prseparat, ana unc. duas. Had. Gentianse, Had. Zedoariee, Pip. Cubeb., Myrrh. Elect., Camphorse, Bolete laricis, ana unciam. T/ie above ingredients to be digested with 500 ounces of 'proof spirit in a loater-batli for twelve liours ; then ex- pressed and ten ounces of disulpliate of quinia added, tlie mixture to be replaced in the water-bath until all the qui- nia be dissolved. The liquor .^ when cool., is to be filtered^ and is then fit for use. TREATMENT. 1 '"»7 Tr will 1).' s(vn that eacli luilf-oiinci' of lli»' tincture con- tains seven and a half ,i;rains of »piininf. It is reconi- menth'tl to i;iv(; half an onner of this tinctnrc at the onset of the paroxysm; if this does not control it, the same quantity must bf n'lx'aicd in four liours. If it cannot be retained by the stomach, it may bf administered by the rectum, in oiiiii-e (loses every hour. It is claimed that the tincture is retained by the stomach when all other remedies are rejected. Prof. Machnui says that h.3 has seen the most hopeless cases— those manifesting a degree of severity whicli seemed to i)reclude the possibility of recovery— com- mence to convalesce as soon as the i)atient was brought uiiil<'r the inlluence of this remedy. I will (|uote Prof. Maclean's rules for its administration : "The tincture is administered in the following manner: One-half ounce (half of a bottle) is given alone, without dilution, after tlie bowels hav(- been evacuated by any con- venient purgative, all diink being withheld ; in three hours the other half of the bottle is administered in the same way. Soon afterwards, particularly in hot climates, pro- fuse, but seldom exhausting, perspiration is produced ; this has a strong aromatic odor, which I have often detected about the patient and his room on the following day. "With this there is a rapid decline of temperature, imme- diate abatement of frontal headache — in a word, complete defervescence, and it seldom happens that a second bottle is required. If so, the dose may be repeated as above. In very adynamic cases, if the sweating threatens to prove exhausting, nourishment in the shape of beef-tea, with tlie addition of Liebig's extract and some wine or brandy of good quality, may be required." No special rules can be laid down in regard to tlie admin- istration of stimulants in pernicious fever ; the condition of the patient must be your guide. They are simply means used to aid in carrying a patient over a dangerous period. Their continued use in large quantities is objected to hy those who have had the most extended experience in tin? management of this fever. I will repeat in as few words as possible the imixjrtant 168 PERNICIOUS FEVER. things to be remembered iu the treatment of pernicious fever. Do not Avait for the action of a calomel purge. Do not resort to any depleting measures ; patients with this fever cannot bear depletion. However mild the paroxysm ma}^ be, no time should be lost ; bring the patient as rapid- ly as possible under the influence of quinine and opium, or, if "Warburg's Tincture" is used, administer it in full doses as early as possible, and continue its administration until convalescence is fully established. LECTURE XV. DENGUE FEVER. Morbid Anatomy. — Ettologj/. — Symjytoins. — Differ eutial Diagnosis. — Treatment. — Chron ic JIalarial Infection. Before leaving the class of fevers which has just been engaging our attention, I wish to say a few words concern- ing a fever which, although it may not properly be included in the list of malarial fevers, yet it seems to me that it can be best considered in this connection. It has received the names, dengue, break-bone, and dandy fever. It is neither an intermittent nor a reniittrnt fever ; nor is it a pernicious fever. It is an acute disease which appears as an e])idemic in hot climates. It is characterized by a febrile excitement remitting in its character, and is accompanied by more or less intense arthritic pains, attended by the development of a papillary eruption resembling that of measles. M(»Knir) Anatomy. — The moibid anatomy of this variety of fever does not diifer essentially from that of the severer types of malarial fever, except tliat a ciilancous eru]»tion commences on the ])abus of tln^ hands and extends rapidly over the entue body. In most cases, arthritic changes of a rheumatic character are present ; usually the external lym- phatic glands are somewhat enlarged. This disease seems to be an exantiu-matous mahirial fever, with a rheumatic or neuralgic element. Etiology. — l)<'iigue or break-bone fever may jirevail epi- demicallv in well nuirked malarial districts, or it may be 170 DENGUE FEVER. met with as a sporadic disease. Its infection has been carried in clothing from one seaport to another. Some claim that tlie disease depends upon a specific contagion ; but its contagious character has not been established. The intensity of the malarial poison unquestionably has some iiitluence in increasing or lessening the severity of tliis fever. In districts slightly malarial usually its type is mild ; but in districts strongly malarial its type is severe. It attacks all classes and all ages, rich and poor, black and white, the very young and the very old. Occasionally it has occurred as the i3recursor of yellow fever. In 1827 a very extended epidemic of this fever prevailed in the West Indies ; during the prevalence of this epidemic, the specific poison of the disease was transported in clothing and mer- chandise to many neighboring seaports. Symptoms. — Tiie period of incubation is estimated from three to five days. The initiatory sj'mptoms are very sud- den in their manifestation, and the development of the fever is very rapid. In the majorit}^ of cases, the earliest symp- toms are headache, photophobia, great restlessness, chilli- ness alternating with flashes of heat, and pain in the back, limbs, and joints ; the small Joints SAvell, and there is sore- ness and stiffness of the muscles. The skin becomes hot and dry, and in some instances the temperature reaches 107° F. The pulse is rapid, ranging from 120 to 140 beats per minute. The face is flushed and the ejes red and watery. After the fever has continued about twelve hours, the pains in the joints become intense, the pain in the back shoots down the sciatic nerve, and now nausea, vomiting, and pain in the epigastrium are usually the prominent symptoms. At this stage of the fever the Ijmiphatic glands become involved ; the inguinal glands are first affected, then those in the axilla and neck ; they increase very rapidly in size, and become exceedingly tender. The testicles enlarge, or rather the epididymis, and the swelling continues until the subsidence of the other symptoms. The active febrile excitement continues from twelve hours to three or four days, when it subsides, leaving the patient in an exceed- SYMPTOMS. ingly feeble and prostrate condition. Somctiines tlie fev(n- abates suddenly, with the occurrence of critical synii)ton»s as in re]apsin«j; fever, such as profuse sweats, diarrluea, or epistaxis. Then the patient is in a ])assive condition for two or three days, and ])asses into the ])eriod of remission. The jiains now become less, the glanduhir swellings diminish, there is less of febrile excitement, but it does not entirely subside. After two or three days a second paroxysm occurs, and the fever returns. About the same time intervenes between the first and second paroxysm as occurs between the iirst and second inuoxysm of relai)sing fever. When the fever returns it is more intense, the pain in the joints is more severe, and tinally, when the fever has reached its height and the i>ain is most intense, usually on the fifth or sixth day, an eruption makes its appearance. It first ap- pears upon the italms of the hands, then u})<)n the neck; soon it extends downward and is seen upon the chest, and tinally spreads over the entire body. Usually it is pai)il- lary in character and very closely resembles the eru])tion of scarlatina. In most cases, as soon as the erujjtion is developed, the fel)rile symptoms subside and the i)titieut goes on to convalescence. From the intense arthritic pains accom])aiiying the papil- lary eruption, and from the glandular swellings, you will be able to recognize this peculiar type of fever. As the second paroxysm of fever subsides, the ])atient is left with stiffness and soreness of the joints, which sometimes does not pass away for weeks. Occasionally the disease assumes a ty- phoid type, the tongue becomes coated with a dark brown coating, the gums become red and spongy, the i)ulse is slow and feeble, and the surface is covered with a cold sweat. As soon as the eruption appears, the patient is generally free from fever, and passes on to a rapid and C()mi)l»'te con- valescence. In vtny severe cases the ])ain in the testicles will con- tinue after the subsidence of the fever, and a serous effusion will take place into the tunica vaginalis. The joints will remain ])ainful and flabby. Th^re will be extreme nervous- ness and an.xiety. The heart's action will be intermittent, 172 DENGUE FEVER. and tlie lympliatic glands, which have been enlarged, form indurated tumors ; they very rarely suppurate. The dura- tion of this fever varies with the period of remission. Its average duration is about eight days. In those epidemics where there is an absence of articular pains, the mucous membrane of the mouth and throat be- comes involved. The course of the disease may be divided into periods. First, that of febrile exacerbation, lasting two or three days, then an intermission of two or three days, then a second febrile exacerbation which lasts two or three days, then convalescence begins. Differential Diagnosis. — This fever may be confound- ed with rheumatism, or with remittent fever. In some of its phenomena it closely resembles relapsing fever. It may be distinguished from remittent fever by the per- sistency of the rheumatic and neuralgic pains, by the cuta- neous eruption, and by the length of the remission. It may be distinguished from rheumatism, as it prevails epidemically, and a period of febrile excitement precedes the arthritic phenomena. It may be distinguished from relapsing fever by the eruption and by the character of the remissions. Prognosis. — The prognosis is always favorable, although the symptoms which attend its development may be alarm- ingly severe. The prognosis is only unfavorable when it occurs in the very aged or in feeble infants. Treatment. — This fever always runs a definite course, and its treatment is the symptomatic treatment of fever, combined with well recognized anti-rheumatic remedies. It is claimed that emetics and free purgation diminish the intensity of the fever. A favorite combination is ipecac, calomel, and colchicum— these to be administered every night in cathartic doses. Calomel should never be admin- istered alone, nor in combination with other drugs, if its spe- cific effect is likely to be produced. The administration of colchicum with spirits of nitre and nitrate of potash, in such proportion that profuse diapho- resis may be produced, in connection with the administra- TKEATMKXT. 17^ tion of cfforvescing clraii,ii:hts, will usually afTonl relief from the i)ain in the lu'ad ami rnMi)s. Should the arthiitii- ])ains still be felt, o])iuin may he administered in sudicient quan- tity to alVord relief. J)urinii: the remission tlie bowels should be ke])t freely open with saline i)Ui-i;atives, and quinine combined with an alkali should be given at stated intervals. Narcotics ma}' be uiven in small doses to produce sleep, should the patient be wakeful. l\v the em])l(>yment of these measures a return of fever mav br pivveiiipd and the arthiitic ])ains will grad- ually subside. If this i)lan is i)ursued, should the fever return, it will be mild in character, atteiub'd by little con- stitutional disturbance. The weakness and exhaustion which attend convalescence may l)e combated by the free use of wine or malt liquors. The diet should be most nutritious. Nourishment should be administ(M-ed at stated intervals, during the night as well as during the day. The lymphatic enlargement, especially in the inguinal region, should be treated locall}' with iodine. Citrate of iron and quinine will be found of great service during the convalescing period. If a single joint remains swollen and tender for a considerable period after the sub- sidence of the fever, the occasional application of a blister is recommended. In some epidemics, relapses after an interval of two or three weeks have been of freqm^nt occur- rence. They run a milder course than t\ui primary fever. The relapses more closely resemble an attack of articular rheumatism than they do the primary fever. Quinine is said to furnish great ])rotection against a relapse. CHRONIC MALARIAL INFECTION. There is still another form of malarial manifestation closely connected with the subject which has been engaging our att<^ntion. of which I will brietiy speak. It has be(»n termed malaiial cachexia, or better, c/zro/^/V mrtlarlal infec- tion. I do not include it in the list of malarial fevers, although it may be a se([uela of any form of acute malarial 174 CHRONIC MALARIAL INFECTIOTTS. disease. It ma}' be developed in those who have never suflfered from any form of malarial fever, but who have resided for some time in a malarial district. For instance, a person who has had repeated attacks of Intermittent or remittent fever, and has become exceedingly anaemic, with an enlarged spleen and enlarged liver, may be regarded as in a condition of chronic malarial cachexia, and is in a condition to present the phenomena of chronic malarial infection. Again, a person who has never had a distinct paroxysm of malarial fever, but who has lived for some time under malarial influences, the malarial poisoning never having been intense, becomes anaemic with enlarged spleen and liver, and presents the phenomena of chronic malarial infection. Morbid Ax atomy.— The morbid anatomy of chronic malarial infection does not differ from that of the severer types of malarial fever, except in the more advanced stages of the tissue- changes. For instance, the spleen is often ten or twelve times its normal size, tough, firm, and resistent. Its surface is uneven, its capsule enormously thickened, and more or less adherent to the adjacent organs. Its substance is rich in pigment matter, and presents the minute changes either of simple hyperplasia or amyloid degeneration. Simi- lar tissue-changes take place in the liver and kidneys. In some instances the muscular tissue of the heart undergoes fatty or amyloid degenerative changes. CEdema of the sub- cutaneous cellular tissue, and an accumulation of fluid in the serous cavities, are common attendants of chronic mala- rial cachexia. Etiology. — It is unnecessary to repeat what I have al- ready said in regard to the causes of malarial infection. It may be the result of prolonged exposure in a district only slightly malarial, or of a short exposure in a district strongJy malarial. Symptoms.— Those who are the subjects of chronic ma- larial infection complain of vertigo, ringing in the ears, loss of memory, disturbance of the sight, loss of appetite, nausea, dyspeptic symptoms, and jDain and oppression in the epigastrium. The bowels are rarely constipated ; often in tilt' iiKirniiiij; ]»nu-nt. If the individual has repeatedly suffered from malarial fever paro.xysms, or if he has resided f(jr some time in a inahirial district, even though he may not have had a distinct malarial ])aroxvsm, thoimh none of the 12 178 CIIKONIC :\rALARIAL IlSTFECTIOlSr. phenomena to wliicli I have just referred have been de- veloped, and though that peculiar malarial cachexia which is so characteristic of malarial poisoning is not present, yet it is always well to carefully consider the question of malarial infection. AVhile the manifestations of chronic malarial poisoning may be called legion — and in many instances they very closely simulate the phenomena of other diseases — still, with a histor}^ of possible malarial exposure, by a system of ex- clusion 3^ou reach the fact that the patient is suffering from some form of blood poisoning. When you have reached that conclusion you are able readily to determine the nature of such poisoning. In very doubtful cases you may arrive at a diagnosis, or perhaps confirm an uncertain diagnosis by treatment, in the same way in which we sometimes detect syphilitic infection by the effects of treatment. Progn'OSIs. — The prognosis in chronic malarial infection depends upon the severity of its manifestations. The degree of enlargement of the spleen and liver is a reliable indication of its severity. When the symptoms are mild and the spleen is but slightly enlarged, and when neither ascites nor oedema of the lower extremities is present, the prognosis is generally good. If the patient is very anaemic, the spleen very greatly enlarged, and the area of hepatic dulness very much increased, the prognosis is unfavorable. When dis- tinct tumors can be detected in the spleen and liver, they indicate an exceedingly grave form of malarial infection ; if the tumors are large, they can rarely be reduced. If the individual in whom these tumors are found removes from a malarial district, a long time may elapse before they ap- parently very much interfere with his health and comfort. You must take into consideration the possibility of your patient being able to take up his permanent residence in a non-malarious region, before you make a prognosis in any given case. So long as such a patient is under malarial influences, however slightly malarial they may be, the progress of the disease cannot be permanently arrested ; and when the 'lUKATMKXT. 179 manifestations of thegrav.'i- forms of lualaiiul iiifrctioii :ir«» l)ivsciit, tlii'iv is little prosjx'ct I hat the disease can be t<'ni- jKnaiily ivli.'vcd so long as the patient remains in tiie mahiiial ho-malarial " different signiiications have been given by dilferent observers. By one class the term has been employed to indicate the presence of malaria, and also the specific poison which produces typhoid fever. By anotlier class of observers the term has been employed to indicate the presence of malaria, and also a septic i)oison which differs from the speciiic poison that gives rise to ty- phoid fever. There is still anotlier class of observers who doubt the existence of such a form of fever, and regard the so-called t3'])lioid element as nothing more than a '' typhoid con- dition/' liable to be develojted in connection with remittent fever, as well as many other diseases. The term ty})ho-nialarial is a convenient one for the first class of observers, and is one which can be em])loyed by them without confusion : wlicn-as, for thf second class of observers, it is exceedingly inconvenient, giving rise to con- 182 TYPITO-MALAEIAL FEVER. fusion, because it does not embrace the views held by them regarding the etiology of the disease. But we have the term, and I shall employ it as one denot- ing a fever which is produced by the combined action of a septic and a malarial poison. As far as possible I shall use the word septic when speaking of the poisons which are associated in the production of the disease, and the term typhoid will be reserved for that peculiar condition known as tlie " typhoid condition," and for the specific dis- ease known as typhoid fever. You will meet with some cases of typho-malarial fever in which the septic element predominates, and others in which the malarial element is predominant. The preponderance of the leading features of the one or the other of these two forms of fever will enable you to determine with a good degree of certainty the course, prognosis, and treatment of each individual case. The distinguishing lines, however, between these two ele- ments are not always sharply defined, but almost impercep- tibly the symptoms dependent upon one poison become mingled with those developed by the other. Both of these elements may be modified in their manner of development and in their morbid anatomy, by the occurrence of various intercurrent complications, such as scurvy, pneumonia, etc. Morbid Anatomy.— The changes which take place in the constituents of the blood in typho-malarial fever, so far as we are yet able to determine, are similar to those which occur in typhoid fever, combined with those which are char- acteristic of malarial fever ; the presence of free pigment granules in the blood is often a strong point in its differen- tial diagnosis. In connection with these blood changes, there are more or less parenchymatous changes in the internal organs similar to those met with in other forms of fever and in acute in- fectious diseases. The liver is increased in size, and its cut surface presents an appearance which closely resembles that known as nutmeg liver. Sometimes it presents the peculiar bronzed color of the liver in remittent fever ; at other times it very closely resembles the liver of yellow fever. A mi- croscopical examination shows free fat and more or less :m()K1!I1) anatomy. 183 bro'.vn ])i,i;ni(Mit graiuilrs in tli«' licpatio fells. In mosf r-n-^r"? of this fever the splcrn is enl:ir<;ed, softened, and of an al- most Mack eolor. The Mali)iuhian bodies are prominent, and ]iresent the aiijM'aiance on the torn surface of the spleen of little tumors, which vary in size from a ])in's head to that of a pea. 'i'he orn-an is rarely as much enlarged or softened as in tyi)lioid or remittent fevers. It is always the seat of more or less ])igmentation. No uniform change will be noticed in the Jcklneijs, except that of hypiTjrniia, which Avill be most marked in their cor- tical substance. The Itmr/s at their most depending portion are the seat of more or less extensive hypostatic congestion. Splenization of the lungs is not as frequently present as in typhoid fever. The l/rort is pale and flabby. Its muscular fibn^s ai-e the seat of a granular degeneration similar to that which takes place in the heart in typhoid fever. Exsanguinated clots more or less iirm may be found in its cavities, but they have nothing peculiar about them. They closely resemble those found in ]iersons who have died from failure of heart power. They ai'e larely, if ever, the direct cause of death. My own examinations of the intestinal lesions of this fever have led me to adopt, for the most part, the descriptions which have been published by Dr. J. J. Woodward, of the U. S. A. In fact. Dr. Woodward's investigations in this direction may be regarded as exhaustive. That the intes- tinal changes of typho-malarial fever very closely resemble those of typhoid fever there can be no (question ; b}" some the}'- have been regarded as identical, but I think, if we vi^ry carefully observe them, some very marked differences can be recognized ; especially if we attempt to divide the stages of their development into periods so as to correspond to the days and weeks of the fever, as is possible with the intes- tinal changes of typhoid fever. As in typhoid f(wer, the principal and almost constant changes are to be found in and around the closed follicles of tile intestinal tract. These changes are made n)anifest by the gradual enlargement of the follicles, which, as tluy enlarge, become more or less pigmented. 184 TYPiio-:\rALArwiAL fever. xVt tlie post-mortem examination of one who has died of this fever, you will usually tind these glands in all stages of this pathological process, from slight enlargement and softening to ulceration of the entire follicle. The summit of the enlarged follicle is the first seat of the ulcer. These ulcers may involve a single follicle, or they may invade the adjacent mucous membrane, and produce ulcers from one- half an inch to an inch in diameter. The largest and most extensive ulcerations are to be found in the ileum and in- volving the Peyerian patches. The edges of these ulcers are irregular and everted ; their base is usually of a grayish color, often mottled with black points. These ulcers may extend into the submucous tissue and involve the muscular coat of the intestine, and even perforate the peritoneal covering of the intestines. In the earlier stages there is little to distinguish these intestinal changes from similar ones which develop in ty- phoid fever, except, perhaps, the tendency to the deposit of black pigment in the enlarged follicles. In a later stage, certain peculiarities are present, which are often sufficiently distinctive to designate the case as one of typho-malarial fever. For instance, in typho-malarial fever there is a grad- ual elevation of the mncous membrane surrounding the enlarged follicles, which, if ulcers exist on their edges, reaches a thickness of from three to six lines. These ulcers differ from those of typhoid fever in that the enlarged patch rises abruptly from the mucous mem- brane, and in such a manner that the summit is often larger than the constricting base. Besides, the umbilical depression so often seen in ordinary typhoid patches prior to ulceration is rarely observed in typho-malarial fever. As I have already stated, the ulcers in typho-malarial fever present ragged, irregular edges, which are usually exten- sively undermined, in consequence of the erosions ex- tending into the submucous tissue, rather than into the glandular layer of the mucous membrane. This undermin- ing of the edges is much more extensive than in typhoid ulcers. The mucous membrane between the follicles presents the Mor>r!TD AXATo^rr. 1,95 ordinmy appoarnnre oC catanlial iiillaininafion, naim'ly, th(Mv is more or less coiif^estion, timu'ractioii, and in the later stages thickening and softening of its tissue. Tlie minute anatomical changes which att('ne, do not essentially differ from those which I have already described as occurring in ty})hoid fever, except that they have no regular stage of development marked by days and weeks, the processes are slower in their develo})ment, and the presence of ]ugnient in the enlarged and ulcerating follicles stamp it as depending upon an essentially different exciting cause. Hence, although the intestinal lesions of this fever very closelv resemble those of typhoid, tliey are not identical, but evidently belong to another type of dis- ease. Undoubtedly, there are cases in each of these two forms of fever between which, by the intestinal lesions alone, it is impossible to draw the line of distinction ; but in typi- cal cases this is easily done. Intestinal perforation, and a consequent peritonitis, the result of the intestinal ulc(^ration, may occur in typho- malarial fever, but you will rarely meet with such an acci- dent. Usually the mesenteric glands are more or less en- larged, and in the advanced stages of the disease more or less softened. They are of a livid color, and more or less pigmented. The greatest enlargement of these glands will be found in that portion of the mesentery which corresponds to the most extensive and advanced intestinal changes. The principal changes in the structure of the glands are similar to those which occur in a purely- inllamniatory process. Occasionally, minute ulcers are met Avitli in the mucous membrane of tin* stomach and large intestines, and the mu- cous membrane of the stomach is not unfrequently very greatly softened, and the mucous membrane of the huge intestine, if there have been any manifestations of scurvy during the progress of the fever, will be thickened and softened, perhaps extensively ulcerated, presenting an ap- pearance, in some instances, clo.sely resembling those found aft(T death in chronic malarial dvsenterv. "NViiile, there- 186 TYPIIO-MALAEIAL FEVER, fore, we find no pathological lesions wlilcli can be regarded as characteristic of tliis type of fever, and while the lesions which we do find very closely resemble those of typhoid fever on the one hand, and remittent fever on the other, still there are marked difi'erences which distinguish it from either of these fevers sufficiently to stamp it as a distinct type of fever. Etiology. — It is difficult to determine the trne etiology of typho- malarial fever. That malarial poison is necessary for its development there can be no question. It is equally certain that some other poison besides malaria is in opera- tion whenever this fever prevails. That this poison is not the specific poison of typhoid fever is apparent from the fact that its development and spread, as far as can be de- termined, is in no way connected with the excrements of one suffering from this fever. There are a few facts connected with its development which are now well established : First. — It is only met with in malarial districts. Second. — In the majority of instances, when this fever has prevailed, its develoj^ment has been preceded or attended by marked, and easily recognized, anti-h3^gienic conditions, such as overcrowding, bad sewerage, and other conditions favorable to the development of septic poison. Tliird. — That it is a non-contagious clisease, and is never propagated from the affected to the healthy, either directly by personal contagion, or indirectly by morbid excretions. Fourth. — In its morbid anatomy and symptomatology it is a combination of two well recognized forms of fever. The special symptoms and lesions of one or the other of these fevers stamp its character, and indicate its alliance to a ma- larial or septic type of fever. In large cities, in which malarial diseases are prevalent, sewer gases seem to furnisTi the se'ptic element which is so necessary for the development of this type of fever. The history of disease in our own city during the past few years furnishes striking examples of the combination of these two poisons in developing a type of fever which it seems to me must be classed under this head. SVMI'IOMS. 187 Symptoms.— It is ov.mi moiv diHiculi to prosont a tyi)icnl l)'R'tuiv of tliis IVvcr ihaii of l.vplioii>ro.\iMi:itily Irui- of all, oi- cvt'U llie majority t)f cases, is iiupossil)le. lis clinical history vaiics as the malarial or septic eh^nient pre- dominates. Besides, there are a huf^e numbt^- of cases in which neither of these elements can be said to predominate, for the ]>alient almost insmsiMy ])asses from a malarial into a typhoid condition. Theiv ai'- also certain anti-hyi!;i<'nic conditions uhicli may be ])resent, which f^ive to the fever an nnusual and jifculiar type. For example, when those con- ditions exist which favor the development of scurvy, if typho-malarial f<'v<'r is ])revailing, as the patient enters upon the s(H'ond week of the fever the scoi-butic ]>h(Mio- nicna will become jirominent. At times the dysenteric element may be engrafted on this fever, which shall greatly modify its course, and lead to a train of symptoms and morbid changes which shall veiy closely ally it to ei>i(li'iiiic dysentery. The course of this fever may also be greatly modili((l by certain local complications which are especially liable to occur during the second or third week. The presence of any of these conditions will greatly change its clinical liistory, but the i)henomena which attend its early develop- ment will always be sufficient to determine its true character. In considering in detail tin' symptoms of this fevtM-. I will iirst di'scribe that class of cases in which the malarial da- ment is predominant. This ty])e of fever is usually ushered in by a distinct chill. In some instances no premonitory symptoms are present, in other cases the chill is preceded by wandering pains in the limbs and back, headache, loss of appetite, and a feeling of great exhaustion. In a huge ])roportion of cases, in the early stage, the countenance has a ])eculiar waxy, clay- colored, or yellowish tinge. The chill varies in duration from half an hour to an hour, and in character closely resembles the chill of simph' ivmlttent ftvir. It is inime diately followed l)y active ft.-brile symptoms, the temjtera ture rising in a f.-w hours to KKJ" F. or loi" F. The pulse 188 TYPHO-MALARIAL FEVER. readies 100, and is full and forcible. The excretions are all cluH'ked, and there is mental disturbance and sometimes delii'iuni. When once established, the fever pursues a variable course. At its onset, and for the first few days, its phenomena often closely resemble those of simple remittent fever, though the remissions are never so well defined as in remittent, and there is at the very onset of the fever an amount of intestinal disturbance which is rarely present in sinii)le remittent. The existence of abdominal tenderness, especially in the right iliac fossa, is a strong point in the differential diagnosis of typho-malarial and simple remit- tent fever in favor of the former. As the temperature rises, nausea, vomiting, and epigastric tenderness are present in a greater or less degree. These gastric symptoms bear a close resemblance to those which attend the development of remittent fever, while the intestinal and abdominal symp- toms are similar to those of typhoid fever. Diarrhoea may precede the chill ; in most cases it is- present during the period of fever. At first the tongue presents a pale, flabby appearance, with a smooth surface ; soon it becomes covered with a white or yellowish-white coating ; later it becomes red and the coating becomes brownish ; in severe cases it may suddenly become clean, red and shining, and sordes may collect upon the teeth and lips. In those cases in which a scorbutic element exists, the tongue is enlarged, pale, and flabby, its surface smooth and covered with a white fur, which is thickest on its edges, the gums are swollen and present the characteristic appear- ance of scurvy. In those cases in which a dysenteric element is present as the fever develops the dysenteric symptoms become promi- nent, the discharges from the bowels are blood-stained and watery. The tongue soon becomes dry and brown, and the patient shows signs of extreme exhaustion, with few of the gastric symptoms which are usually so well marked in the early period of the fever. Throughout the whole course of the disease there is a marked tendency to periodicity, the exacerbations usually assuming a tertian type. In fatal cases, as the patient SYMPTOMS. 189 reacli«\s tlic second or tliiid wrck, the symptoms are very like those of fatul tyi»lioicl ieVL-r : the i)rostratioii IxM-omes moit' and more eom])k'te, tlie pulse readies 130 or 140, is feebh- aiul irrfuiilai-, the ])atient ^nadiially passes into a state of stui)or and coma, involuntary evacuations take place, and death ensues. In cases that recovei-, symi)t(jms of anit'iidinrnt nia\' ])ii noticed V)etw«'en tlie tenth and twrntiftli thiys. The ton,ii;ue begins to become clean, the al)dominal symptoms subside, the pulse becomes less frequent and fullt-r, tin- distuibance of the nervous system disai)])ears, the a])i»etite gradually returns, and the patient enters upon a tedious convales- cence, which is attend(»d by more or less diarrhoea, mental stupor, cardiac irritability, and a slow return of mental and pliysical vigor. The train of symptoms thus l)rieliy sketched may be greatly nioditied by a variety of complications. Not unfn.'- queutly pulmonary complications develop during its second week, and so change its phenomena that the fever element may be overlooked and the pulmonary element alone engage the attention of the physician. Suppurative intiammation of the cervical and inguinal glands sometimes compli<'ates this type of fever, and leads one to the mistake of regarding it as purely a suppurative fever. Again, scurvy under certain anti-hygienic conditions may so modify the usual phenomena of ty])ho-nuilarial fever, that it has led some to regard this fever when developed under such circumstances as an entirely new type of fever, entirely losing sight of its malarial elemtmt, and classing it among the infectious fevers. The scorbutic element in this class of cases is developed in connection with the malarial exposure. LECTURE XVII. TYPHO-MALARIAL FEVEE. Symptoms {continued). — Differential Diagnosis. — Progno- sis. — Treatment. I HAVE mentioned tlie prominent symptoms which attend the development of that type of typho-malarial fever in which the malarial element predominates, and will now speak of those present in the seiytic type of this fever. Although the premonitory symptoms of this type, such as lassitude, headache, pains in the back and limbs, resemble those of typical typhoid fever, either a distinct chill or a complete intermittent or remittent paroxysm ushers in the febrile symptoms. The rise in temperature following the ushering-in chill has no typical range ; in some cases the rise is gradual, not reaching its maximum before the middle of the second week ; in other cases the rise is sudden, reaching 104° F. or 105° F. within twent3^-four hours after the occurrence of the chill. Throughout the whole course of the fever the same tendency to periodicity exists which was noticed in the malarial type of this fever. In typhoid fever, during the first week, there are indis- tinct forenoon remissions and afternoon exacerbations, but in this fever the remissions are well marked, especially on every second or third day, causing the fever to assume a more or less distinct tertian or quartan type. One of the earliest symptoms is well-marked hepatic tenderness ; with SYMPTOMS. 101 tlit^ iH'pat'u^ t«'iul('rnesa then? is (MilarujtMiiont of (li<* si)let'ii, which, us the IVvlt proi::n'SS('s, reaches a imicli lar;i;ei- size than is ordiiiaril}- met with in lyi)h()id f.-Nci-. I)iii-in,<^ the first vveels. the piiNc is full ;iiid lar.-lv iiioiv liiaii IdO heats per minute, but duriiii;- ih'- second and third wt^eivs it is small and c<)inpi'essil)le, and in severe cases iutermitteut, and ranges IVoni 1 JO to i:}ti prr minute. The appearance of the tom;ue Aaries with the period of the fever. At lirst it is swolh'U, with red ])rojectin,u- ])a})ilh*e, and lias a li^ht wliiti' coating. As the typhoid condition l»ecomes more })roininent its a])i)earan('e changes; it becomes dry and brown, and fie(pieiitly the brown coating cracks, and fissures are formed in tlie mucous membrane uiKh-nieatli. Should the tongue become moist and begin to clean, you may regard convalescence as established. The coating is removed in two ways, either gradually from the edges to tlie centre, or it is thrown off in Hakes. In the lattin-case, after tlie removal of the coating, the tongue assunu'S a beefy red appearance, and after a short time may again bciome brown and dry. Under such circumstances there will be a renewal of the fever-sj'mptoms. After the fever has continued a few days the surface becomes dry and harsh, and the skin assumes a bronzed hue, which is quite characteristic of this fever ; sometimes, instead of this bronzed hue of the surface, there is well- marked jaundice. The changes in the mine do not dill'er IVoin those which usuall}' attend febrile excitement. The urint? gradually diminishes in quantity and decj»ciis in color until convales- cence commences, when it increases in ([uantity until con- valescence is reached. It is rarely albuminous. Dlarrhdca may occur at any ]ieriod. It is not usually excessive until the second or third week. There is nothing cliaracteristic about the discharges. They are usually of an exceedingly f«^tid odor, water}^ ami dark-colored ; in tim later stag(\s of the disease they sometimes contain blood. In sonu' instances the character of the stools is termed bil- ious, and an exn-essive hejKitic secretion is then indicated ; at oth"r limes they are of a dark clay color, showing a de- 192 TYPnO-MALARIAL FEVER. ficioncy of tlie biliary secretion. With tlie diarrhoea there is usuall}'^ more or less abdominal tenderness, especially in the right iliac region; but the tympanitis, which is so con- stant an attendant of typhoid fever, is rarely well marked in typho-malarial fever. In many cases there is retraction of the abdomen. As I have already stated, headache is a very constant and prominent symptom in the early period of this fever. It often precedes the ushering-in chill. As the fever pro- gresses it gives place to a delirium, which is never violent, but which is muttering in character, and is attended by rest- lessness and insomnia, or by drowsiness, subsultus, picking at the bed-clothes, and great nervous prostration. If deli- rium is not present, or after it has disappeared during con- valescence, there is great lack of mental vigor and a ten- dency to mental sluggishness. The other nervous phenom- ena, which are usually present in any condition when marked typhoid symptoms exist, are not prominent in this fever. The subsequent phenomena which may attend its development will vary with the intensity of the fever and the resisting power of the patient. In fatal cases, towards the close of the second week, symptoms of extreme prostration come on, the piatient gradually passes into a state of stupor, which lapses into one of coma, and death ensues. In cases that are to recover, by the end of the second week the tongue begins to clean, the gastric and intestinal symptoms, with the exception of the diarrhoea, begin to subside, the pulse becomes slower, the nervous disturbances disappear, the appetite returns, and the patient enters on a convalescence which is usually protracted. It is apparent that the early stage of this fever very closely resembles that of simple remittent, while its latter stage as closely resembles that of typhoid. The phenomena of both stages may be modified by cer- tain anti-hygienic surroundings, to which those suffering with this fever may have been subjected prior to, and during, its development. Thus, when it prevails among those who have suffered privations, been badly fed, badly SYMTTOMS. 193 clotlit'il, ovorrrowdrd in )>a(lly voiitilatrd a])artinonts, sur- roiiiult'd by (lt'C()in|>()siiistanf<'S, altliou.u;!! tin* fever is ath'iidrd l)y I lie siime l»'lu>iMs wliicli occur in the course of ty])!ius fever an* iu no way peculiar to it, yet they are of such frec^uent occurrence, and are devel- oped durinii: it^ active progress and modify its pheno- mena to such a (h'gre.'. that it is necessary that tliey should be taken into account in the study of its pathoh)gical lesions. You will rarely make a post-mortem u])on one who has died from this disease without linding the evidence of some complication that has occunvd dui-ing tlie progress of the fever. These coin])licati()ns will vary according to tile peculiar type of the eiiidemic which is pnn-ailing at tlie time the death occurred. In one epidemic the complica- tions will be pulmonar\', in another they will be almost ex- clusively cerebral and spinal, in another nearly all will be glandular in character. The pulmonary complications are bronchitis, pneumonia, pleurisy, pulmonary congestion, and oedema. In most cases these pulmonary complications are developed during the primary fever, before convalescence commences. Their advent is always insidious. You may have an ex- tensive capillary bronchitis develop with very few of the rational symptoms of bronchitis present until within a very short time previous to the death of the patient ; in fact, the bronchitis might pass unrecognized but for the presence of its physical signs. All the rational symptoms of pneumonia ma}^ also l)e absent, and still a physical examination of the chest may reveal a whole lung in a state of pneumonic consolidation. Tlie pneumonia which complicates typhus is of the catarrhal variety. It often leads to pulmonary gangrene, so that gangrene of the lung in connection with the development of typhus is not of infrequent occurrence. Pleurisy is of so rare occurrence that it maybe passed with the simple statement that it is an occasional complica- tion, its physical signs only revealing its presence. At most of the autopsies you make of typhus fever patients you will find there has been pulmonary congestion and oedema. In many cases, when it is associated with cai)illarv bronchitis or juieumonia, it is the immediate cause 14 210 TYPHUS FEVER. of death, and great care should be taken in your physical examinations that you may detect its commencing develop- ment. Laryngitis is often associated with the more extensive bronchitis Mrhich occurs during the active part of the fever. The only cerebro-spinal complication which is met with in typhus fever is meningeal inflammation. As I have stated, in a large majority of autopsies of ty- phus fever you will find serum in the meshes of the pia mater, but that is not a certain sign that meningeal inflam- mation has existed prior to death. In addition to the sub- arachnoid effusion, there must be an exudation of plastic material ; the arachnoid must have lost its shining appear- ance, and be thicker than normal. When such appearances are found it shows that the case has been complicated by meningitis. The development of delirium and active cere- bral symptoms is not positive evidence that the patient is suffering from meningeal complication, for the delirium and cerebral excitement may occur independently of meningitis. It is by the character of the delirium, and by the change in the pulse and the appearance of the pupils, that this complication is recognized. Glanclnlar Enlargements.— 'Y\\q glandular enlargements and inflammations which occur in the course of typhus fever are peculiar in their character, and are rarely met with in typhoid, and then are not extensive ; but in typhus fever the external glands of the body— especially those about the neck, the parotid and sublingual— of ten become so much enlarged and inflamed as to interfere with deglutition, and not infrequently^ these glandular enlargements are ap- parently the immediate cause of death. The inguinal glands sometimes become so enlarged as to interfere with the return circulation, and, as the con- sequence of this interference, swelling of \\\^ lower extremi- ties may be developed. There is a swelling of the lower extremities which depends upon a different cause. It may occur at the beginning of convalescence ; then the limbs will present very nearly the same appearance as that notice- able in the condition ciAlQx}. 2)Jilegmasia dolens. Under such ETIOLOGY. 211 circunistniicfs you iikiv lliiiik iIk- ]);iticiil lins jililrhii is. \()ii will nTollt'cl llial 1 linvc slated lo ^ou lliat the volun- tary niusclcs undergo (Ic.ucncialioii, and that the same kind of def^eneration occurs in the luuscular tissue ol' the heaii. AVhen this does occur the walls oL' the heart: become veiy tkil)by, and when this chan^ue has reached a certain ])oint there is developed a tendency to the formation of cjols in tlie heart cavities, and a slowini;" of th(^ general circulation. The result of such retarding or obstruction of the return circulation is the formation of thrombi in tlu? superficial veins, which interfere with the' return circulation, and a swelling of the lower extremities follows ; this closely re- sembles that which is seen in phlegmasia dolens. AVith this swelling of the lower extremities, su])])uration and cel- lular inllammation may occur, which often results in the fornuition of quite extensive abscesses. It is an established fact that whenever the return circula tion is slowed from any cause in any disease where there is great feebleness of heart power, very frequently thrombi form in the veins of the lower extremities. This is often well illustrated in the latter stages of phthisis, when swell- ing of one or both lower extremities occurs as the result of the formation of venous thrombi in the superficial veins. Di.'^icases of the organs of the special senses, which so frequently complicate typhoid, rarely occur in typhus fever, and there are no serious or constant conqjlications of the digestive organs. We have now noticeil the moi-e jirominent lesions of typhus fever, aiul although tin'i-e an; none which can be regarded as characteristic, still they widely dilf(M- from those of any other form of fever, and more especially from those of tj'phoid. Enor.oGY. — I now pass from the study of the pathologi- cal lesions of typhus fever to its etiology. At the i)resent day this fever is regarded as depending upon a specific poison, of whose exact nature we are ignorant. All ob- servers agree that in the majority, if not in all instances, it is the ])rodnct of co/i/'n/i'/n, and that the contagion only emanates from the bodies of those who are alTected with 212 TYPHUS FEVEE. the fever. More recent German writers state tliat tlie tj^plins poison is a germ which is capable of indefinite re- ])roduction. This is a matter of theory, and not fact, for no one as yet has been able to determine the existence of snch germs either by microscopical or chemical research. Careful clinical observation has established this fact beyond a doubt : that there exists a specific typhus poison, which can be communicated from the sick to the healthy, which some declare is never of spontaneous origin, while others maintain that the poison may be generated "^e novo.'''' Some have strenuously maintained that it can be devel- oped by overcrowding and filth ; others, who have seen the largest number of typhus fever cases during the past ten years, maintain that at least it is very doubtful whether typhus fever is ever of spontaneous origin. It is possible to develop a fever from overcrowding, imperfect ventilation, filth, and a combination of causes belonging to this cate- gory, but such an one is a septic fever, and not typhus fever. Some observers have gone so far as to express the opinion that scarlet fever and typhus are closely allied both in their etiology and morbid anatomy, and that typhus fever is no more likely than scarlet fever to be of spontaneous origin. Tlie results of my investigation of the origin of the epidemic of typhus fever which prevailed in this city from July, 1861 to 1861:, have led me to the belief that typhus poison is of endemic origin — in other words, that there are certain endemic centres ; that Ireland, Italy, and Russia are the great centres, and that, whenever it occurs in other locali- ties, it has been conveyed from these endemic centres to those localities. In the month of July, 1861, in one day fourteen cases of typhus fever were admitted to the fever wards of Bellevue Hospital, of which wards I had the charge. Previous to this time, for several years (I think for more than ten years), there had been no case of typhus fever in the wards of the hospital. Immediately I commenced investigations in order to ascertain the origin of the fever in these cases. I found that the fever had its origin in the upper story of a KTIOLOGY. 213 rear teiKMuent-houso in Mulberry Street, in tlie most lillliy portion of the city. The tirst case was that of a little girl, who had been brought into the house, ten days before she siekeued, from a sliij) wliicli iiad come froni Ireland, and which had eases of Lyplius fever on board. Two weeks after her illness commenced, her aunt, the only other occu- pant of the apartments (consisting of a room and dark bed- room), sickened of fever and died. In gradual succession, nearly every family residing in the building took the fever. Becoming frightened, some of these families moved into other streets, formed the nucleus for the development of the disease in the dilferent localities to which th(^y removed, and it soon became a widespread epidemic. There were two hundred typhus fever ])atients at one time in the hos- l)ital. These families were as well nourished and lived in as well ventilated apartments as thousands of their class in other parts of the city. The only difference was that ty})hus poison was brought to them in the person of the little girl, and, on account of their badly ventilated apartments and their utter disregard of all hygienic laws, they furnished a fit soil for the rejjroduction and spread of that tjphus poison, the constant and unrestrained intercourse between the healthy and the sick being the means b}' which the fever was spread. T found unmistakable evidence that ])ersons living in healthy localities, simi)ly by visiting friends sick with the fever, contracted tlie disease. The histories of those cases which were developed within the limits of the hosi)ital showed that a residence in an at- mosphere necessarily more or less tainted with tyi)lius poison is not sufhcient to develop the disease, but that it is necessary for the subject of the contagion to have been brought in contact with an infected person, or within the atmosi)here immediately imi»regnated with his exhalations. The fact that no em))loyee in the hos])ital, who was only brought in contact with the clothing of fever i)atients, con- tracted the disease, as well as the absence of any evidence that the disease was ])roi)agated by such clothing, goes far 214 TYPHUS FEVER. to prove that typlius fever cannot be propagated by fomites alone. The certaint}^ with which every unprotected person who was brought in personal contact with fever patients contracted the disease, proves the contagious power of the poison. The distance that typlius poison can be transmitted through the atmosphere (from the manner in which the disease was contracted by some of the house physicians), would seem to be limited. It has been proved by actual experiment that the contagious distance of small-pox, in the open air, does not exceed two and one-half feet, and it would seem that the contagious distance of typhus fever is even less than two and one-half feet. The question now arises, can this poison be conveyed in the clothing ? During the epidemic to which I have referred, when ty- phus fever patients were brought into the hospital, their clothing was removed in the reception room, and after- wards washed and packed away in a lower room of the building. Upon a most thorough investigation made at that time, I found that not a single person contracted the disease whose duty it was to wash or pack away the clothing ; but every one whose duty it was to carry the fever patients from the reception room to the hospital ward took the fever. Every physician and nurse who had the care of typhus fever patients contracted the disease ; those who were on the surgical service escaped. Every clergyman who came to administer spiritual conso- lation to patients in the fever ward fell a victim to the dis- ease. I have brought forward these facts to show that during this epidemic there was no evidence that the disease was either of spontaneous origin, or that it was transmitted from the sick to the healthy except by direct personal con- tagion. Typhus poison is undoubtedly present in the body exha- lations and the expired air of typhus fever patients ; but it requires a concentration of the poison to render it infec- tious. Slight exposure is not sufficient ; it requires a con- centrated poison and a prolonged exposure. The more nu- ETIOLOGY. 215 merous tlif tyi)lius f.-vrr patients are, tlie more powerful dors the eoiitai^ioii becoiiit.' ; yet a siii.s;le exposure even to SLK'li an atmosphere is rarely siillieient to develop the dis- ease ill ail individual who is in good liealth at the time of the exjiosure. If any of you are so eircumstant-ed as to be obliged to tak.' I lie medical eliarge of typhus fever i)atients, you should make your visits as slujrt as possible, and when you are about to auscultate the eliest of a fever ]nitient, take a full inspiration at an o])en window, and hold your breath while you are listening to the respiratory sounds, never inhale the air from the bed of the patient as you examine the posterior surface of the chest. As a rule, make your visits short to a typhus fever patient, avoid inhaling the exhalations of the body, never make a visit until after eat- ing ; if you observe these simple directions, you will in the majority of instances escape contagion. The length of the period of incubation varies. For the development of the disease, it usually requires about two weeks of exposure, such as comes to one who is around those sick with the fever. Repeatedly have J noticed this fact in my own case. I have never had typhus fever, and have never taken sjjecial care to avoid infection. My im- munity is probably due to some special constitutional idio- S3'ncrasy. I have noticed that whenever I enter upon a typhus fever service, I do not experience any effects from the exposure to typhus poison until about two weeks has elapsed, then I begin to suffer from a peculiar form of head- ache which continues for about two weeks ; the })eriod before tlie commencement of the headache corresponds to the period of incubtition, and the period of headache to the average duration of the disease. At the present day, the estaldished belief is that typhus fever attacks an individual but once, and that those who have had typhoid fever are to a certain degree protected from typhus. Of all the typhus fever patients treated in Bellevue Hospital, only three gave histories of having ])re- viously had the disease. I recall the case of a nnin, seri- ously ill, who was treated in the fever-tents for typhus fever, 216 TYPHUS FEVEE. had tlie cliaracteristic eruption, left the fever-tents well, and in three weeks returned with the fever, and was more seriously ill than during his first attack of the disease. From the facts which I have brought before you, we must reach the following conclusions : First. — That typhus fever is due to a specific poison. Second. — That this poison is communicated from the sick to the healthy only by personal contagion — that is, the recipient of the poison must be brought in contact with the personal exhalations of the infected person. Tliird. — That where there is free ventilation, personal con- tagion is confined to narrow limits. Fourth. — That the evidences of the spontaneous origin of typhus are not conclusive, although there can be no ques- tion but that overcrowding and bad ventilation favor its spread and increase its severity. Fifth. — Typhus poison passes into the body mainly through the respired air. Whether it can be taken into the system in the food and drink is still an unsettled question. LECTURE XIX. TYPHUS FEVER. Symptoms. I WILL continue tlie history of typhus fever by giving you an outline of the phenomena which attend its develop- ment, and afterwards speak of some of its more prominent symptoms. Its advent is usually sudden — there are no constant pre- monitory symptoms. In some cases, for a few days, there may be a feeling of indisposition, jierhaps of headache, loss of appetite, and vertigo ; bur in a large majority of cases it is ushered in by a distinct chill. This differs from the chill of ])neumonia or that of malarial fever, in that it is short, sharp, and sudden. It may amount to nothing more than a chilly sensation. Following the chill there is a severe and steadily increasing headache; it is frontal, and increases in intensity from hour to hour. This is accompanied by a more or less severe pain in the back and limbs, especiall}^ in the thighs. The headache of ty})hus is more constant and persistent than that w hich attends the development of any other fever; usually, after a few days it diminishes in intensity. A sen.se of extreme prostration ver}' soon follows the ushering-in chill. In some cases the patient is com- pelled, within twenty-four hours from the commencement of his sickness, to take to his bed from muscular weakness. 218 TYPHUS FEVER. This loss of muscular power will sometimes sliow itself by the unsteady, tottering gait of the patient, and is more marked in the early stage of typhus fever than it is in any other disease. At one time, while I was making my visit in the fever ward, my house physician, w^ho was sickening from typhus fever, staggered and fell by my side from loss of muscular power. He died on the eighth day of the disease. Within the first twenty-four hours after the chill the tem- perature may rise as high as 105° F. or 106° F., although at the same time the patient may complain of a chilly feeling, and will draw up to the fire or cover himself with blankets. It is a peculiarity of this fever that, during the first two or three days, the patient experiences a sensation of cold- ness, w^iile the thermometer shows the temperature to range at 105° F. or higher. During the first week of the disease the temperature remains at 104° F. or 105° F. There will be morning and evening variations, most marked at noon and midnight ; but these variations follow no regular course, as in typhoid fever. From the eighth to the fourteenth day the temperature is liable to sudden depression. As a rule, the temperature falls between the eighth and four- teenth day. There is, without doubt, a day of crisis in this disease. In typical cases, before the fourteenth day there is a marked decline, and often a sudden fall in temperalTure. By the beginning of the second week the temperature ranges at its highest. If there is a sudden rise in temperature dur- ing the second week, it is almost certain evidence that some complication exists. At first the tongue is swollen and covered with a white coating. It presents very much such an appearance as is seen in many nervous affections. As the disease progresses, after a day or two it assumes a yellowish brown color, and the coating becomes thicker ; later it becomes dry, dark, and fissured. Nausea is sometimes present, rarely vomit- ing. The abdomen is free from pain, except over the liver ; the bowels are constipated. Some enlargement of the spleen can usually be detected quite early. The pulse is accelerated from the very beginning of the SYMPTOMS. 219 fever, ranging from 100 in lli»' morning to 110 or 120 in tho rvciiiim; th." accclcnitiou is grratfr in childrm than in adults. A I the onset of the fever tlie ])nlse is full, l)ut it soon beromt's soft and eompressible, and Jinally feeble. It is rarrly dicrotic. It is only in the severest cases just preced- ing dcalh that till' ])alsi' becomes irregular and intermitting. The face is Hushed, the conjunctivjc injected, the ex])res- sion of countenance is dull and heavy, and as the fever progresses, the cheeks assume a mahogany color. The sleep is disturbed, and when the iiatient is awake his mind is confused ; in very severe cases delirium is very early present. Between the fifth and eighth, usually on the fifth day of the disease, an eru])ti()n makes its appearance ui)on the sur- face. It appears first upon the sides of the al)domen, and gradualh' extends over the whole anterior ])ortion of the body, except the face and hands. It is more marked upon the trunk than on the extremities. At first the eruption consists of dirty pink-colored spots, varying in size from a mere i)oint to three or four lines in dianu?ter. These spots are slightly elevated above the surface, and temporarily dis- appear on iirm ])ressure. After a day or two the eruption becomes darker in color, and assumes a purplish hue. It is no longer elevated above the surface, does not entirely disa])i)ear on firm pressure, and the spots have no well-detined margin. This eruption is made up of irregular spots, varying from a point to two or three lines in diameter, either isolated or grou])ed to- gether in patclies, presenting a very irregular outline ; in children it often resembles the eruption of measles. When the eruption is abundant it imparts to the skin a mottled aspect, which has given rise to the term "mulberry rash of typhus." Another distinctive peculiarity is, that each spot or patch remains visible from its first a])])earanc(; until con- valescence is established or death occurs, and it is often seen upon the bodies of those who have died of typhus fever. In some cases of typhus there are only a few s])ots of the eruption, while in other cases they are very abundant, and 220 TYPHUS FEVER. the surface of the body presents the well-marked mottled appearance. In a certain proportion of cases, after the eruption which I have just described has been visible for a few days, there will appear, scattered over the surface, small dark spots, due to minute subcutaneous hemorrhagic extravasation ; these are called petechise. On this account the disease has been called petechial typhus ; but these petechise are by no means distinctive of typhus, for they are also met with in other diseases. The majority of cases of typhus which you meet will have no eruption except the "mulberry rash." When the petechial spots are ]3resent you will find a more severe form of the disease, and more extensive blood-changes than usual. In all severe cases, at the close of the first week the head- ache, which has been the most troublesome symptom, dis- appears, and delirium comes on. The delirium will vary in character and severity in different epidemics, being much more violent and active in some than in others. Some- times, at the ver}^ outset of the disease, the delirium is very active, the patient shouts and talks more or less inco- herently, and is more or less violent. If not restrained, he may throw himself out of the window. This period of intense nervous excitement may last two or three days, during which the countenance becomes livid, the conjuncti- vae injected, the hands tremulous, and suddenly the patient may pass into a state of apparent coma. It is not that of complete coma, for the patient can be easily aroused ; but he lies upon his back, with a tendency to slip down in bed, picking at the bed-clothes. It is not a state of uncon- sciousness, although one of apparent coma, for tlie mental processes are going on with great activity, and the imagina- tion will conjure up a great variety of liorrid fancies, and the visions which pass before the patient will be distinctly remembered after recovery has taken place. This condition has been called " coma vigil." During this period the ex- perience of years may be crowded into a day or an hour, and the patient may feel that he has lived a lifetime while in this state. Those who have the greatest mental power and possess the highest culture have the most distressing fancies RYMI'TOMS. 221 (lurinLT this soiiiiiohMit iicriod. U", in this condition, tlifiT is a tt'iuh'iicy towards a fatal issuf, the i)ati»'nt will jtass into a inon» coniplt^te stujior. ani)earance. The patient has no longer power to move his body ; he lies on his back with his head thrown back. ])t'rhaps is only able to make slight tremulous motions with his hands. The urine collects in the bladder, and, if not removed with a catheter, dribbles away. The extremi- ties become cold, but the body temperature remains at 105° F., or it may rise as high as 107° F. or 108° F. In one case under my observation it rose to 110° F. just preceding death, while the extremities were cold. If the case is tending to a favorable termination, about the fourteenth day of the fever there is an amelioration of all the symptoms. The patient falls into a quiet sleep, from which he awakes conscious and convalescing. The pulse and temperature fall, the tongue becomes clean and moist, the delirium subsides, and there is a desire for food. After two or three days the pulse reaches its normal standard and strength gradually returns. This is an outline of the prog- ress of the disease in a severe case of typhus fever, termi- nating either in death or in recovery. In a mild case there will lie no delirium. The temperature may nr)t rise above 102° F. ; the tongue is neither brown nor dr3^ There is no great acceleration of the ]uilse, never beating faster than 120 per minute, and that only for a very short j)eri()d. During the entire course of a severe or mild case of ty- phus f»*ver, there is no gastric or intestinal disturbance, no diarrlnra, no distention of the abdomen, no ])ain in tin- right iliac fressure ; then the color of the 15 226 TYPHUS FEVER. spots becomes still darker and darker in hue, and finally they are not affected by firm pressure. Another peculiarity is that each patch or cluster remains visible from its first appearance until the termination of the disease. The erup- tion may appear upon any portion of the body. Usually it first makes its appearance upon the tj-unk, soon spread- ing to the extremities ; ver}^ rarely is it seen on the face. When the eruption is scanty, it is limited to the chest and abdomen. In some patients the eruption, though well de- veloped, is not prominently marked ; the spots are pale and undefined, and though grouped in patches are so irregular that they give to the entire surface a faint, dingy appearance. The question now arises, is the presence of this eruption so constant in typhus fever that by it we may with certainty make the diagnosis of this disease 1 I believe that it may be discovered by a careful examina- tion in nearly every case of typhus fever ; it is more likely to be indistinct in children than in adults. When typhus fever is prevailing, an ephemeral fever is often met with, which has many of the prominent s^anptoms, but not the characteristic eruption of typhus fever. This ephemeral fever or febricula is undoubtedly due to typhus poisoning, yet it is not typhus fever. In a case of fever, where there is a question as regards diagnosis between ty- phus, typhoid, malarial, and septic fever, all of which have many phenomena in common, I should not be willing to make the diagnosis of typhus fever unless the eruption was present. RespvTatioii. — Usually, during the first week, the res- j)irations do not exceed twenty or thirty per minute, but during the second week they often run up to forty or fifty per minute. In cases where there is great prostration ac- companied by stupor, the respirations sometimes fall to eight or ten per minute. Under such circumstances they are often irregular and puffing in character. Hypostatic congestion of the lungs, if extensive, is attended by great frequency of respiration and evidences of cyanosis. The occurrence of these changes in respiration ought always to lead you to make a careful examination of the chest. The SYMPTOM:^. 227 breath of a ty]>hus fever patient lias an odor wliicli closely resembles that exhaled bv the skin. Thi' (I iff est ire sf/stc/ii. which is so icieatiy all'ected in ty- ]>h(»id fever, is v.-ry lilth', if at all, disturlx'd in tyjihiis fever. Nansea and voinitiiiir are rare, and an examination of till' alxlomen presi'nls nothing abnormal. There is no tym))anitis or tenderness ou pressure. Spontaneous diar- rlid'a is of exceedingl}' rare occurrence; the bowels are generally consti]tated. Intestinal InMnorrhage is of rare occurrence, and when it is present depends either upon congestion of the mucous mend)rane of the colon or on hemorrhoids, which accompany an engorged portal circu- lation. Urine. — The urine in typhus undergoes important changes. The quantity varies somewhat with the amount of fluid taken into the stomach ; usually it is diminished during the iirst week, sometimes to one-fourth the normal quantity. In the advanced stage of severe cases there is sometimes complete suppression of urine, but more fre- quently the quantity of urine increases during the later stages of the fever. The quantity of urea excreted in twenty-four hours dur- ing the first few days of the fever is increased, and the in- crease is in ])roportion to the intensity of the fever. In the majority of cases it remains abnornuilly increased until the period of crisis is reached (about the fourteenth day), when it gradually, or in some instances ra])idly, falls below the normal standard. In all severe cases, during the first week of the disease, a small amount of albumen is always found in the urine ; when the quantity is large, the case may be regarded as very severe. In the severer cases the urine will also be found to con- tain vesical and renal ejnthelium, and when the (piantity of albumen is large, epithelial and fatty casts of the urinifer- ous tubes will l)e ]>resent. In this connection it is important to bear in mind the ne- cessity of daily inquiry' into the expulsive power of the bladder. When there is little cerebral disturbance, the 228 TYPHUS FEVER. urine is passed witliout difficulty ; bnt wlieii stupor and a tendency to coma exist, there is often retention or an involuntary dribbling of urine, wliicli might lead one to think that there was no accumulation of urine in the bladder. It is safe to inquire, at least once a day, as to the state of this organ, and if involuntary discharges of urine occur, the contents of the bladder should be evacuated by means of a catheter. LECTURE XX. TYPHUS FEVER. Sympfovis.— Differential Diagnosis^. —Pror/nosis. This inoniiiii;- I Avill si)eak of the complications of typhus fever, and its differential diagnosis. In typhus as well as in typhoid fever, you must be pre- pared for the occurrence of com plications. Altliough they do not properly belong to tlic primary disease, yet they so modify it that they enter very largely into its history. Reference has already been made to them under tlie lunid of anatomical lesions, yet it is necessary that I should again speak of them under the head of symptoms. In a large number of cases which terminate fatally, drath is due to some one of these complications. Most of these commence before the cessation of the primary fever; oc- casionally convalescence is interrupted by their occur- rence, and indefinitely prolonged. Doubtless, in in;iiiy in- stances, tln'y de])end upon the weaken. 'd condition of the lieart induced by the ty])lius poison. In some r])idemics they are all pulmonary; in others they are all c.'r.'bral. The advent of i)ulmonary complications in this fever is al- ways insidious ; tin; cough and expectoration which usually attend pulmonary diseases are either absent, or so slight as not to attract the attention of the physician. Frequently, rapid l)r<'atiiing and lividity of the face are the first obvious indications of extensive disease of the lungs. When these symi)toms are prescMit, a careful ]»hysi- cal examination of the chest should be madf. 230 TYPHUS FEYEK. Broncliith may come on at any period during tlie fever, and it may continue after the fever has subsided. So long as it is confined to the larger tubes there is little danger, but sometimes suddenly and insidiously it extends into the smaller tubes and is complicated with pulmonar}^ congestion and oedema. Under such circumstances it may be the direct cause of death. The pneumonia which comi)licates typhus fever is lobular in character, and frequently is preceded or accompanied by bronchitis. It has a tendency to terminate in abscess or gangrene. During life it is not always possible to distin- guish it from hypostatic congestion. If, however, the dul- ness on percussion is confined to one lung, if the respiration is bronchial and the pneumonic sputa is present, the pneu- monia is readily established. The seat of the pneumonia is generally at the upper portion of the lung. Laryngitis is sometimes a very serious complication of typhus. It may be croupous in character, but the more common form is that of acute oedema glottidis. Its occur- rence is readily recognized by the signs of laryngeal obstruc- tion which attend its development. Whenever 3-ou meet with extensive swelling of the glands about the neck, with great tumefaction of the mucous membrane of the pharynx, you must be on the watch for the occurrence of this compli- cation. On account of the extensive blood-changes which some- times occur in severe cases of typhus fever, the blood readily escapes through the walls of the vessels, giving rise to ex- tensive hemorrhages from the mucous surfaces and into the cellular tissue. The occurrence of the hemorrhages is pecu- liar to certain epidemics, and when they occur it is during the first week of the fever. Meningitis is the only cerebral complication which you will probably meet with in this fever. This occurs more frequently in children than in adults, and is not present in every epidemic. The cerebral symptoms, which are such constant attendants upon typhus fever (as I have already stated), do not depend upon meningeal inflammation ; thpy belong to the regular history of the disease. If, during the SYMrTOM>?. 231 coiirso of tho fever, tlinv is a (Icrp-seatcd ]):iiM in tin* licad, with ivstU'Ssncss, wliich siiows itself by a coii-laiil atttMiii)t, to r ])r('srnr in tyi)hiis fever. Mcniiu/ifis. 'I'hf (lilVcivntial tlian'nosis betweni tyjiliiis fever and (•tM-t'bro-s})iiial ini'iiiii,i;itis is difHciilt. Not iiii- frequeutly, days may elai)se bcfon; you are abh; to decide whether a case is one of typlius fever or of cerebro-spinal meningitis. To show liow ditricult is the dia,2;nosis between these two affections, I will mention a circumstance which occurred a short time since in l^M'llevue Hospital. A pa- tient was brought into the hos])ital directly from a slop, and the diagnosis of cerebro-s])inal meningitis was made by several of the att^mding staff ; but at the autopsy there were found none of the lesions of meningitis, but all the changes corresponded to those found at the autopsies of patients dying of typlius fever. Yet there are many distinguishing points of difference between the two diseases. The headache of meningitis, at the outset of the disease, is more distressing than that of ty- phus, and it alternates with delirium. These are the early sym])toins of meningitis. When delirium com(>s on in ty- l)hus fever, the pain in the liead ceases. Pliotophobia and contracted pupils are among the early symptoms of meningitis, and the patient is greatly dis- turlx'd by noise, while in typhus fever he seems indifferent to both. Inequality oC the pupils, strabismus, ptosis, and ])aralvsis are common in meningitis and ran? in typhus. In meningitis the countenance is expressive of ])ain, wild- ness, and anxiety ; in tyi)lius f.-vi-i- ir is l)lank and stupid. Again, in m^'uingitis the ])ulse is lirst slow and full, then rai)id and irregular, and lastly intermitting ; while in typhus fever it is lapid at the outset of the disease, and is easil}' compressed. Lastly, the eruittiou of typhus fcviT js diaractfristic. If an eruption is present in nu'iiingitis, it has no regularity in its development ; it may a])))ear within twenty-four hours after the development of the lirst symi)tom of the 234 TYPHUS FEVER. disease, or it may be postponed for several days, or it may not appear at all. It does not appear on the fifth or sixth day of the disease, with the nniform regularity of the erup- tion of typhus fever. You may find petechia? in meningitis as well as in typhus fever, but, as I have already told you, tluy are not characteristic of the latter disease. The temperature rises more rapidly in typhus fever than in meningitis, and reaches a higher range. Rigidity of the muscles of the neck is not always positive evidence of meningitis, for sometimes it occurs in typhus fever. Pneumonia. — Sometimes a latent pneumonia with ty- phoid symptoms is mistaken for typhus fever ; especially is this the case when the latter is prevailing. I frequently saw cases where such a mistake had been made, while in charge of the typhus fever patients on Blackwell's Island, during the epidemic to which reference has been made. In these cases you will have active typhoid symptoms, such as dry tongue, delirium, high temperature, etc. The countenance in this pneumonia, although the cheeks may have a purplish hue, does not exhibit that dull, heavy expression so commonly seen in typhus fever. Although there may be delirium in both instances, the delirium in the former disease is of a milder type than in the latter. The characteristic pneumonic expectoration is not usually pres- ent in these cases, and you must not therefore rely upon that symptom in making your differential diagnosis. The physical signs of pulmonic consolidation will lead you to pneumonia, and, unless the typhus eruption is present, this will be sufficient for a diagnosis. If pulmonary con- solidation is a complication of typhus fever, it will not be developed until after the sixth day of the fever, the time when the eruption should have appeared. If no eruption is present, the pneumonic consolidation may be regarded as the primary affection, and the symptoms which simulated those of typhus fever may be regarded as secondary. Delirium Tremens.— T[\^i delirium of "delirium tremens" may sometimes so closely resemble that of typhus fever, that the one may be mistaken for the other. The mistake has been made in Bellevue Hospital, and typhus fever pa- DIFFKKKNTIAI, I>I ACXO.SIfl, 23.") tients liavr Ix-.-n phic'd in tin- cells, sii])])()sin^ tln'in to bo casi's of (Iclirinin hvmcii^. If iIm' *-(ltTirimii ri-cinrns" is iiiu'oin])licaft'(l hy |mfimi(ini:i, l:ik<-tlic tciiipi'iat iiic of tho patieiii ; tlhii ii will Itc very easy to make :i (lilTcrential (.liairiiosis. for in "(Idirium trciiKMis" the fcmjMMatiire is rarely above lOO" F., while in lypliiis fever willi (leljriiim tlie tlieniioiiietrieal ian,<;e is 104° F. or 105" F. You may have a rai)i(l jmlse in (h'lirium tremens, and often the patient lias a brown, dry tonuiie. and other typhoid synqitoms ; but there is only a sliu'lir rise in temiterat ure ; besides, tlu're is no eru])tion ])resent. The attaclv is not nsliered in by lieadache, but by an inability to slet'}), and the circum- stances which })recede and give rise to such an attack will establish beyond a dou1)t the true nature of the attack. Acuti' Bri(/hf'!< I>isr((se. — It is not surprising that acute urjcmia from acute parenchymatous nephritis should be mistaken for tyi)hus fever. The brown, dry tongue, the tendency to stupor, the contracted pupil, the low mutter- ing delirium, and all the phenomena of the typhoid state, as well as the albuminous urine, belong to both diseases ; but the temperature is not raised in unemia as it is in typhus fever, and the cpdema which is always present in acute uraemia is absent in typhus fever. Erysipelas, pyaMuia, septictpmia, and all similar acute blood diseases are often attended by many of the symptoms which attend tin? development of ty})hus fever. In pyaMuia and sei)tica'mia you have irregular chills, followed by fever and })rofuse sweats, with evidences of septic and ]iya'inic ])oisoning ; in erysipelas, you have the evidences of a localized i)hlegmon. You must remember that erysipelas is sometimes ushered in by all the phenomena that attend the ushering in of typhus fever; this is before the local inflammation shows itself. In such cases it is im- possible to make a difl*erential diagnosis until the local phenomena which chaiacterize erysipelas show themselves, or until the typhus eiuption apiiears. In many of the acute infectious diseases you will be comi»elled to wait until the time for the a])p-'aiance of the erui>ti(»n before you can ex- clude tyi»hiis fever. 236 TYPHUS FEVEE. When typlins fever is prevailing, and yon are M^atchful in regard to its appearance, you will usually have little difficult}^ in diagnosis. You must alway bear in mind that sometimes typhoid, typhus, and relapsing fever prevail at the same time, in the same locality. The importance of early forming a correct differential diagnosis between typhus and typhoid fever cannot be over- estimated; and in order that you may be the better able to accomplish this, I will now review the prominent symptoms of each, and compare them. By so doing, we shall review their etiology, morbid anatomy, etc. The first point to be considered in the differential diag- nosis of these two diseases is, that typhus fever is sudden in its advent, while typhoid fever comes on insidiously, and is slowly developed. In the majority of cases of the former disease there is a chill at the commencement, and severe pain in the head, whereas in the latter there is only a chilli- ness, some aching in the limbs, and a slight headache. Muscular prostration and progressive muscular weakness appear earlier and are much more marked in typhus than in typhoid. Second. — The range of temperature in the two forms of fever greatly differs. For example, in typhoid fever we commence on the first day with a slight rise in temperature, which continues, with morning remissions and evening exacerbations, until the end of the first week, when it has reached its highest point ; during the second week it re- mains at about the same degree, with only slight variations ; during the third week there are more marked morning re- missions ; and by the end of the fourth week the tempera- ture has reached its normal standard. In typhus fever, the temperature rises rapidly, and before the end of the second day reaches 104° F. or 105° F. Whatever degree is reached on the third day may be re- garded as the maximum temperature ; after this time there are slight, in-egular variations until the tenth or twelfth day, when the temperature begins to fall, and rapidly reaches the normal standard. DirFKKKXTIAL IHAOXOSIS. 2:"57 T/{ird.—Thi.':iv two f(.iiiis of frv.-r dilTcr \ovy ni:nk-'on the loins when it cannot be found on any otlier part of the body. As a rule, the spots in typhus are nu- merous ; while in typhoid they are not very abundant. In typhus fever, at first the spots are small, slightly ele- vated, of a dark pinkish hue, and disappear only on lirm pressure. As the disease advances they become darker, and linally are not affected by firm pressure and remain visible from the time of their appearance until death occurs or convalescence is established. In typhoid fever each spot is rose-colored, slightly elevated, and disai)pears on slight pressure. Each spot remains visible for tliree da^^s and then disappears, to be followed by another crop. Usu- ally, the eruption is visible about two weeks, and when it disai>pears leaves the skin unstained, whereas in typhus the eruption disappears and leaves a stain upon the surface. There is a mottling of the surface in tyi)hus fever which is not seen in typhoid, and has been described as the i/iul- herry rash. It would seem as though a differential diagnosis might be as easily made between the eru])tion of these two forms of fever as between the eruption of measles and that of scarla- tina. There ma}^ be cases which will cause you to hesitate as regards diagnosis, but wlien the eruption is developed there need be no (.question as to which form of fever it be- longs. Fourth. — The brain symptoms in these two diseases also differ. In tyi)hus fever they api»ear early, and the head- ache and delirium are more Intense than in ty])hoid. Deli- rium in tyjilioid more commonly appears at the end of the second or during the thiid week of the disease ; whereas ill 238 TYPHUS FEVEK. typlms it appears early, and before tlie end of the second week lias disappeared if recovery is to take place. Fifth. — As a rule, in typhus fever constipation is present, and you will be obliged to make use of some mild cathartic in order to move the bowels ; whereas in typhoid fever diar- rhcEa is one of the prominent symptoms. Tympanitic distention of the abdomen, gurgling, and ten- derness in the right iliac fossa3, and perhaps intestinal hemorrhage, are all phenomena of typhoid fever, but are never present in t^'phus fever. ^/^^7i.— Another point in differential diagnosis relates to the duration of the fever, and here we have a marked differ- ence. In tj'phus fever, usually convalescence will be established before the end of the second week ; some say the tenth is the critical day, but I think it may be any day between the eighth and fourteenth. The average duration of typhus then may be regarded as fourteen days ; whereas in typhoid fever the average duration is from twenty-one to thirty days ; twenty-one the minimum, and thirty the maximum number of days. >Sfe?)d?i^7i.— Typhus fever is contagious ; typhoid fever is non-contagious. Typhus fever is due to an animal poison ; typhoid fever is due to an animal poison developed in con- nection with vegetable decomposition. The fact that one is contagious and the other non-con- tagious renders the differential diagnosis of great importance. Elglitli. — When we come to the pathological lesions, and consider the manner in which death occurs in these two forms of fever, we readily see how widely they differ. The characteristic pathological lesions of typhoid fever are the changes which take place in the intestinal glands, such as ulceration or tendency to ulceration. In all cases these characteristic lesions are present. Suppose 3^ou have a case of what you have called typhoid fever, and you follow it to the dead-house, but do not find ulceration or evidences of a tendency to ulceration of Peyer's patches, then you may be quite sure that you have made a mistake in diagnosis. Tf, oil llir ollhT liaiid, voii li:iv<' :i case of su|)})os('(l typhus fcNcr. ;i!i(l you I'dllow ii lo i lie (Iriid-housc, and liiul iilct'ialioii of Tcyi r's it;itfli«-s, you iu:iy be eciiially ct'i'taiii that you have iiKuh' a iiiisiakf, niul tliat you liave hccu treating: a ('as«» of I yplioid, and iiol lyjihus fever. The ])ari'iichymatous chiiimcs wliirh ar<' coiunioii to lioth diseases have aheady been sulHcit'iii |y roiisiih-ird. LastJij. — Tyjihus fever is i;"eiiei'ally e])i(h'iuic ; t\]ihoid is always endeniic. lu regard to the ])rotectioH wliich one attack of ty])]ius fever furnishes a'e general causes : Fh'fii. — From coma. This is the result of ovei wli.'lming the system with ty])hus })oison. The ])atient does not die from the effect of a prolonged high t«'mj)erature, nor from complication, but dies as i)atients die in acute uraemia, because the system is overwhelmed by the typhus poison, and the functions of organic life are arrested by its action on the nerve-centres. 240 TYPHUS FEVER. Second.— J) eat\i may occur from syncope due to heart failure, whether the heart failure is the result of the pro- longed high temperature, or the direct action of the typhus poison. A continued temperature of 105° F. or 106° F. is very liable to be followed by fatal syncope from failure of heart power, although the evidences of parenchymatous degeneration of the heart may not be present. ^/^/^yZ.— Death may occur from complication. Let us now study in detail the individual symptoms and signs which render the prognosis unfavorable. A imlse of more than 120 per minute, continuing a num- ber of days, intermittent, and sometimes irregular, bespeaks an unfavorable prognosis. A hurried and difficult respiration, with turgidity of the face, due either to cerebral or pulmonary oedema, renders the prognosis unfavorable. Delirium which is very active and accompanied by great muscular prostration, as indicated "by subsultus, slipping down in the bed, and accompanied by that condition known as " coma vigil," lasting for a number of days, is almost a certain indication of a fatal termination. The " pin-hole pupil " mentioned by the old writers is an unfavorable omen. It does not necessarily indicate the presence of meningitis, as was once supposed. Great mus- cular prostration at the very onset of the disease renders the prognosis unfavorable. Marked impairment of the special senses, accompanied by very great rapidity of the pulse, is an element of unfavor- able prognosis. The more abundant and the darker colored the eruption, especially if accompanied by petechial spots, the more un- favorable the prognosis. In children the eruption is lighter in color than it is in adults, presenting an appearance similar to the typhoid eruption. In adult cases, where there is dark mottling of the surface confined to the ex- tremities, with evidences of blood extravasation, indicated by the presence of petechise, your prognosis must be un- favorable, but the case is by no means hopeless. A dry, brown, retracted, tremulous tongue is seen only in riKxiNosis. 241 sovorc cases. A lon.sx-contiiuK'd lii.irli t<'in]v'ratiin> is always an niirav<)ral»l(' syiiii>t»)ni. (in-at (liiniiiutioii in tlic (iuantity of uriiK' is an unfavoiaMf symitl<»ni, as is also th»» i)resence of casts and all)nnirn in tlh' niinc. Itrtcntion of urine is a nioiv unfavoialilt' syniittoin tlian incontiiifnce of urine ; convulsions and coma an- liaMr to follow such retention. You must renu'inber that in tyi)hus ffver, more than in anv <»ther disease, the ])ati('nt may ])ass into an a]»i»arently liojH'less condition, and alieiwanls rally and recover. A patient who sei'nis to be overwhelmed with the poison, who has '-conui vigil,'' "pin-hole jjupils," rolling of the tongue, and a feeble, irregular, but intermitting pulse, may recover, although these symptoms warrant an unfavorable i)rognosis. "Coma vigil," more tliau any single sym])tom, warrants an unfavorable prognosis. Thi^ first indicution of recovery is a diminution in the fre- quency of the pulse. The pulse may have been 120, but on the tenth, twelfth, or fourteenth day, it begins to diminish in frequency. The tongue has been brown and dry, sub- sultus and delirium may have been present, even "coma vigil" may have manifested itself ; there has been great muscular jn-ostration ; the patient, attem])ting to rise from the bed, may have fallen upon the Hoor ; now, the pulse begins to get slower, the patient falls into a refreshing sleep and awakes perfectly conscious ; his countenance is changed from the dusky hue to an almost natural api)earance, and he desires food. In other words, within twenty-four hours an entire change comes over the patient, and that change is first indicated by a diminution in the frequency of the i)ulse, accompanied by a fall in temi)erature. The fall in tempera- ture is not extreme; perhai)s a fall of two degrees is first noticed. My experience goes to show that there is an attemjit at convalescence npon the eighth day of the fever. Especially in those cases that recover, u])on that day you will notice a slight fall in temperature, although the temperature may again rise ; upon the twelfth or fourteenth day there is a distinct fall in tem])eratureand diminution in the fre(piency of the ])ulse that is indicative of convalescence. IG 242 TYPHUS FEVER. The mode of recovery in these two forms of fever, typhus and typhoid, is perhaps tlie most distinguishing clinical feature. In typhus, recovery is rapid ; while in typhoid it is markedly slow. Of all the conditions which influence the prognosis in ty- phus fever, age and tlie liahits of the patient have as great, if not greater, influence than any other. I am convinced of this from an experience in the care of typhus fever patients which dates back almost to the very commencement of my study of medicine, for very early did I have the care of a typhus fever ward. In children, typhus fever is a very simple form of disease. The rate of mortality is very low. I remember having the care of sixty children with typhus fever, and among these only one death occurred. This is as low a rate of mortality as you can expect in measles. When the patient has passed the middle period of life, there is great danger from typhus fever. So with the in- temperate, and those who have lived amid unfavorable hy- gienic surroundings. The bright, educated person, the one with an active brain, is less likely to recover than is the stupid, uneducated one. For example, the hod-carriers may have the worst type of typhus fever, and pass through it with safety, stupid when they contract the disease, and stupid when they get well. Let a man with an active brain contract the disease, and the '■'' coma mgiV comes on, the imagination is vivid; failure of heart power is present early, and death is almost certain to follow. LECTURl] XXI. TYPHUS FEVER. Trent iiirnt. I HAVE already completed the history of typhus fever, with the exception of its treatment, and now invite atten- tion to the more prominent measures which have been and now are employed in its management. You will notice that in many respects these measures are similar to those pro- posed for the management of typhoid fever patients, yet the treatment of these two diseases differs in certain essential particulars. When the symptoms are mild, very simple measures are all that is required. Of these, confincincut to bed, cooling drinks, mild aperients, a milk diet, and free ventilation are tlie chief, and, indeed, all that is required. It is alsi) important to observe the sam(> rules in regard to tln' arrangement of tlie sick-room \vlii( li were recommended in the case of typhoid fever patients. Tlie more perfect the ventilation, the great«'r the atnouiit of fresh air around the patient, the better his chances for recovery. The majority of cases of typlius fever are usiiered in by active, and severe symptoms, such as would tempt one to adopt a vigorous plan of treatment — symptoms which at one time were thouirht to indicate the employment of lieroic antiphlogistic measures. You must remember that these active symptoms are due to the effect produced on the ner- vous system by a jioison contained in tin* circulating blood, and that this cannot be eliminated by any means of which 244 TYPHUS FEVER. we have any accurate knowledge, certainly not by vomit- ing, purging, sweating, or bleeding. AVitli these symptoms there is great prostration of the vital powers and a rapid metamorphosis of tissue. Although the symptoms seem urgent, and the patient has a flushed face, a rapid pulse, congested conjunctivae, and a high temperature, not a sin- gle measure must be resorted to which has a tendency to diminish the vitality of your patient. Dr. Tweede, of Lon- don, states, as the summing up of his experience upon tins point, that although at one time he supposed bleeding and the so-called antiphlogistic remedies were necessities in the treatment of typhus fever, yet for the past ten or fifteen years he has not seen a single case in which depletive measures were admissible. Writers upon this disease usually consider its treatment under two heads— the preventive and curative. I prefer to use the terms prophylactic and remedial or medicinal, for I question our ability to cure disease. You can do much to prevent the development of many diseases, and, as guardians of the public health, this will constitute an important part in the active labor of your pro- fession. How, then, can you prevent the development of typhus fever % Medical skill cannot prevent the importation of the disease into localities where it is not indigenous. This is beyond the power of medical men, for it is controlled by state and national authority. Consequently typhus fever will probably continue to be imported into districts where it does not originate. For example, we shall occasionally see the disease in tliis city; it may appear in any of our commercial seaports, and from them it may be carried into the interior. Yet we can do much to prevent its spread after it is imported, and can prevent its development as an epidemic when it is car- ried into any locality in the interior. It is important that the flrst case or cases of typhus fever which are developed in any locality should be closely watched. They should be immediately quarantined. The dwellings in which the fever has broken out should be depopulated, that is, in a tene- TKKATMKNT. 21.1 incnt-lioiist' in wliicli the ffvcr has iiiadc its ri])])(>ai:m('<', all the ramilii'S shoiikl be removed, and the house should Ix' thoroughly disinfected. The disiiir.'ctioii must l)e ihoiou-li. not for a few houi-s, hut foi- one or two days, and afterwards the house should remaiu open for tlu; free circulation of air for a considerable length of time before persons shouhl be allowed to again inhabit the rooms. Before we conclude the subject of treatment you will see the importance of following these directions. If typhus fever occurs in the dAvellings of the wealthy, tlieir houses must be quarantined. All persons must be prevented from visiting them, and. all persons within the dwelling must be prevented from going abroad. After the sick have recovered, there must be the same thorough disin- fection as in the tenement house. All these regulations must be as carefully observed among the rich as among the poor. It is the rule, that though a person may be well fed, well clothed, and well housed, and be ever so cleanly, yet if brought in contact with the ])oi- son of typhus fever for a sufficient length of time he will contract the disease. Usually, in epidemics of typhus fever there are certain foci from which the dis(^ase spreads. Perhaps the points from which the contagion more especially emanates are within an area of half a mile square, and yet the disease may have lieen prevailing for two, three, or even four months. Under such circumstances it is possible to ])revent the spread of the fever by the means just indicated. As far as its manag(Mnent in iios])itals is concerned, I would say you sliould never undertake it within brick or stone enclosures. If possible, patients should be ]>laced in lu-oad ])avilions or tents, so that the largest ])ossible amount of fresh air shall be in circulation about them. It is not sufficient to have free ventilation in t h-- ordinary acce])talion of that tei-m. The opening of a window will not ac('om])lish the desired result. Remove all the windows in a room, re- gardless of the cold, and cover the ])atienis with a >n(licieut nundier of l)lankets to ke-.']) them warm. Allow fnsli air to surround them. 246 TYPHUS FEVEE. There are certain conditions wliicli predispose to the de- velopment of typhus fever, such as the conditions caused by interference with nutrition, by want of cleanliness, bad ventilation, want of food, and habits of intemperance. In Ireland, when famine occurs, then the people suffer most from typhus fever ; then it prevails as an epidemic. When it prevails epidemically in Ireland, then we aie al- most certain to receive a certain number of cases in New York. Fatigue, anxiety, and anything which tends to lower the vitality of an individual render him susceptible to the in- fluence of typhus fever poison. Remember this, and also what I have before told you in regard to eating before you enter a ward filled with typhus fever patients. When the typhus fever manifests itself you can now understand how important it is that the guardians of the poor should not only enforce cleanliness, but that they should feed the poor better than at other times. If cleanli- ness is observed, the dwellings thoroughly disinfected, and the poor well fed, the most virulent epidemic can soon be stayed. The effects produced by such measures are some- times wonderful. In the year 1861, at the commencement of the epidemic, when, as I have before stated, the first case occurred in a tenement-house in one of our down- town streets, it was six weeks before it spread from that locality. The spread of the fever should have been stopped at that point ; but very little attention was paid to it, and it began to spread from one point to another, until some six or seven thousand cases were developed. Many of our prominent citizens sickened with the fever and died. This epidemic could have been pre- vented had measures been taken early to prevent the spread of the disease. It seemed to me that our city authorities were responsible for a large proportion of the deaths which occurred during the prevalence of that epidemic. We now come to the medicinal treatment of this disease. Medicinal Teeatment. — As I have already stated, medi- cines are powerless either to arrest the j)rogress or shorten the duration of this fever. TUKAl'MKNT. 247 Tlie iirst point wliicli I sli.-ill discuss iiiultM- tliis lifui"! re- lates to iKMitraliziiii!; the jxtisoii. This, many authors chiim, can be doiif, ami tlie progress of the disease thus be ar- rested. In my own experience I have found no medicinal agent wliich can neutralize or destroy ty])lnis ])oison, or wliicji has powei- to arrest the progress or shorten the dura- tion of tliis fevtr. DiU'ereut remedial agents liav»' been i)ro- posed for the acconiplishTueiit of this result, aceoiding to the views held in regard to the nature of the t3-phus poisc^n, and its effects upon the system. At one time the mineial acids wei-e supposcr'd to possess this power, and were administered for that ])ur])o;ir a statciiit'iit alivndy mad**, tliat 1 ht'lleve quiniiif to l)t* tlu' more i)o\v('rriil antipyretic of tlie two argents. You will find that tlic temperature rises more quickly in ty])hus than in typhoid, after it has l)een reduced l>y l\u; cold bath, and all through the early jtari of the fever you will be (»bli<::ed to resort to the bath much mon; frequently than in typhoid. The mh's for the administration oC the baths in lyjihns fever diifer somewhat from those that govern you in ty ])hoid. In typhus fever, as soon as the temperature of the patient rises to 104° F., he must be placed in a bath the tempera- ture of which is about ten degrees below that of the patient ; gradually, by the addition of ice or ice- water, bring the tem- perature* of the bath down to 68^ F. or 70° F. The patient must be kept in the bath until his temperature falls to 101° F. or 10"2° F., then taken out, quickly dried and placed in bed. For some time after the removal from the bath, the axillary temperature will continue to fall, as the trunk parts with heat to the extremities. As soon as the tem- perature rises again to 104° F., the patient must receive another bath. If the patient is suffering with intense pain in the head, or is actively delirious during the bath, ice-bags may often be ap])lied to the head with benefit. If the cold baths do not readily reduce the patient's tem- perature, or if the fall is of short duration, antipyretic doses of quinine must be administered, according to the rules given for its administration in the treatment of typhoid fever. As soon as you have passed the first week of the disease, having kept the patient's temperature below 103° F., usu- ally it will not be necessary or advisable to continue the l)aths. In most cases antipyretic doses of quinine will l)e found sufficient to keep down the temperature, JVoio, if not l)efore, there will be evidem'e of h(\art failure, and the question presents itself. Shall alcoholic stimulants beadmin- istered? In tliis connection 1 will mention tlie rules which have governed the profession in the administration of stim- ulants in ty])hu< f<'ver. 250 TYPHUS FEVER. The liistory of alcoholic stimulants in the treatment of typhus fever dates back about forty years, to the teachings of Graves andStokes, since which time until quite recently tliey have constituted an important element in the treat- ment of this fever, receiving the approval of almost the en- tire profession. Even at the present day the habit of ad- ministering alcohol in large quantities in fever, and not unfrequently in an injudicious manner, has become almost universal. Most writers have regarded a frequent feeble pulse, with feeble cardiac impulse, even though cerebral symptoms may be present, as certainly indicating the ad- ministration of alcoholic stimulants. The directions were, to commence their administration early, and in sufficient quantities to control the pulse. It was thought that the earlier their administration commenced, the better the chance for recovery, as the failure of heart power, which makes its appearance in the later stages of typhus, would be pre- vented. iSTo limit was given as to the quantity to be ad- ministered; and when typhus fever was treated in Belle vue Hospital, not unfrequently it was forty or fifty ounces of whiskey administered in divided doses within twenty-four hours. The object to be accomplished was control of the pulse. This could in most cases be done for a time, but as the dis- ease advanced, and the patient became more and more over- whelmed by the typhus poison, alcohol lost the power of giving force to the pulse. Under such circumstances, the rule was to give it ad libitum, for alcohol was regarded as the only agent by which the life of the patient could be saved. I remember administering from a pint to a quart of brandy to a fever patient within twenty-four hours. Now, what is the effect produced by the administration of large quantities of alcohol into the system \ After carefully studying for two years the action of alco- hol on typhus fever patients, I became convinced that in some patients, if not in all those who were severely ill, especially where there was interference with the function of the kidneys, its beneficial effects Avere doubtful, if its action was not decidedly injurious. That stimulants will control TUKATMKXT. 251 llir-|)uls(' and sustain the licarfs action for a time, there (.•an be no question; l)ul 1 found that in ail scviTe cases there canu' a liiiir wlim alcnliol. in iioucvri' lai'.i^e doses it was •••ivcn, ei'asrd to have tliis power. I'x-sich's, it must he renieniber.'d that larn-e (|uaiitities of alcoliol thus admin- istered disinrl) nuliiiion, h'ssen secretion, i)r('V('iit tlicrlinii- nation of mva, and tend to induce a slate of c(jnui whicli cannot n-adiiy be distinuuished from tliat induced ))y the disease itself; allofwhicli imisi necessarily greatly increase the danger of ;i fatal lennination. During the prevalence of the last ei)id('mic of typhus fever, I took charge of the fever-tents on Blackwell's Island, with tlu> intention of testing the effect of the wilhdiawal of stimulants in the treatment of typlius fever. In my earlier professional life I was thoroughly imbued with the idea (for I was ahnost born into the profession from a tyjihus fever ward) that alcohol was a necessity in the treatment of typhus. My house i^hysician, Dr. Engs, Avho took the immediate care of the fever-tents under my direction, had had a large experience in the treatment of typhus fever in Bellevue IIosi)ital, had there contracted the disease, and believed that his life had been saved by the free use of stimulants. As we assumed the charge of tln^ tents I ordered that no stimulants nor medicines should ])e administered to any inniatt} of the tents. The cases, as they were brought into the tents from the city, were of as severe a type as any wc had treated in rx'lle- vue nos))ilal ; sonn* were in a state of coma, with an im])er- cejitible radial pulse, and all the signs of si)eedy dissolution, —conditions which I had been educated to regard as most certainly indicating the free administration of stimulants. The rule which I established was faithfully carried out with the following results : W hih- t he fever was in Bellevue, the ratio of mortality was one death in every five ; and in th<' tents, one in sixteen. I do not claim that the great diminution in the ratio of moitality in the tents, as com] >a red with that of Bellevue nosi)ital, wasdu^' to the non-adminis- tration of stimulants in the one case, and their free aduiin- 252 TYPHUS FEVEPw istration in the otlier. I do, however, most certainly affirm that my experiments in tlie tents convinced me tliat the beneficial effects which had been ascribed to the use of alco- hol in typhus fever were not fairly due to it. Although I would not entirely discard the use of alcohol in the treat- ment of typhus, still I would greatly limit its use and give it only as an occasional aid, to carry my patient over some peculiar time of danger from heart failure. Typhus fever patients under twenty-five years of age rarel}" require or are benefited by alcohol, unless they were of intemperate habits prior to the attack. To the old and feeble its occasional administration may be of great benefit, and at times be the means of saving life. A copious dark eruption, with coldness of the extremi- ties, specially indicates the use of alcohol. As a rule, delirium, headache, scanty urine, and intense heat of surface contra-indicate the use of alcohol. In any case when you decide to administer alcohol, care- fully watch the effect of the first few doses ; the same rules should govern yow that were laid down for the administra- tion of stimulants in typhoid fever. It is impossible to give any positive instructions as regards the quantity of stimu- lants required in each case. It is very rarely necessary at any time during the fever to give more than eight ounces of brandy during twenty-four hours. If this amount will not sustain the heart power, I am confident larger quantities will fail to do it, and also that such administration has hastened the fatal issue. As soon as the symptoms, on account of which the alco- hol may have been resorted to, are relieved, the quantity must be reduced, or its administration altogether stopped. I do not altogether condemn the use of stimulants in t3-phus fever, but I do so as regards stimulants as a plan of treatment ; and, where the patient can be freely exposed to fresh air, I doubt if their use is often required. To diminish the frequency of the pulse, when it follows the reduction of the temperature by the application of cold to the surface, and the administration of quinine in anti- pyretic doses, cardiac sedatives have been employed, such TliHATMKNT. 2.")3 as veratruni, aconite, uiul dii;lt:vlis. The ra])id puis*; in t3'i)lius l\'V('i\ aftt'i- the first onset of the disease, ol'lfii is not due to the hi,u-li t<'iiiii<'ialm<', l)iil l<» i\u- failiiiv of In-art power; when such is the ease, digitalis sh(juld be <'iu- ployed. Digitalis diuiiuishes the rretjueiu'y of the i)ulse, by increasing the i)t)wer of ilir li< ait, and at the same time it increases the secretion of urine, wliich frequently is scanty, and tlius, to a limited extent, becomes an elimina- tive. From four to six drachms of thi' infusion of digitalis may often be given with beneht during twenty-four hours. If the heart power cannot be sustained b}^ the moderate use of stimulants and by digitalis given as indicated, we are helpless so far as remedial agents are concerned. The treatment of the special symptoms of typhus fever require only a passing notice. The headache, when intense, is best relieved by cold api)lications in the form of ice-bags. If it is accompanied by intolerance of light, a blister to the back of the neck will be found to give relief. Sleeplessness in any stage of the disease, if it continues for two or three da^^s, must be relieved, for it is of itself suffi- cient to cause a fatal termination. If sleep does not follow the applications of cold to the head, opiates may be ad- ministered in full doses. I have seen tyi)hus fever patients that had not slept for forty-eight hours drop into a quiet slee]) within a few hours after they had been exposed to free ventilation. (treat care should be exercised that their ai»aitni<'nts are kei)t perfectly quiet and darkened. When delirium and other cerebral s\ in])tonis are asso<'iate(l with sleeplessness, hydrati' of chloral may be carefully employed. Stupor is to be countera<-ted V)}- pnjmoting the action of all the excreting organs, applying external stiniulanls, and administering diffusible stimulants, the most serviceable of which are coffe(», musk, and canq)hor. In the early stage of the disease the cold chjuche may l)e t'in]»loye(l. Two remedies have been recoinnnMided for the coma of tyi)hus, namely, valeiian and i>hos}ihorus ; neither of these remedies have seemed to me to be eilicacious. 254 TYPHUS FEVER. When tliere are evidences of great prostration in connec- tion with any of these sjjecial sj^nptoms to whicli I have referred, the moderate administration of stimulants may be resorted to, and if relief follows the first few doses their use may be continued. In the treatment of the complications which I stated to you were liable to occur during the course of typhus fever, you must be guided by general principles and by the symp- toms in each individual case, never forgetting that the primary disease has a tendency to induce great nervous j)rostration and depression, and that the heart's action forbids the use of all depleting remedies, and indicates a supporting plan of treatment. The pulmonary and laryngeal complications, as well as erysipelas, bed-sores, and gangrene, are to be managed in the same manner as was proposed when they occur as com- plications in typhoid fever. Diet. — This is of primary importance. Though the pa- tient refuse all nourishment, if possible he must be required or even compelled to take it. As the digestive powers are impaired, great care is required in selecting and administer- ing the proper nourishment, and it must be given at stated intervals, var^^ing from one to two hours. Care must be taken not to over-feed — much harm may be done in this way. When the patient clinches his teeth and obstinately refuses all food, or is unable to swallow, his life may sometimes be saved by pouring liquid nourishment into the stomach by means of a long tube passed through the nose. Milk best serves the purpose as an article of diet. It may be given ice-cold, if desired, and in such quantities as the stomach can receive and digest. If more concentrated nutrition is desirable, the yolk of eggs may be beaten up and added to the milk. The management of patients during convalescence from typhus fever is a matter of very great importance. As soon as the fever ceases, most patients convalesce rapidly unless there is some complication, and the chief duty of the physician is to prevent premature exertion and ex- posure to cold, and to restrain the patient in the gratifica- TUl'.A'l'MKNT. 255 tioii i)f ail inordinate! ai)i>('tit»'. At tliis time pot I.t or alo may Itc (alvi'ii lo iiuTcasc tlif power of assiniilalion. Tlui miiii'ial aridv. l*ciu\ian l>;irk. and iron may also be given as tonics; these art' part icidarly ealli-d I'oi- when llu' ]>ulse is slow and feeble. It is imp(H-tant to unard anaiiist any sudd»'n physical eJTort diirinii- the early jjcriod of eonvaleseence, as it may lead to coagulation of blood in the veins. An opiate or liydrate of chloral is sometimes required to ])i()duce sleep during c()nvales('enc<\ III all cases great beiielit will be derived from a tem- poiary change of residence, and daily exercise in the open air. LECTURE XXII. RELAPSING FEVER. Morbid Anatomy. — Etiology. — Symptoms. — Differential Diagnosis. — Treatment. Having completed the history of typhus fever, I shall this morning invite your attention to the next in the list of contagious fevers, namely, relapsing feT)er . This is no new form of disease. It was described more than a century ago by Dr. Rutty, and since that time has prevailed as an epidemic disease in most of the countries in the northern part of Europe. There is no reliable history of its occurrence as an epidemic in this country until about four years ago, when an epidemic prevailed in this city. It has been reported that in the year 1844 a vessel landed, in Philadelphia, passengers ill of relapsing fever. At one time, while typhus fever was prevailing in Buffalo, some twelve or fourteen cases of relapsing fever were reported, but it is altogether probable that they were cases of irregu- lar typhus fever, for when relapsing fever has been intro- duced into a locality it is not limited to one or two dozen cases. Morbid Anatomy. — In this disease there are no patho- logical lesions of so uniform occurrence as to indicate its special anatomical character. In a word, there are no char- acteristic lesions. There are changes present in some of the organs which very closely resemble those that are met with in typhus. Spleen.— in. the majority of autopsies, if death has oc- MoKlill) ANATOMY. 257 currrd in tin' active jn'iiod of the disease, tlie s})1. 203 the relapse occurs in tlie morning, sometiiiu^s in the iiflci- noon. hut more finiucntly it conies on at night. Till' ivlaj'si" iiiny be ushered in by a chill, oi- it may occur without a chill. The pulse may begin to increase in ra],)i(lity and in (u.-lve hoins n-acli 140 ])er minute. With the rajjid pulse, the temperature rapidlj- rises to 100° F. or 170° F. and even as high as 180° F. Usually tin' fever which at- tt'iids the relapse is more intense than the primary fever, the liver and si)leen become as enlarged as during the pri- mary I'evel'. It is claimed by some observers that the ])arasites which are said to be present in the blood during the primary fever, disappear during the remission, but reappear in greater numbers during the relapse. The relapse usually lasts three or four days. In a few cases I have seen it last six or seven days, and in some it does not continue more than forty-eight hours. After it has continued a certain period, a second remission is developed ; this, like the lirst remission, comes on suddenly, is accompanied b}" a profuse perspira- tion, and in twenty -four hours from its commencement the pulse and temperature have reached their normal standard. From this period, the patient usually goes on to complete recovery. As many as three or four lelajjses may occur, but ordi- narily the convalescence becomes complete after the second remission. Convalescence from rela})siiig fever is usually rapid, but the patient for a long time remains in a weak condition, suffering more or less from ai'thritic and muscular pains. The apjjetite returns slowl}-. An anjemic murmur, which is often very distinct during the active period of the fever, is heard for two or tliree weeks after tlie commencement of convalescence. Q^^dema of the feet, due to general anaemia, is often quite marked duiiiig convalescence. The period of convalescence is usually as long as both the period of fever and remission ; not unfrequenlly six or eight weeks elapse before relapsing fever patients are able 10 resume their accustouK^d avocations. At the commencement of convalescence, the decrease in 264 RELAPSING FEVER. the size of tlie spleen is rapid, but frequently it is a long time before the organ reaches its normal size. Complications. — Few complications have been noticed during the course of relapsing fever. In some epidemics pneumonia has occurred quite frequently; at other times it has been exceedingly rare. When it does occur, it is often double. Sudden collapse may occur as a complication of relapsing fever, either during the primary fever or during the relapse. Tlie pulse suddenly becomes small, irregular, or inter- mittent, sometimes imperceptible. The cardiac impulse is feeble, the heart sounds are lost, and the patient rapidly passes into a condition of collapse, and dies. The collapse may come on suddenly in cases previously mild. Fost-fehrile opMlialmla is another very remarkable com- plication or sequela of this fever. It has been observed in most epidemics. It presents two distinct stages, the amau- rotic and the inflammatory. During the flrst stage the patient complains of impaired vision, with motes and lumi- nous circles floating before the eyes. The inflammatory stage is characterized b}^ intense circumorbital pains and lacrymation, without injected conjunctivae or marked con- stitutional disturbance. Recovery is tedious, and, unless the case is carefully treated, may end in complete loss of sight. Both eyes are rarely attacked ; the right eye is most frequently affected. Dlarrhwa and dysentery are common complications, and in some epidemics they are the chief cause of death. They are most likely to come on during the relapse. In our epidemics the most frequent complication is hemorrhage from the mucous surfaces, especially from the stomach and intestines. In two cases that came under my observation hemorrhagic pachymeningitis was the cause of death. In very rare instances, abscess of the spleen, accompanied by py?emic symptoms, have occurred during the relapse and convalescence. Pregnant females, no matter at what stage of pregnancy, usually abort during an attack of relapsing fever. Differential Diagnosis. — The diagnosis of relapsing ]m:o(;no>;is. 2G5 fever is not difficult iC ynu have tln^ mtire history of the case; but, at the eoinincHccnit'iit of an ('])id('iiiie, during the })rinKir\' fever, you will n<'ccssaiily be in doubt as to your (.liaunosis. The diseases with wliicji it is ])ossil)le to confound rejajis- ing fever are typiius, tyjilioid. n-iiiit h-iit, yt-llow. and ox (before the eruption), and measles. It differs from all these diseases in the suddenness of its invasion, in the short duration of the ])iiniar\' fev.-r, and in its termination in a crisis, and in the alnn)st uniform occur- rence of a relapse between the third and fifth days. Then the muscular and arthritic pains, which an? such constant attendants of relapsing fever, distinguish it from the other forms of fever. A severe form of relapsing fever, attended by jaundice, resembles very closely, in its general appearance, yellow fever ; but the high temperature and ra])id pulse which attend the development of the former readily distinguish it from the latter ; besides, when the relapse comes on, there can no longer be any question as regards diagnosis, for yellow fever is a disease in which a relapse rarely occurs. Small-pox simulates relapsing fever only duiing the period of invasion. You need make no doubtful diagnosis after the third day, when the red spots appear along the edges of the hair. Prognosis. — The prognosis in relapsing fever is always good. During our ei)idemic about three per cent, of all the cases treated in hospital terminated fatally. This is a lower rate of mortality than we have with measles. Usually deaths from relai)sing fever occur, not from the disease, l)ut from some complication. During the epidemic in this cit}', syn- cope during rela})se was the most frequent cause of death. Rela])sing fever patients may dii' of hemorrhage from some of the mucous surfaces. A fatid t'-iininaiion nuiy occur from bronchitis, ])nenmonia. or otliei- judmonary comi)li<'ations. During one Russian epidemic ])arenchyma- tous hemorrhage was a freipn-nt cause of dt-atli. Diai'i'lid'a and dysentery occuiring during convalescence sometimes cause a fatal ternnnati-,<>;est. My exi)erieuce leads rue to place relapsing fever i)atients under the best hygienic nianage- nient, with free ventilation and a mild diet, and then care- fully watch lest some complication should occur. LECTURE XXIII. EXANTHEMATOUS FEVERS. Small-Pox.— MorMd Anatomy.— Etiology.— Symx>foms. This morning I shall commence tlie history of the exan- thematous fevers. They are three in number, small-pox, scarlet fever, ^.ndi measles, or variola, scarlatina, and rube- ola. These are distinct diseases, more markedly so than any of the varieties of fever which have been engaging our attention. Some writers, not regarding them as distinct diseases, have described them under the general head of acute exan- tliematous diseases. It seems to me that they should be included in the list of fevers : first, because they are infec- tious, and depend for their development upon distinct poi- sons as specific in their nature as those that develop typhus or typhoid fever ; second, for the reason that active febrile symptoms attend their development and mark their pro- gress ; tJiird, because they run a definite course, one marked by regular stages of development and decline, and with rare exceptions they attack the same person but once. I shall speak first of sniall-pox or variola. Since the day of .Tenner's wonderful discovery, small-pox has not occu- ])ied the attention of the profession as it did previous to that time. Prior to this discovery, small-pox was dreaded like the plague, and when it did prevail, cities, and often whole countries, were depopulated b}^ it. With the discov- ery of vaccination, a new era was developed in its history. During the present century epidemics of small-pox have MoKIiil) ANA'I'oMV. !2''>0 not Ihm'u ,ij.-iv:il]y IVinvd. Diiiiim' lli." ]k\<\ six or ('i<;-lit years, lio\vi-v.'i\ I his dis.'Ms.- lias Ixm'ii oii iIk; increase, and the death ivc<)ri(lei:uion. It cannot be from an\- failure in t he ])rotective ])ower of the nn'aiis which we ])ossess [ov i)reventin,L!; its develoi)ment, but I'roni llie im])erfecr manner in wliicli sucli nn'ans are employed. Vac- cination. ])ro])-'rly ]ierforme(l. is a jx-rfect ])rotection against its develoi)menl. The tinth of this statement no one of ex- tended exi)erien('e Avill (iuesti(jn, altlioni;-li vaccination, as formerly jiractised in tliis city, seemed to fail to protect tlie masses from the contagion of small-pox. I shall consider this part of its history more fully under the head of vaccination. I will now call your attention to the anatomical lesions of small-])ox. Besidi^s those which occur ui)()n tlui mucous mi'nibraut's and skin, congestions of the iiitci'iial oi-gans may be regarded as the most piominent. The anatomical changes which occur in all cas(^s will vary in degree, if not in kind, witli the type of the variola. Tliree distinct types of this disease are recognized, to which have been given the names '■''variola fliscrda^'" " ta- riola coiijluens,'" and ^'-variola liemorrJnKjlcay MonniD xVnatomv. — You will rarely make a ])ost-morteni examination u])ou one who has died of small-])ox, without linding more or less intense congestion cf the lungs, the l)rain, the liver, the spleen, and the kidneys. Peihaps the most constant lesions affecting the viscera are ])arenchymatous degenerations; sometimes these are sim})lv granular infiltrations, at otiwr times they consist of an acute fatty degeneration, resembling that ])i()duced by phosphorous poisoning ; this is really a fatty infiltration. If the liver and kidneys are far advanced in fatty cliange, the walls of the heart will usually be found yellow, thd)by, and brittle. In the iKMuorrhagic form of small-pox, besides these changes you will find small hemorrhages in nearly all the 270 SMALL-POX. viscera, with ecch3niioses of tlie serous membranes and fluid blood in the cavities. Every mucous membrane may be the seat of a hemorrhage. The characteristic anatomical lesion of small-pox is to be found upon the mucous membranes and upon the skin. This lesion is usually spoken of as the eruption. It does not differ essentially in the different varieties of the disease ; the modifications which are met with are due rather to its duration and order of development than to any difference in the anatomical changes. If we study closely these surface lesions, we will find that they pass through regular stages of development and decline. The first change that is noticed looking toAvards the development of this lesion is congestion of the papillae. In some cases this congestion seems to occur in spots, while in other cases it is quite uniform. The congestion of the papilbie gives rise to the little red spots upon the surface, which are the first to mark the development of the eruption. The papillae, which are the seat of the congestioii, will very soon be found to be surrounded with cells, which are larger than those seen in the normal tissue of the part. These cells very rapidly undergo granular degeneration. Most of these cells have escaped from the blood-vessels or are changed tissue-cells. As these new cells accumulate, they cause the epidermis to become elevated, and as the result of the elevation we have a little papule formed at the point of redness. The papules which are formed at the red point are due to the changes in the surrounding cells, changes in the rete-Malpighii and in the capillaries, and also to a certain extent to new-cell infiltration. After these changes have taken place, you will notice a serous infiltration upon the surface of the papule, or per- haps into its substance. This serous fluid is simply the serum of the blood which has escaped through the walls of the congested capillaries, and formed upon the top of the papule a little elevation which is recognized as a vesicle. In a certain proportion of cases, you will find that, soon after the vesicle begins to form, its centre becomes de- pressed. This depression or umhllicaUon^ as it is usually :\fn];iMI) AN'ATo>rV. 271 callt',1, has been accountfd for in dilT.'Tvnr ways by (liir.-niit obsorvers. Some explain it by saying that »ach ])apule and subse- quent vesiide liohls iniprisou.'d at its centre eitlier a hair- folliele or the duct of a sw.at-<,dand, and tliat Avlicn this ei>idermidal layer of the papule is elevated by the serous exudation or infiltration, the portion immediately about the hair-follicle or the sweat-duct is held down, and a depn^s- sion is produced at the exact point where the hair-follicle or duct of the inland maybe situated. Anotlier exi)hination (which I regard the better one) of the umbilication of the vesicle is, that the serous infiltration takes place more rapidly at the pus-cells into the vesicle and the formation of the pustule may take ])lace without extension of the inflammation into the cellular tissue beneath, and necrosis or death of the jiart will not follow ; but, if yduced, which necessarily will be followed by a cicatrix and i)itting. Remember that pitting is the result of a slough that has been ])roduc<>d by an extension of the inflammatory process into the deeper tissues. 272 SMALL-POX. Wlien the cellular tissue becomes involved in inflamma- tion it readily undergoes the sloughing process. This is the reason why we have pus so readily formed and in such quantities, when in any pax't of the body an apparently s]in'li:>ii:ic sji);ill-])()X rroiu their (It'vclojtmciit in the ordinary forms of the disease ; the only diUnviice is. that tiieir contents are bloody instead of serons or pnndent. In tlie liejnorrhagic variety, hirger or sniaUer lieinorrlui- ges take place into the cellular tissues ; in the milder foiTns they tnke place only in the layer beneath the ])apilla' ; while in the severer forms they take jjlace beneath all the cutaneous layers ; even the subcutaneous fat may be infil- trated with blood. No changes in the walls of the vessels have as yet been discovered which will account for these hemorrhages. These extravasations more frequently occur in those cases in wliich (h-ath takes place before the period of ])Ustulation is reached. Etiology. — The etiology of small-pox is a subject which at different times has engaged the attention of the profes- sion. At the present day the opinion is almost universal that the disease is propagated only by contagion ; that is, that it is a disease which can only be produced by its own specific poison, and is communicable only to persons who are not protected from its influence. There has been considerable question as to where the vi- rus of small-pox is located. Some claim that it is exclu- sively in the pustule, and that it is not possible for a person suffering from small-pox to give the disease to an unpro- tected individual unless some of the virus from the pustule is brought in contart with a cutaneous or mucous surface. This is a mistake. That small-pox can be conveyed by means of virus taken from a pustule there can be no ques- tion ; but you may rul) the cutaneous surface of an unpro- tected person with pus taken fiom a small-]iox ]>iistnlt\ and unless there is an abrasion of the surface the ])oison will not enter the body and the person will not become inocu- lated with I lie disease ; but if you ])lace the virus in contact with a mucous membiane of an un])rotected pis(>n i:;:iiiis cut raiici" into tin- syslrin ; IIh- most })r()b;il)lt' of tlu'sr virws is, Ihat it is priiicipMll}' iibsorlx'd by the mucous mt'ml)niiit' of tlir ii'spiratory truck during res})iration, and it is also jxohaltlf that exceediuf^ly iine particles detach from the ])uslul('s and crusts, which are suspended in great num])ers in tlie air surrounding small- pox patients, and that these convey the contagion, Tliere are no facts to sustain the recent views as to tlie parasitic nature of this contagion. The length of time wdiich elapses after exposure to, and n'ception of, the variola contagion before the disease is de- veloped varies from ten to thirteen days. This is called the period of inouhatioti, during which the recipient of the poison usually presents no abnormal symj^tonis. If the poison is introduced into the system through inoculation, only fortj'-eight hours elapse before the characteristic phe- nomena of the variola are manifested. It is not known what change takes place in the body of the infected person during this period of incubation. Usually, twelve days after exposure, the person who has contracted small-pox begins to feel chilly ; this feeling of chilliness increases until he has a distinct chill. This has been termed the initial stage, or the stage of initiatory fever. Symptoms. — TIk,' transition from the stage of incubation to that of initiatory fever is sometimes abrupt and some- times gradual ; usually it occupies two days and is fol- lowed by the eru]>tion. In this stage there is greater vari- ation in the intensity than in the duration of the symjitoms. The intensity of the symptoms bears no relation to the severity of the attack. Not unfreiiurntly, the most violent S3'mi)toms in the initial stage are followed by a mild attack of variola ; wliilr mild symptoms in tln' iintial stage are fol- lowed l)y the gravest form of small- jiov. With the chill, which maj' be more or less severe, there is s«'vere pain in the head and back, especially in the middle of the back; with this ])ain there will be a ra])id rise in tem])eiature. During the first day the temi)erature may rise to 104" F., during the second day to 105° F.,and by the third day it mav reach loG° F. or 107 F. ; in some cases it has been 276 SMALL-POX. said to liave reached 109° F. With this rise in temperature there will be an acceleration of pulse ; it may reach 100 or 120 beats per minute. In the strong and robust person, the pulse will be I'uU and not easily compressed. In females, and in the weak and feeble, the pulse has less volume, but usually is more frequent ; it may reach 140 beats per minute. At the very onset of the disease, the pulse become mark- edly increased in frequency, and the temperature becomes very much elevated. At this period, usually, there is more or less nausea and vomiting, and there will be soreness of the throat. This soreness of the throat may have preceded the chill by twenty -four hours, but now in many cases it will be quite severe, and the patient will comi^lain of more or less difficulty in swallowing, and of pain in the pharynx. The extent of the trouble in the throat will depend upon the severity of the attack. In the severer forms of the disease, by the tliird or even before the end of the second day, there may be delirium. In all cases, the face will be flushed, the conjunctivse con- gested, and there will be throbbing of the carotids. "With these sj^mptoms, there will be great restlessness, and an anxious expression of countenance, with somnolence. The respirations will be short, frequent, and labored. Many suffer from extreme vertigo, and in children convulsions are not infrequent. By the evening of the second, or morning of the third day, usually swelling and diffuse redness of the tonsils and soft palate are present ; not unfrequently the swelling and redness of the mucous membranes extends into the larynx, causing hoarseness and huskiness of the voice and a stridulous cough. Some writers describe an initial erythematous rash which precedes tlie eruptive stage of small-pox. This rash is so rarely met with in this country that it seems to me to be an accidental occurrence rather than a symptom of the initial stage of the disease. During the fever of invasion patients are languid and weak in projDortion to the severity of the fever. Fre- SYMPTOMS, 277 qiKMitly, williiii twenty-four hours. nft'T the usln-iiuij: in rhill the stiongesL luid must vi^'orous will he unable Lo ^et out of hed. Thei-e is iihva3'S loss of appetite ; nausea and v()niitin<^ are fiequentl}' i)resent. If vomiting' occurs it is present at tlie very beginning of tlie initial fever, and continues with great obstinacy throughout its entire course. in the henioiilin- gic variety the matters vomited may contain blood. Stage of Empfioiis. — By the third day of the disease, at least after the initial fever has continued three full days, an eruption will make its appearance ii])on the face, espe- cially along the edges of the hair. I will describe the eruption as it develops in a moder- ately severe case of discrete variola. It first ap})ears in the form of slightly elevated macuhe. These are of a pale red color, varying in size from a millet-seed to a pin's head, or even larger. These little red spots look veiy much like flea- bites. In most cases the forehead, nose, and ui)per lips are covered lirst. If you closely watch them you will find that they gradually increase in size ; the increase is attended b}' a sensation of itching and burning of the surfa(;e. Usually, about twelve hours after their appearance upon the face, similar small red points appear upon the body and extrem- ities; first on the body, then on the legs and arms, and lastly on the hands and feet. They are always less abun- dant on the body and extremities than on the face. On the second day of the erui)tion these sjjots assume a daiker red coloi-, become elevated and distinctly papular. On lln' third da}' tliey becojue more conical in sliapi', and at theii- ai>ex a vesicle is formed, which gradually enlarges until the fourth or fifth day, when they reach the size of a small pea, and ai'e s])herical in shape. In a majority of instances, as tiny iiilaige, a dej)ressi()n is formed, which gives to them an unibilicated ap})earance. At the centre of the depression the ojx'uing of a hair- follicle or sweat-gland will often be found. The appear- ance of eruption is attended ]»y a subsidence of the febrile sym])toin<, tlie ])atieiir no longer com])laiii^ i>f pains in the head and back, the temperature falls two or three degrees, 278 SMALL-POX. and the pulse diminislies fifteen or twenty beats in fre- quency. Stage of Suppuration. — Ahout tlie sixth day of the eruption the contents of the vesicle, from the admixture of pus-corpuscles, gradually become turbid, and by the eighth day the pustules become fully formed, and the disease en- ters on the stage of suppuration. The integument in the immediate vicinity of the pustule now becomes red and tumefied, each pustule being surrounded by a broad red base, and where they are thickly set they become conflu- ent. The face swells to a shapeless mass, and the patient becomes frightfully deformed. The itching now becomes almost unbearable, and causes the patient to scratch him- self, thus causing ultimate disfigurement. During this pe- riod a characteristic sickly odor is emitted. As I have already stated, the eruption appears on the trunk and extremities a day or two later than on the face, and on these parts it passes through its stages two or three days later than it does on the face ; consequently, suppura- tion may be complete on the face while it is still taking place on the extremities, and the eruption may be perfectly discrete on the trunk, while it is confluent on the face. About the eighth or ninth day of the eruption the pus- tule is fully formed ; the stage of suppuration is complete. Then commence the retrograde changes. The pustule either ruptures, discharges its contents, dries up and forms a yel- lowish crust, or it shrivels and dries up witho-ut rupturing. This is called the period of desiccation. Stage of Desiccation. — Desiccation commences in those parts in which the eruption first appeared. As the drjdng down of the pustules takes place, the redness and tenderness of the skin lessens, and the countenance begins to assume a more natural appearance. At first the crust adheres quite firmly to the surface, but between the eleventh and four- teenth day of the eruption it is separated from the surface and falls, leaving a stain of a reddish-brown color, with ele- vated edges and depressed centre, which remains visible for five or six weeks. These spots gradually become lighter in color, until finally, if there has been destruction of the SYMPTOMS. 279 cutis, a ])it will be fornu'd of iri-t-attT <>r less depth, of a wliitt' color, .Lciviii-i; to tlif face a " * ]iock-mark<'d" a|)j)ear- aiu't', which will remain duriiiii; the life of the iiulividual. 1 liav.' already stated to you iliat the febrile syni])toms ii:radually increase in severity until the third day of tlu; dis- ease, when the eruption a})pears and the fever sul)sides. Then the vesicles form, the formation (jf which is attended by only moderate fever. On the eighth day the ])ustules are fully formed, and the suppurative, or, as it is called, the second a nj fever comes on. This secondary fever often commences with a distinct chill, the pulse becomes frequent, the temi)erature rapidly rises, perhaps reaches a higher ele- vation than it did during the initial fever, sometimes rising as high as 108° F. or 109° F. ; it reaches its nuiximum when su]ipuration is at its height. As desiccation commences, the temperature begins to fall, and by the time the crusts are fully formed the temperature reaches very nearly a normal standard. If the temperature rises again, its rise is due to some complication, such as erysipelas or some phlegmonous process. With the fall of the crusts, the patient's appetite returns and he is able to sleep ; convalescence is now fully established. LECTURE XXIV. SMALL-POX Symptoms {continued). — Differential Diagnosis. — Prog- nosis. I HAVE already given you tlie liistory of the symptoms of an ordinary case of discrete small-pox. This may be regarded as a prototype of all varieties. This morning I shall call your attention to the points of difference between the other varieties of small-pox and that variety whose history we have been considering. The dividing lines between these different varieties are not sharply defined; one varietj^ grad- ually passes into another variety. It is unnecessary for me to consider all the forms into which this disease has been divided by medical writers ; frequently the basis of the division is merely arbitrary. We will therefore confine our attention to the more common and well-recognized varieties. Confluent Small-pox, or Variola Confluens. — This is a much more severe form of the disease than variola discreta. It develops far more rapidly and is much more fatal in its results. The fever of invasion is usually much more severe, and of shorter duration, frequently not lasting more than forty- eight hours. The eruption spreads rapidly over the entire body, often appearing simultaneously on the face and the other portions of the body. The red dots which mark the first appearance of the eruption are very numerous, especially on the face and hands ; on the first day of their appearance SYMrT(>Ms. 2R1 they are almost ronflucnl. On tli<' s(>r(m(l day the skin is int(MiS('ly red inid swolh'ii, and so tliit.'kly studded witli lai;uv llal \i'>iclcs thai they r:i])idly unit.(^, sii])iiiirai ion spcH'dih' follows, and llali'-nrd. yllowislicoloi-cd conliucnL ])at("luvs aiv roinicd u]h)Ii a dark, irddrufd, swollen skin. Giadiially tliese ])atclies run togetlier over a still larger sur- face, and tile epidernus is elevated in llie foiin of lar.i^e, Hat bulhe, which are filled with a sero-i)urulent llnid. In this way the entire skin of the face is covered by an immense bulla, and I he patient is as unrecognizable as though he wore a mask. While the eruption may be completely conlluent on the face and hands, on other jjarts of the body it remains distinct, and never becomes conlluent except over limited spaces. The period of desiccation is slowly reached. Large con- centric crusts are formed over the confluent patches ; these adhere firmly to the skin, while b(^neatli them suppuration of the papillary layer continues. The true skin is more or less extensively destroyed, and when the crusts have fallen, there is left extensive loss of substance in the cutis, giving rise to pits and ugly scars, which have a tendency to contract, often producing permanent and unsightl}^ disfigurements. In tliis vai-iety of small-pox, the eruiition is often confluent upon the mucous mend)rane of the mouth and throat ; it may in- volve the mucous membrane of the posterior nares, and ex- tend into the larynx. In sonn? cases the attending ])haiyn- gitis is so severe as to lender di'glutition imi)ossil)le. The pharyngeal inflammation is submucous, and is frequently accompanied by more or less enlargement of the parotid and sublingual glands. When this condition exists there is danger of the sudden development of a?dema glottidis, for the occurrence of which you should bt^ on the watch. Du- ring the year that I had charge of the Snudl-pox IIos])ital, there were three cases in the hospital of twlema glottidis; one case ternnnated fatally before I reached the patient ; life was saved in the other two cases by the performance of laryngotomy. In confluent small-])ox the severity of the constitutional sym])toms corresi)onds to the severity of the local manifes- 282 SMALL-POX. tations. The temperature during the initial fever often readies 10G° F. or 107° F., and in very severe types of the disease it may rise as high as 110° F. The pulse is corre- spondingly frequent and feeble. After the appearance of the eruption the temperature falls slowly to 103° F. or 104° F., where it remains until the stage of suppuration is reached ; then it again rises, in some cases even higher than during the period of invasion. Violent delirium is very frequently present during the fever of invasion, as well as during the period of secondary fever, and not infrequently patients pass, quite suddenly, into a state of coma. Uncontrollable vomiting and obstinate diarrhoea are not infrequent, coming on during the fever of invasion and continuing throughout the course of the disease. In all severe cases typhoid symptoms manifest themselves soon after the appearance of the eruption, and patients often lie for days in a semi-con- scious state, with dry, brown tongue, subsultus, a low muttering delirium, and all the attendant phenomena of intense nervous depression. In all severe cases albumen appears temporarily in the urine. Complications occur much more frequently in confluent than in discrete small-pox. Inflammations of the serous membranes, especially pleurisy and pericarditis, are the most common. Croupous and catarrhal pneumonia fre- quently complicate the severe bronchial inflammation from which so few patients with confluent small-pox escape. Vakiola Hemoekhagica. — There is another form of small-pox which can hardly be regarded as a distinct variety, but rather as a modification of those varieties which have just engaged our attention, and which has been called liem- orrhagic variola. It differs from the varieties already de- scribed, not in the manner of its development as far as the initial fever is concerned, but in the appearance of the eruption. This hemorrhagic tendency is often manifested as early as the first appearance of the eruption, by the dark color which the eruption assumes. Sometimes the papules become hemorrhagic from the very moment of their devel- opment ; at other times they first become vesicles, and then become hemorrhagic. Again, at other times, the hemor- PIFFEllKXTIAL niAONOSIS. 283 rhago lirst shows itself aft»'r tlu^ vesicles become pustules. In some cases the eruption over the whole bod}- becomes hemorrhan becomes liemorrhagic as soon as the papules have attained the size of a lentil, and the hemorrhagic change comes on slowl}', generally comuK^ncing upon tlie lower ex- tremities. Petechije and ecchymoses usually appear be- tween the points of eruption, if the small-pox is of the discrete variety. In connection with the hemorrhagic eru])tion, at thlius fm-cr. Tn both diseases then.' may 1x3 delirium, ]»ain in the head, veirii^o. hi^h temperature, and evidence of great distui])an('e of the nervous system. I know of no symptom which will enable you to make a positive diagnosis during the ver}^ early period of the dis- ease. Of course, if typlius fever is prevailing, or if small- pox is prevailing, and the patient has been exposed to either one of these contagions, you will be able to make a diagnosis without much dithculty. Usually there is greater loss of muscular power in typhus fever than in small-pox, but this symptom is not always well marked. By the third day, the appearance of the eruption upon the face, where it is first seen, settles the question of diagnosis. The eruption of typhus fever is first seen upon the abdo- men, and it may extend over the whole body without appearing on the face. It rarel}^ appears before the fifth day of tlie fever. If, therefore, you wait until the eruption appears, the differential diagnosis between small-pox and typhus fever can be readily made. Ml hhtfjitis is another disease which small-pox, in its initial stage, resembles. I have seen a case of small-pox treated for several days as a case of meningitis. TIkm-c is always considerable cerebral disturbance, and a full, hard, bounding pulse in the initial stage of small-pox. Photopho- bia and intense })ain in the head, as also nausea and vomit- ing, may be present in both diseases. Unless it may be the expression of the face, there is often no distinguishing mark between the two diseases in their <'arly stages. Tn meningitis there is usually a pale, anxious expn'ssion of countenance, whereas early in small-po.\: the face is Hushed, and day by day the fiush deejjens until the eruption a]i])ears. There is often a uniform redness over the entire surface of the body in confluent small-pox when the eruption appears, or at least that portion of it where the eruption makes its appearance. 286 SMALL-POX. On the appearance of tlie eruption the differential diag- nosis between tliese two diseases is readily made. I wish to impress you with tlie fact tliat it is miicli better to wait in all doubtful cases, perhaps in every case of small-pox, until the eruj^tion appears before attempting to make a diagnosis. It is an unfortunate occurrence whenever a patient, who is not sick with small -pox, is sent to a small-pox hospital, and it is equally unfortunate whenever a small-pox patient is retained in a family or neighborhood a sufficient length of time to expose the remaining members of his own family or other families in the neighborhood to the contagion of this disease ; but there is little danger of infection until the vesicles are fully formed. ProgjSTOSis. — The prognosis in any case of small-pox de- pends upon the amount of the eruption ; the more abun- dant the eruption, the greater the danger to life. The prog- nosis also depends upon the type of the disease. Unless some complication arises, the majority of cases of discrete small-pox recover ; while of continent small-pox, which is a much graver disease, nearly one-half the cases prove fatal. The best record obtained in the Small-pox Hospital on the island was one death in every five cases. In the hemor- rhagic variety, whether discrete or confluent, a fatal termi- nation is almost inevitable. Only a very few cases of the hemorrhagic variety recover, and when recovery does take place it is only reached after the patient has passed through an apparently fatal condition of coma. The ratio of mortality is always lower at the end than at the beginning of an epidemic. It is more fatal in the sum- mer than in the winter. The age of the patient greatly influences the prognosis. In infancy and in extreme old age the ratio of mortality reaches its maximum. Among adults, the prognosis is worse in females than in males. In the intemperate the prognosis is always bad, for with this class of persons the disease is liable to assume a hemorrhagic type. The intem- perate die in discrete small-pox when the temperate wdll with almost certainty recover. In the overworked and badly-iiourislu'd tlie prognosis is luid. Robust and h.":ill liy persons ]kiss tlirough a seven^ t3^pe of the disease nnicli more safely tlian those enfiM'l.l.'d hy syphilis and oth.-r chronic forms of the disease. The severity of the fever of invasion is not a safe guide in jirognosis. Sometimes a severe initial stage prec(xles a mild form of the disease ; sometimes patients with this dis- ease pass into a state of complete unconsciousness, remain in that (■onditi(Mi for some time, then the eruption begins to change in color, and linally recovery takes place. Such cases, however, are exceptional. However well (hn-eloped the eruption may be, or however well tilled the vesicles, you must remember that the eighth day is the commencement of the suppurative fever, which is the period of the greatest danger. Upon this day you may find your patient ]Kissing into a state of collapse, the result of the depressing intluence ui)on the nervous system produced by the large' extent of surface involved in the suppura- tive process. If patients do not die until the second week of the disease in most cases the fatal result is due to exhaustion, although death may occur from complications. Usually they pass into a typhoid condition, the result of the excessive drain upon the system wliile the supi)urative process is going on. Secondary syphilis is occasionally developed during the period of desiccation. All such cases that have come under my observation have proved fatal. Tlie most frequent complications wliich cause death are those which occur in the throat and air-])assages. In some instances swelling of the glands of the neck and mucous membrane of the throat takes place to such an ex- tent as to seriously interfere with deglutition and resjiiration. AVhen this occurs it becomes a great element of danger, and mattM-ially affects your prognosis. The tongue may become swollen to such an extent that the patient will be unable to ])rotrude it, or, being able to protrude it, will not be able to retract it. Under such circumstances deglutition is almost impossible, and, as I have already stated, oedema glottidis is Mable to occur. You may have laryngeal ulceis. and ulcers occurring in the trachea and in the bronchial tubes. These 288 SMALL-POX. may give rise to clianges wliich will so interfere witli respi- ration as to cause the death of tlie patient. Death may also occur from general bronchitis or pneumonia. Perhaps the most dangerous complication is acute fatty degenera- tion of the kidney. Whenever, in the course of the disease, the urine becomes scanty and high-colored, but especialy when it becomes so at the commencement of the secondary fever, you may then be certain that you have kidney com- I)lication. Under these circumstances your patient may pass into a condition in which convulsions will be devel- oped, and coma and death ensue. Before leaving this subject I will call your attention to a case of confluent small-pox which came under my observa- tion about one month ago. I make mention of this case that I may impress upon you the importance of one symp- tom as regards prognosis, that is, the abundance of the eruption. I was called in to visit a gentleman who v/as in the initial stage of the disease. I liad charge of him up to the third day of his illness. At that time an abundant small-pox eruption had made its appearance. He then passed into the hands of a younger physician, who seemed amazed when I said to him that I thought the patient would die. A few days later the physician informed me that the patient was doing well, and he thought I had made haste in my progno- sis. In reply I said, " wait until the nintli day." Upon the eiglitli day I saw my professional brother again. He then re- marked that the patient was very much worse, and he was afraid he was going to die. He died a short time after our last conversation. ^N'ow, the only symptom which led me so early to make an unfavorable prognosis was the abundance of tlie eruption. In the hemorrhagic variety of small-pox usually the stage of suppuration is not reached— the patient dies before that period on account of the extensive changes which take place in the blood. Under such circumstances you are lia- ble to have complete suppression of the urine, or, at least, suflficiently complete to give rise to ursemia in addition to the small-pox poisoning. TREATMENT. 289 Tkkatmext. — We now come to the treatment of small- pox. Tlu' lirst question that arises under this head is, liave we any means by whicli we can arrest its devel()j)ment after the initial fever has been established i In vaccination, pi-o})erh' ])erf(H'med, we undoubtedl}' ])()ssess a means by which we may prevent one from contraction of the disease when exposed to its infection. But the question now arises, have we any power to arrest the develo]unent or niitiii,ate the severity of the disease after the initial fever is established^ No reliable alliiinativc an- swer has been iriven to this question. It has been ])roj)osed to accomplish this by blood-letting, emetics, diaphoretics, purgatives, cold-baths, and more recently by the subcutane- ous injection of tlie vaccine-virus.. All of these means have been tested and have failed toaccom})lish the desired result. The assertion that large doses of quinine, given during the stage of invasion, will shorten the duration and modify the course of the disease is verified only by the experience of its author. Quite recently, it has been claimed tliat carbolic and sali- cylic acid will destroy the septic poison of variola, and thus shorten and modify its course. My own experience as re- gards their use has not been sufficient to decide the ques- tion for myself, but I am unable to find any statistics whicli sustain such an assertion. During the fever of invasion all that you can do is to treat special sjnnptoms. Place the patient in bed in a large, well-ventilated a])art- ment ; if possible keep the temjjerature of the room below 60° F. I remember that, in the Small- ]iox Hospital, those patients did best who were ]>laced in barracks which were so open, that frequently, during the winter months, when I made my morning visit, I would find little snow-drifts on tht' floor between the beds. When the body temperature ranges ns high as ]()7^ F. or 108° F., it may be necessary to e^nploy cold to the surface, and to give antipj'retic doses of (piinine to reduce the tem- perature. If the headache is severe and the face flushed, iced compresses and ice-bags to the head will usuallv afTord 19 290 SMALL-POX. relief, K tlie vomiting is severe and constant, iced carbonic acid water may be given, and if tlie vomiting is attended by great restlessness, hypodermic injections of morphine are indicated. Administer siicli food as can be readily as- similated. I have found nothing better than iced milk and seltzer water. If the bowels are constipated it is well to relieve them by enemas of cold water. In those cases in which the eruption is tardy in making its appearance, and the temperature is higher, sometimes, if the patient is kept in a warm bath for fifteen or twenty minutes, the development of the eruption is hastened. When the eruption has appeared, the measures to be em- ployed will vary with the character of the eruption. The milder forms of discrete variola require no interference. In the severer forms the attendant symptoms will decide the means to be employed. Sooner or later, sometimes ver}^ early in the severer forms of the disease, you will find 3^our patient sinking from the depressing effects either of the small-pox poison or of the suppurative process which is taking place upon the surface of the body. Under such circumstances you will be com- pelled to resort to the use of stimulants. There is no ques- tion but that the free use of stimulants for a few days, just at the period of suppuration, in very many cases does much to save life. At this time you may find your patient with a dry tongue, a frequent, feeble pulse, blue lips and finger ends, giving evidence that he is rapidly passing into a state resembling that met with in the latter stages of typhoid fever. Active delirium is frequently present ; the patient insists upon getting out of bed. Under these circumstances, the life of your patient will often be saved by the judicious use of stimulants. If the delirium is excessive, hypodermics of morphine may be combined with the administration of stimulants. During the stage of desiccation, warm baths employed every day, or every other day, give great comfort, and assist in the falling of the crust. After the baths, the surface should be freely oiled. Complications will be treated according to the general rules which ";overn their treatment. If abscesses occur TltKATMENT. 201 in the sulx-utaiit'oiis (is.sii<>, tlu'V should early be freely OJH'IK'd. We aiT ])()\vt'r]('ss wlit-n we coint' to dca! wiili lln' licmor- rliagic form of siiiall-i)()\. A1iIi(iiil;1i tonics and st iiiiiilaiits have been hiulily r«'ConiMifiidfd, they tlo little i^ood. Tiaiis- fiisioii has been juoposcd and ))ra('tist'd with no dclinite results. If till' inoulli and jtliarv iix ari' vci-y iniicli iii\o|\rd, and there is dillicully in dt',«;lulirion, iee-cold caibonaled water with a weak solution of niur, tinct. ferri used as a garuli' will often give great relief. Sometimes the stronger anlis(-])tic gargles, such as carbolic acid and i)erraanganate of ]iotash, will be of service. There is still one point in the treatment of sniall-])ox which is deserving of attention, and that is, what means may be employed to prevent the ])itting, es])ecially upon the face, which is so fi-equent an accompaniment or the re- sult of small-pox ? As I have already stated, the erui)tion first makes its a])pearance upon the face; there it is usually most abundant, and is most liable to be followed by pitting, and there it passes more quickly through all its stages than upon any other part of the body. In order to prevent the pitting, it has been proposed by some to exclude light and air from the surface covered by the eruption. For this pur- pose a great many substances have been employed, such as collodion, gutta-})ercha, certain forms of ])laster, li(|uid paper, etc., etc. All these substances are to be so applied as to form a mask for the face, which should c()m])letely exclude light and air from the surface. You will recollect that I stated that the pitting was due to the formation of a slough, and that the slough was seated in the areolar tissue, and that if by any means you can so interfere with the inflammatory process as to prevent the formation of a slough, you will ])revent the i)itting. It was claimed by those who advanced the theory, that excluding light and air prevented i)itting ; that it did this i)y ])r«.^veut- ing the occurrenci- of sloughing. At the time wIh-u I had charge of so many sniall-]>o\ ])a- tients, 1 look ])ains to test all tliosr ;i]t{tlicaiions, whi<-li at that time had l)een and are still lecomniended for that })ur- 292 SMALL-POX. pose, and I satisfied myself that about the same results were obtained in the use of every remedy, and in no case was pit- ting prevented. Certain j)atients were much more scarred than others, but that was the natural result of the disease. Some have proposed to coagulate tlie serum in each vesicle by means of iodine or nitrate of silver, and so arrest the inflammatory process and prevent pitting. But the use of these means has been attended by the same unsatisfactory results. The only means which I found of certain value was simple cold-water dressing applied over the face, after having ruptured each vesicle before it became a pustule. In this way, I was able to diminish the intensity and extent of the inflammation. This plan of treatment I adopted in twenty cases of confluent small-pox, and it not only gave the patients very great comfort, relieving them to a certain extent from the intense itching, thus avoiding rupture of the vesicles by scratching, but in not a single case that recovered was there bad pitting. In the treatment of small-pox, the prevention of pitting is of greatest importance to a certain class of patients, especially young unmarried females. LECTURE XXV. SMALL-POX Treatment {continued). — Inoculation. — Vaccination. — Varioloid. ^VE will now consider the two recognized methods for rendering small-pox poison so innoxious that, when one has been exposed to its influence^ he will be perfectly safe from infection. These two methods are known as inoculation and vaccination. Inoculation was first introduced into En,ij;land in the year 1781, by Lady Montague, who first practised it upon her own child, slir having become familiar with the practice while travelling in Italj', wlicre the practice undoubttnlly originated. Subsequently it was quite generally i)ractised throughout Great Britain. Pus from a small-pox pustule was introduced beneath the epidermis of one wlio had been prepared, by diet and general liygienic measures, for the safe development of the disease. It was claimed that the disease resulting from inoculation was a modified small- pox, differing from the original disease in that it ran its course more rapidly, was attended b}^ the formation of a fewer number of pustules — perhaps no more; than twenty or thirty upon the entire body— and was said to rarely terminate fatally, the ratio of mortality being about one in one hundred. The patient who had the disease in this manner was equally protected with those who had the disease in the ordinary manner, being exempt from a second attack. 294 SMALL-POX. The disease developed by inoculation passed tlirougli the regular stages of a case of ordinary small-pox — tliat is, there was the iiiitial fever, the eruption, and the desicca- tion, one stage following another in regular succession. This procedure was found more or less unsatisfactory, for it had its disadvantages ; there was danger in it, and inocu- lated persons could communicate small -pox to others. During the latter part of the last century. Sir William Jenner observed that, in some of the northern counties of England, persons employed in dairies, who suffered from a certain form of ulcer upon the hands, did not contract small-pox when exposed to the influence of its poison. He also found that these ulcers found upon the hands resem- bled pustules found upon the udder of the cow, and seemed to have been caused by contact with them. Jenner made a thorough investigation of the subject, and arrived at con- clusions sufficiently satisfactory to himself to warrant the experiment of taking matter from one of these pustules found upon the udder of the cow and introducing it into the arm of an individual who was supposed to be unpro- tected from tlie contagion of small-pox. After the sore upon the arm had run its course, he exposed the individual to the infection of small-pox, and in this way he estab- lished its protecting power. His first experiment was made in the year 1791 ; but it was not until six years afterwards that the experiment was repeated by any other person. During these six years it is probable that no member of the profession ever received more anathemas or more scurrilous abuse than did Jenner. He was attacked by the leading physicians and surgeons of Great Britain, and persecution and ridicule so followed him, that placards with caricatures of Jenner were posted throughout the streets of London and the principal towns of Great Britain. Jenner kept steadily at work and repeated his experi- ments, until he became fully convinced that by vaccination perfect protection could be obtained against small-pox. Within the short space of six years Jenner compelled the profession to admit his statements and adopt his practice, YArrTXATTOV, 205 and. within the fivo or six years followin^^ its first n^n^fr. nition, th«' ]M-actice of vaccination b.M-amr uniTornily recog- nized and practised. \'accination was introduced into this country in the year 1802, by two Boston physicians, and it very soon l)ecaine the practice of the entire profession. At the present time tlK're is no question among tlie intellig,.nt portion of tlie profession, but that vaccination, properly pcrrornied, is a perfect protection against tlie infection of small-pox ; if persons contract small-pox after they have been vaccinated you may infer it has not been properly performed. We have no other means of protection. We will now study the subject of varrinnfion. There are two methods of performing it. One method is to take the cirus directly from the cow, this is called hovine virus ; the other method is to take the virus from a vesicle de- veloped upon the human body, perhaps a vesicle removed from the original by several vaccinations, this is called liumanized virus. It has been a common practice to us(^ virus taken from a vesicle that was removed from the original vesicle by two, five, ten, twenty or even forty vaccinations, on the supposition that just as perfect pro- tection was afforded as though the vaccine was taken directly from the cow. Within a few years it has been found that such a large projxtrtion of the population were not protected from the infection of small-pox, and that cases of small-pox were so markedly increasing in nunibei-. that a retuin has been made to the horirie virus. To-day, this foi-ni of virus is used by a majority of the profession. I use it Ixn-ause when I obtain a perfect vesicle, alN-r its introduction into the svstem T am convinced that tlu,^ person is thoroughly protected against the infection of small-pox poison. T never liave this assurance when I use the humanized virus. Dr. .Tenner found that there were several pustules de- veloped on the udder of the cow, which closely resembled each other, but that only one contained the \\y\\< wliich afforded protection from small-]iox. In obtaining bovine virus it is of the greatest importance that the genuine vesicle be 296 SMALL-POX. sol(>ctod. In ordin* to make the selection it is necessary one should be familiar with the peculiarities of each variety. Dr. F. B. Foster and Dr. E. H. Pardee, of this city, have given this subject much study, and their experience and facilities enable them to furnish bovine virus which is per- fectly reliable. If humanized virus is used, not only is the protection less certain and less permanent, but there is danger of intro- ducing into the system the infection of other diseases. I have in my possession facts which prove beyond the possi- bility of a doubt that syphilis can be conveyed from one person to another by vaccination. In two instances, which came under my own observation, it was so conveyed when the humanized vaccine lymjDh was employed. Cutaneous eruptions may also be conveyed by humanized vaccine virus, which may cause the development of very ex- tensive and serious cutaneous diseases. Again, it must be remembered that if any chronic or acute skin disease exists at the time the vaccine vesicle is running its course, the protective power of the vaccination will be altogether destroyed or very greatly modified. In obtaining vaccine virus for use, both the bovine and the humanized virus should be taken from the vesicle on the eighth day. The lymph should be taken from the vesicle before the inflammatory process has commenced which is to change it into a pustule. A few years ago it was the common practice in this city to use the vaccine crusts, but this prac- tice has fallen almost entirely into disuse because of the great danger of transmitting disease from one individual to another. Always use the bovine virus when it is possible to obtain it. If compelled to use the humanized virus, use the lymph. You must puncture the vesicle in such a manner that the lymph cannot be contaminated by the blood ; this is best clone by introducing your instrument parallel wdth the arm. The lymph which flows from such a puncture can be pre- served upon the convex surface of a piece of quill, and con- veyed from one individual to another. Vaccine virus se- cured from the human arm in this manner is less liable" VACCIXA'I'IOX. 207 tli;m any otlitM- form of liuin:niizy direct transmission. The operation is sim]>le, and one with which you are doubtless familiar. It is not neces- sary for me to say anything in regard to the manner of performing it. Any irregularity in the development of the vesicle de- stroj's in a greater or less degree its protecting power. When an individual has been previously vaccinated, it is liable to run an irregular course. A primary vaccination, such as the first vaccination of a child, should pass throuffh the foUoiolng regular stages ; if it does not., it fails in its protecting poicer : Upon the third day after the introduc- tion of the virus you will notice at the point where it was introduced a little red spot. By the fourth day this little red spot will be occupied by a vesicle, and at the commence- ment of the fifth day you will begin to see around the vesicle a little yellow margin. Xow you liave a vesicle with a yellowish- white margin at its base. This vesicle goes on increasing in size up to the eighth day, when you will notice that it has become umbilicated, and that there is around it a distinct areola. Previousl}' there has been a trilling areola present ; now it becomes very distinct. The vesicle is free from inflammation, and now is the time to take the lym])h for the purpose of vaccination, for the vesicle is comi)lete. The lymph should l)o taken only a short time before using it. Now a change is to take place in the vesicle, and l)y the n»^xt day you will notice that tin; areola has extended, ])erliaps so as to m<'asure an inch in diameter; this areola goes on extending itself through tlie ninth, tenth, and eleventh days, when it will have reacln', 301 and ill the sliort tiiuo ivquircd for tlu" formiilioii and sepa- ration of the crusts. The entire jx'riod of tlie ciiiptive stage often does not hist more than a week. Rarely are there cicatrices or pits aftri- the disappearance of th.- niip- tion. In vaii()h»id and viliiohi ihc pustulfs ])ass throUL;li simi- lar stages. We lirst havi^ the small red spot, then vesicles form, often within twelve hours after the ai)i)(,'arance of the eruption. These vesicles rapidly increase in size ; sometimes they are umhilicated ; by tin ' end of the third day their contents sometimes becomes i)uruh'nt, without any tume- faction of the surrounding skin. On the fifth day desicca- tion commences, and is often completed b}^ the seventh day. The majority of the pustules simply dry up, without pre- viously bursting, forming brown crusts which are thinner and smaller than those of variola. In varioloid you rarely have the regular period of devel- opment such as you have in variola. In variola there is the period of eruption, during which the vesicle is perfected ; this is succeeded by the period of suppuration, then by desiccation, about fourteen days being required to complete the process ; while in varioloid the course of the eruption is irregular, and is usually completed within one week. Again, in varioloid there is but little constitutional dis- turbance after the appearance of the eruption. It ivseiii- bles variola in the severity of the S3nnptonis during the period of invasion, during which time you will not be able to determine whether the case is one of varioloid or one of sniall-])ox. If you are watching, lest sinall-i)o.\: may be developed, then you may be led to susjiect its advent from the severe pain in the head and l)ack. and from the gem'ral febrile disturbanc(? following an exjjosure to the infection of small-],)0X ; l)ut as soon as the eru])tion a])])ears there is an entire cessation of all the active febrile symptoms. Dur- ing the period of invasion varioloid may be said to very closely resemble variola. When an individual is exposed to varioldid. tlie most severe case of conlluent sniall-])<»x may be the result. This fact proves that varioloid is a modified form of small-pox 302 SMALL-POX. wliicli has been produced by vaccination. It is now gener- ally conceded that varioloid is small -pox having a shorter duration and a milder course than nsual. You may say we modify small-pox by inoculation. We do not. There is the same regular development of the dis- ease after inoculation that we have in the ordinaiy form of small-pox ; we only modify its intensity ; while by vaccina- tion we not only lessen the severity of the disease, but we are able to so modify the stages of its development as to shorten its duration. Prognosis.— Usually the prognosis is good. The diagno- sis is readily made. The rapidity with which the vesicles are developed, their shorter duration, the subsidence of the fever, and the appearance of the eruption, together with the usual duration of the attack, are sufficient to distinguish it from variola. Treatment. — The treatment for varioloid is the same as for a mild or modified form of small-pox. The patient should be placed in a large, well-ventilated room, quaran- tined the same as though suffering from variola. If the form of invasion is severe, saline cathartics may be admin- istered. When delirium is present, and the pain in the back is very severe, the moderate use of opium is admis- sible. As soon as the eruptive period of varioloid is reached no treatment is required; the patient passes on to a rapid and complete convalescence. Before leaving the subject of variola, I will refer to a few complications which do not belong to its natural history. As I have already stated, there really is no dividing line between the local affections of this disease and most of its complications. Bronchitis, more or less severe, accom- panies nearly all cases. In some it leads to catarrhal pneu- monia, the occurrence of which is always attended with danger. Pleurisy and pericarditis occasionally occur as serious complications. Laryngeal inflammations are a part of its history. When the laryngitis is accompanied by extensive ulceration of the laryngeal mucous membrane, or when acute oedema, of the vAuioLoii). :j()3 glottis is (.h'vrl()])t>(l, or when it assiiinos a diplitlicritic cliar- acter, you have dt'vclojx'd a scries of coiii])li(;atioiis which often iiiiickly (Irslroy lif"'. Meiiiii^iiis and ('t'rrl)ral coniplioations are not of common occunviicc in variohi, althou^i^h acute menintritis and o'dema of the l)r;rni do sometimes occur ; so that wlien very active delirium or sudilen coma come on durini^ the erui^tive stai^e of the disease tliere is reason to fear their deveh)p- nient. A severe form of conjunctivitis may occur, wliich is some- times attended by the deveh)])ment of ])ustuh's on the ]ki1- pebral conjunctiva ov u\u)n the cornea. Whiii (hey develop on the cornea, jjcrforarion, iritis, and su])puration of the globe may cause destruction of the eye. In liemorrhagic small-pox hemorrhages into the retina sometimes occur, causing sudden blindness. 8ui)i)urative otitis may occur and may be the cause of partial or complete deafness. Pyjemia is a very rare com])lication of variola, although during convalescence superficial cellulitis, terminating in abscess, is not infrequent. In severe cases, during convalescence, oedema of the feet, due to anfumia, is frequently met with, but I have never re- garded it as of serious import. LECTURE XXVI. SCARLET FEYER. Introduction. —Morhld Anatomy.— Etiology.— Symptoms. This morning we come to the study of the second in the list of exanthematons fevers, namely, scarlatina or scarlet fever. This name has been given on account of the bright red appearance of its eruption. Scarlet feoer is an inflammation of the tegumentary in- investment of the entire body, both cutaneous and mucous, accompanied by a fever of an infectious or contagious char- acter. It is a disease of childhood, but may occur at any age. Its development and course is divided into periods : First, the period of invasion, which lasts from twenty -four to forty-eight hours ; then, the period of eruption, lasting from five to seven days ; afterwards, the period of desqua- mation, during which the entire epithelial surface is re- moved. Some authors have classified this disease according to its severity ; others according to the prominent organs of the body which are involved ; others according to the promi- nent phenomena which attend its development. The more common classification, and certainly the sim- plest, is that which divides it into scarlatina simplex, scar- latina anginosa, and scarlatina rn,allgna. I shall adopt tills last classification. Mni;i;ll) ANA'I'oMV 305 Scarlet IVv.'i- lias many dilV.'iviil \y])>'<\ tlies.' aiv as uiilik.- as some of tlif (li-linci l\i»"s of fi-vn-. ]\[()Kini) Anatomy.— Tlit'i-c arc no oliaiacti'ristic- anatonii- ral lesions of tliis (liscasc cxcciit tii()S(^ clianp'S which have tlifir srat in iIk' skin am! imicoiis incinlirain'S. I stat(;d that tilt' characteristic analoinical chain;-. -s of variola were tube found in the eruption wliicii followed rc.L^nihir stages of development, so in scarlet fever the erupiion is lli.' dis- tinu-nisliinii: lesion. The erui)tion makes its ai>pearance on the second or third day after the commencement of the febrile symptoms. At that time it consists of very numei-ons and closely arrgivgated points about the size of a pin's head ; between tiiese the skin is of its natural color. In tyi)ical cases, these points are ecuially distributed over the entiiv body except the face. These red spots are usually circular in shape, slightly elevated above the surrounding skin, and so close to each other that they give a confluent redness to the entire surface. In mild cases the red points remain isolated, and do not become confluent ; as the eruption develops these red points unite. In severe cases the skin becxMues turgid and swollen, and presents a uniformly red and glisten- ing ap})earance. In malignant cases the hyperjemia of the skin is often accompanied by more or less exti^nsive hemor- rhages, causing pt^techiai and extensive ecchymosis. The eruption gradually increases in redness to a certain point, which is not the same in all cases, then remains un- changed for twelve or twent^'-four hours, after which time the redness slowMy passes away. Dining the course of the disease the color often changes with the exacerbations and remissions of the fever. As a rule, the degree of rt'dness depends upon the int<'nsity of the fever, and may vary from a pale red to a dark scarlet color. If the respiration be- comes imjied'-d, the eruption assumes a bluish-red hue. During the first forty-eight hours after the a]>i)earance of the eru])tion, wIm-ii the respiration is nniinpeded, the red- ness completely disapi)ears under firm jjressure, and reap- p<}ars as soon as the ])ressure is removed. After this period, the pressed ])oint do.-s not entirely lose its red color. 20 306 SCAKLET FEVER. In a certain proportion of cases, the eruption only ap- pears in spots on tlie surface of the body, on the trunk, or face, or about the tlexors of the Joints. When it only appears on the face the diagnosis is difficult. In addition to the cutaneous hyperjemia which gives the redness to the surface, there is more or less serous exudation into the "rete Malpighii," which is followed on the decline of the redness of the surface by an abundant epidermic exfolia- tion. This exfoliation marks the period of desquamation, which may immediately follow the decline of the redness or it may be delayed a few days. This is due to an exces- sive production of newly-formed epidermis, and the process may last only a few days, or if the eruption is abundant it may continue for several weeks, and may recur a second time on the same surface. After the desquamation has ceased, it does not reappear, except in cases of relapse; these are followed by renewed and sometimes by a very complete desquamation. In connection with these cutaneous changes the scarlatina poison causes changes in the mucous membrane of the mouth and throat, the most frequent of which is catarrhal pharyngitis, which at first gives to the mucous surfaces of the tonsils and pharynx a red, swollen, and dry appear- ance. After a little time, these mucous surfaces become covered with a tenacious mucus. Upon the reddened mu- cous membrane, small elevations arise, like the smaller follicles in an ordinary catarrh. In mild cases, all these changes disappear in a few days ; in the severer cases, the mucous surface assumes a dark, livid color, the parts become more or less oedematous, and are covered by an abundant secretion. The oedema may be so extensive as to render deglutition difficult ; often the tonsils are so swollen that they touch each other. Besides the redness and oedema of the mucous membrane of the mouth and throat, there is often inflammation of the parotid and sublingual glands as well as of the connective tissue of the neck. This gland- ular infltimmation may end in resolution, but often it termi- nates in suppurative or diffused necrosis. It may give rise to extensive gangrene of the tonsils and adjacent soft parts ; MOIMUI) ANATOMY, 30? somt'timi'3 it is followed by cxtt'iisive abscesses and destruc- tion of the cellular tissue al)out the neck; the skin in the re«z;ion may slough, and not infrequently fatal hemorrhage may result from the destruction of small vessels. Diphtheria is so often a complication of scarlatina angi- nosa, that it has been assume(l that there is some necessary relation b. 'tween the two diseases. Yet diphtheria is as frequently met with in the mildest as in the severest types of scarlatina, and occurs in every stage of the disease; often it is present during the period of incubation, so that the symi^toms of the two diseases appear simultaneously. Again, it is met with during the period of convalescence. In some instances, scarlatina seems to complicate diph- theria. In a mild form of scarlet fever, when the disease runs a regular course, the nasal mucous membrane is usually pale, and its secretion is not increased. When the disease is severe, the nasal mucous membrane becomes secondarily, never primarily, involvtxl. This is the result of a catarrhal affection of the throat. It is a purulent catarrh of the posterior nares, which gradually extends to the anterior nares, and gives rise to a ver}^ troublesome form of coryza. During the eruptive period of scarlatina, affections of the ear frequently occur in connection with those of the throat. Usually these have their seat in the middle ear. They are alwavs tedious and may become chronic. Next to the skin and mucous surfaces, the kidneys are the organs most frequently affected in this disease. There is no question but that, in a certain proportion of cases, re- covery takes place without any kidney lesions; but these are the exceptions and not the rule. The usual, and by far the mildest affection of the kidneys in scarlatina is a ca- tarrh of the uriniferous tubules marked by a more or less extensive epith<'lial desquamation. In some epidemics the scarlatina poison induces croupous intiammation of the uriniferous tubules instead of simjjle catarrh. The tubules of the cortical substance of the kidneys are most extensively affected ; the morbid processes commencing at the Malpighian tufts follow the course of the convoluted 308 SCAELET FEVER. tubules. If the tubules are only slightly affected there will be no symptoms except a slight albuminuria. In Avell-markiHl scarlatinal nephritis, the epithelial cells of th(; uriniferous tubes will be found clouded, enlarged, and changed in shape and position, and frequently entirely destroyed, or they may entirely block up the tubules. Circumscribed inflammatory masses will be found scattered throughout the substance of the kidneys ; these cause the kidneys to present the appearance of interstitial nephritis. Sometimes abscesses form in the kidneys. These kidney changes are rarel}' well marked before the second or third week of the disease, and usually terminate in complete recovery ; they very rarely lead to chronic kidney disease. The character and extent of these kidney changes varies in different epidemics. During some epidemics, the kidney changes are slight ; during other epidemics almost every case, whether mild or severe, will be attended by extensive kidney lesions. At the post-mortem examination of scarlet fever patients, you will always find more or less extensive congestion of the internal organs, such as congestion of the brain, liver, spleen, etc., but these congestions do not vary in character from those met with in other acute infectious diseases. It has been said that the visceral lesions of this disease do not essentially differ from those of typhus fever, that there is the same tendency to softening of the spleen and liver, and that the condition of the cerebral vessels in the two diseases is very similar. In both, the changes in the constituents of the blood are such as to diminish its coagulating power ; in both, the mucous membrane of the stomach and intestines undergoes similar changes, the Peyerian patches will often be found presenting the " shaven-beard appearance." When scarlet fever poison, which usually only induces changes in the skin, throat, and kidneys, excites inflam- mation in the joints, pleura, and pericardium, these latter must be regarded as complications ; they do not belong to the regular history of the disease. Etiology. — The cause of scarlet fever is a peculiar sub- stance which is transferable from the sick to the healthy. Scarlet fever is unquestionably a eonta.^ions disoaso. It, lias been claimed by some that it is only pro])a,<;ated by con- tagion ; by others that sporadic cases do occasionally occur; but there is little doubt, if the history of every cast; of sup- ])()sed sj>ontaneous scarlet fever could be carefull}' taken, it would be found that at no jilace and at no limr had th.-re ever oi'currcd a case of si)ontancous oriuin. Tilt' disease may be conveyed directly fit)m llif alffctctl to the hcaltliy by contact. It may also be conveyed for a fi^w feet throuich the atnit)si)h.'rt% and also by clotliin<,^ wliich has been thoroughly saturated with the scarlet fever poist)n ; therefore it may be considered a portable disease. Animals that have been around those sick with scarlet fever may convey it. I now recall one instance in which the scarlet fever poison was conveyed in this way. For a number of days a little poodle dog had been around childrt>ii sick with scarlet fever, and in a single visit to the children of another family the disease was conveyed. There has been considerable discussion as to whether the disease can or cannot be conveyed in milk. I do not say that this is impossible, but I do not think it probable that it is so conveyed. The infection of scarlatina is not so certain as that of measles or small-pox. When one member of a family is sick with measles, usually every other member of that family who has not had measles will contract the disease ; whereas, one member of a family may be sick with scarlet fever and evt^ry other member may escajie. I stated that some ])ersons seem to have a certain idiosyn- crasy, so that when they are bnnight in contact with the typhus fever poison they do not contract the disease; so certain persons may be brought in contact with the poison of scarlet fever and yet not contract the disease. The poison which they receive into the system has power to pro- duce some of the symptoms, but has nt)t i)ower to fully develop the disease. Scarlet fever can be coniniunicateil fit)iu t.ne intliviilual to anothiM- by inoculatitm. If you take st)me t>f the watery material or serum that can be obtained from the minute 310 SCARLET FEVER. vesicles occasionally seen upon the surface of the body in connection witli the scarlet fever erniDtion, and introduce it into the body of an individual who has not had scarlet fever, it will develop the disease. It has been proposed to inoculate persons who have not had scarlet fever in the same manner as one would inoculate persons who have not had small- pox, and, by so doing, produce a modification of the disease. But it has been found by experiment that those who have been inoculated for scarlet fever have suffered more severely than those who contracted the disease by any of the com- mon methods of contagion. There is no question but that the scarlet fever poison ca,n also be introduced into the system through the respired air, but whether it can be taken into the system through the medium of food or fluids is still an unsettled question. We are now brought to a question of great practical imj)ortance. If tlie disease can be conveyed by clothing, is it safe for a physician to visit patients sick with scarlet fever, and go from them directly to those who have not had the disease ? Unquestionably, it is possible to so conve}^ the disease, but in my own experience I know of no case where it has been so conveyed. The clothing, in order to be sufficiently impregnated with the poison to render it a means of contagion, must be longer exposed than is the case when a physician makes a visit of ordinary length. I do not hesitate to go directly from a patient who has had scarlet fever to one who has never had the disease. While making my daily round of visits on scarlatina patients, I have frequently taken my own child, who lias never had the disease, to ride with me, without fear of conveying to her the disease. Unquestionably, nurses who have been with a scarlet fever patient for a number of days, and whose clothing has become filled with the poison, may carry the disease. Such persons should change their clothing before they go from the sick to the healthy. With regard to the real nature of the scarlatina poison, the oft-repeated question comes to us, Is it a living organ- SYMPTOMS. 311 ism or :ni impalpahle> poison '. It is ininecessary to repeat wliai has hrcii already said u])on this })()iiit. Thr saiiio ar^iuuciits iiuld _ii;()od in rr-rai-d to this fever as in regard to the other levers which we ha\e been coiisich'riiii^. Tlie period at wliicii tiiis disease is most infectious is ])rol)al)ly the desquamative }>eriod, altliougli some maintain that it is most infeetious during the eruptive period. An individual is almost certain never to liave a second attack. The i)eriod of incubation varies from two to ten days, the average duration being from four to seven. Age has a great influence on individual predisposition. Tlie greatest susceptibility to the influence of the poison exists between the second and seventh years ; it rapidly diminishes after the ninth year, so that adults, and esj)e- cially the aged, have only a slight predisposition to the infection. Scarlet fever may be endemic or epidemic. No reason can be assigned for the variations in type or severity of this disease. For years the type of fever which appears in a given locality will be exceedingly mild in character, and the cases will be mostly sporadic, when suddenly, without any assignable cause, a most malignant epidemic of the disease will prevail. Usually epidemics of scarlatina pre- vail in the autumn and spring. Symptoms. — The symi>toms of scarlet fever vary with the type and with the severity of the fever. In moderately severe cases, before the ap]>earance of the eru])tion, the patient will have more or less sevei'e headache, pain in the back and limbs, and at lirst coldness of the surface. In some cases rigor-; will occur, and i)erha])S distinct chills. In children convulsions often occur. These ushering-in symptoms are immediately followed by a sensation of in- tense heat, with great acceleration of the jjulse, which at this time often beats 120 or i;}() per minute. Tliere will also be nausea and vomiting, whicli symptoms are frequently the most ])ersistent and distressing. Besides, there will be a rapid rise in temju'ratuie. Ir may reach l(>:r F. or 1(»4 F., within a few houi-s. Wit hin a jieriod lastin^• fmni twelve to forty-eight hours, th'' average about lhin\-six hours, 312 SCARLET FEVEE. the eruption makes its appearance, and the fever increases. The elevation in temperature is accompanied by restless- ness, a burning sensation, perhaps delirium ; the nausea and vomiting become more urgent, and now the papillae of the tongue become swollen, and the organ presents the appearance of a strawberry. It has been called the " straw- berry tongue" of scarlet fever. This appearance is not commonly seen in the milder cases, but, as a rule, is present in all the severer cases. With the appearance of the erup- tion, all the symptoms, perhaps excepting the pain in the head, increase in severity. The urine, if it has been scanty, will now become more so, and may be nearly suppressed ; if it has been sufficiently abundant, not unfrequently, as the eruption makes its appearance, the urine becomes scanty and high-colored. In some cases the disease is so mild that there is but little disturbance, except that caused by the eruption. In other cases the disease is ushered in by violent nervous symptoms, such as delirium and coma, accompanied by extreme exhaustion, and the patient dies before the erup- tion makes its appearance. In other words, the patient dies during the period of invasion, from the overwhelming of the nervous system with the scarlet fever poison. During the earlier stages of the disease the throat symp- toms are quite characteristic. Adults and older children complain of a pricking sensation in the throat, and difficulty in deglutition ; the tonsils, uvula, and posterior wall of the pharynx are red and (Edematous, and from their appear- ance with the attendant symptoms, in most instances, you are very early able to decide that the case is one of com- mencing scarlatina. There are cases in which the throat symptoms are altogether absent at first, and do not come on until later in the disease. We will now study in detail the symptoms which mark the development of this disease. As I have already stated, the whole course of scarlet fever may conveniently be divided into three stages. First,, the stage of invasion, or the febrile stage. Second^ the stage of eruption. SYMPTOMS. ''i\'S Tliird, the stage of desqiuinuition. The duration of tlie stage of invasion varies in diirtTt-nt cases according to the type of the disease. In most cases, it is from twelve to twenty-four hours ; it may be four or live days. Usually the onset is marked by chilliness and slight rigor, foUowed by a rapid rise in temperature. The skin becomes dry, the face Hushed, and the pulse accelera- ted. At the same time there is slight soreness of tin* throat, the face appears red and dry, the neck is stiif, and there is some tenderness about the joints. Vomiting and thirst are prominent symi)tonis. The tongue is red at its tip and edges, the papilhe are enlargt'd, ;ind it presents the so-called strawberry appearance. Lassitude, pain in the head, aching of the limbs and restlessness are generally present. There may be some delirium at night. Twenty-four hours after the commencement of the fever of invasion, an erujjtion makes its appeanince, when the period of invasion is completed. The period of iiuuibation, or the time which elapses between the exposure and the ap- pearance of the eruption, varies. By some the erui)tion is said to appear as early as twenty-four hours after exposure, while others claim that one or two weeks may elapse after the exposure before the disease is developed, that the average time is six or seven days. You can make no defi- nite statement in regard to the duration of the period be- tween the exposure and the appearance of the eruption. The eruption first makes its appi?arance upon the neck and upi)er portion of the chest, and is first seen as little red dots, varying in size from a line to a line and a lialf in diameter. These gradually coalesce and the erui)lion ex- tends over the entire surface of the body, perhaps on tlie face, and lastly, it appears on the lower extremiti»'S. It ])resents its iMightest apjiearance upon the evening of the fourth day. On the morning of the fourth day, if you draw your fimrer across the surface, a clear, well-defined lin.' will be in:id«', wliich will remain for some time. The distinct white line which follows the finger is a point of some imi)ortance in distinguishing scarlet fever fr.tin roseola, a disease which 314 SCARLET FEVER. lias an eruption closely resembling tliat of scarlet fever. In roseola, the well-defined white line produced by drawing the finger across the surface will be almost instantly dis- placed by the returning redness. It does not remain dis- tinct as in scarlatina. The eruption remains visible six or seven days. Usually, it begins to fade upon the fourth day, and by the sixth day it has entirely disappeared, and des- quamation has commenced. The period of desquamation lasts about two weeks, during which time there is the great- est danger of communicating the disease. At the end of that period, if no complication occurs, the j^atient is well. The fine scales which are so abundantly thrown ofi: contain the specific poison, and they are so delicate that they are blown about with every breath, and carried in every current of air, and are in the most favorable condition to be taken into the system in the respired air. Some have maintained that the contagious period in this disease does not occur until the period of desquamation. This statement is not sustained by clinical facts. The amount of the desquamation depends upon the intensity of the eruption. The skin has a dry feel before desquamation commences. Where the skin is thin, the epidermis comes off in thin scales. Where the skin is thick, as on the palms of the hands and soles of the feet, it peels off in extensive patches. With the desquamation, the fever subsides more or less rapidly. lectuim: XXVII. SCARLET FEVER. Si/mptoms {continued).— Coviplications.—ScquelcE. I WILL briefly repeat some things said at my last lecture in n*iVr(>nce to the phenomena which attend tlie develop- ment of scarlet fever. Its symptoms may be divided into three stages : a stage of invasion, a stage of eruption, and a stage of descpiamation. After a variable length of time from the exposure, var}ing from two to six days, the re- cipient of the bcarlet fever poison begins to have chilly sen- sations, alternating with flashes of heat, rarely a distinct chill. Following this there is some soreness of the throat, headache, pain in the back and limbs : and the temperature rapidly rises, often in twelve liours reaching 104^ F. With this rise in temperature there is an acceleration of the pulse, and not unfrequently very young children will l)e seized with convulsions, rapidly pass into a state of coma, and re- main unconscious until the })eriod of eruption. Aftt.'r the period of invasion has continued two or three days, a rash will appear, flrst upon the* neck and chest ; gradually it extends over the face and trunk, then is seen upon the ex- tremities. This rash flrst apj)ears as flne red dots ; these dots form patches, wliich quickly coalesce. After the second day of the eruption, if not before, the entire surface will present an uniform redness, the color va- rying with the severity of the disease. In the milder eases you will have a bright rose-vd eruption or rash, while ia 316 SCARLET FEVER. the severer types the eruption will assume an appearance resembling the deep-red color of the boiled lobster. The darker the eruption, the more severe the form of the dis- ease and the greater the danger. When the eruption is fully developed you will notice that the surface is some- what elevated, the parts present a swollen appearance, the vessels of the skin seem to be congested, and there will be soreness of the throat more marked than in the febrile stage. Usually, vomiting is present at the commencement of the disease, but becomes more severe and a more marked symptom as the stage of eruption is ushered in ; if not i^res- ent at the commencement it is certain to make its appear- ance with the appearance of the eruption. The vomiting is peculiar, not on account of the matters ejected, but the act of vomiting is projectile in character. In scarlatina the con- dition of the throat depends upon the severity of the dis- ease. In some cases there is simpl}^ a blush of redness over the posterior portion of the pharynx and uvula and ante- rior pillars of the soft palate. In other cases you will no- tice a general tumefaction of all the soft parts of the throat which can be seen, and the tonsils will be the seat of a more or less intense parenchymatous inflammation, which gives rise to a swelling that encroaches more or less upon the pharynx. Again, you will have ulcerative pharyngitis, as it is termed, or upon the surface of the enlarged tonsils and swollen mucous membrane of the phar3^nx you may have an exudation, which hereafter will be more fully described. In the ordinary form of scarlatina, such as I am now de- scribing, when it runs its regular course you will not have much swelling of the glands about the neck, nor very much tumefaction of the soft tissue in the pharynx. The eruption will reach the maximum of development upon the fourth day, and will remain visible six days. Generally during this time the temperature continues to rise until perhaps it has reached 106° F. or 107° F. In the meantime the pulse may increase to 120, or even 140, or per- haps 150 beats per minute, and not unfrequently there is some delirium during this stage ; there may be also more or less stupor. There is an intense itching and burning upon iRREor I. A urn Ks. 317 the surface, and an intense restlessness depend iniz; \\\)(m tlu- congestion of tln' cutaneous covering; of the hody. Lpon the ei^dith day of the eiu])tion you will notice that the temperature begins to decline, and at the same time it can be seen that the eruption has fach'd in a marked degree over the juirts wIi.mv it first made its a])pearance, especially about the neck. This fading of the eruption goes on ra])- idly, so that by the end of the eighth, certainly early on the ninth day, sometimes as early as the sixth day, there is no longer any eru])tion visible on the surface of the body. With the disai»i>earance of the rash, desquamation com- mences, and with this there will be a still more marked fall in temperature and diminished frequency of the pulse. All the febrile symptoms disappear, all the throat symptoms subside, there is no longer any difficulty in deglutition, there is no more pain in the throat, no more swelling of the external glands, if previously it had existed. The desquamation continues for from lifteen to sixteen days, after which time the patient is in a state of convalescence. The entire period occupied by a case of scarlet fever when it runs its regular course is from two to three weeks. Having given you a description of the development of an ordinary case of scarlet fever, I must state to you that this disease is liable to irregidartties in its develoimient and course, and to these it is important that I should direct your attention. It is claimed by some that these irregularitii's (h']M'iid upon the organ or set of organs primarily afTected by tli<' scarlet fever poison. They are rather due to some ix'culi- arity in the type of the disease, to the degree of poisoning, and in some instances to the particular set of organs that are involved in the different epidemirs. In some epidemics you will see even mildrr Coiins of the disease than I have yet described. The attaeculiar elVect ])roduc»'(l H])on the nerve centres by the scar- let fever poison, nor are they due to the effects produced by a liiuli tem])erature, nor by an interferenct^ with the return circulation, but they are due to septic poisoning, a poison- ing entirely different from scarlet fever poisoning. The ner- vous phenomena develop after tlie eru])tion. Durintr the develoi)ing period, you may have noticed a peculiar icho- rous discharge from the nostrils, and frequently you hear it said that the patient has become repoison«>d by scarlet fever poison, but this is not the case ; he has become re- poisoned by the septic element of these discharges. During the period of desquamation you. may have the nervous S3'stem involved, in consequence of the presence of unemic poisoning. The mere terms, scarlatina simplex, scarlatina anginosa, and scarlatina maligna, do not indicate all that may be included under each division. You must remember that scarlatina maligna is that form of the disease in which tiie cerebro-spinal sj'stem becomes early involved, in conse- quence of some peculiarity of the scarlet fever poison ; or it becomes involved while the eru])tion is being developed, and depends upon high temperature ; or it becomes in- volved in connection with extreme swelling of the tissue of the neck, giving rise to interference of the return cerebral circulation, or in consequence of a septic or unemic ele- ment. What the changes are that ])roduce these nervous phenomena, when high temperature is present, is still an unsettled (Question. Again, scarlet fever may run an irreLriilar <'ourse in those cases in which there is jnesenf an extensive inliltiation of the tissue of the neck, with inllatnmatory i)roducts. swell- 320 SCAELET FEVER. ing of the glands, and extensive suppuration. Not infre- quently these cases terminate fatally; doubtless in some cases the extensive suppuration in the areolar tissue about the neck produces this result, and in other cases it is pro- duced by the interference with respiration caused by en- largement of the gland and swelling of the tissues of the neck. In these cases there is a certain amount of danger from oedema glottidis, the consequence of extension of the inflammation from the adjacent tissues. There are cases in which the eruption is not very well marked ; the patient passes safely through the stage of eruption, and the stage of desquamation is fully estab- lished ; but, instead of making a good recover}^ from this point, immense abscesses are raj)idly developed in the cervi- cal region, blood-changes begin to manifest themselves — such changes as allow of the occurrence of hemorrhages — and the patient passes into a typhoid condition, with hem- orrhages occurring from the nose, mouth, intestines, etc., and death ensues. Such a result is produced by the peculiar action of the septic poison developed during the suppurative process. I have already referred to a scarlatinal coryza, in which the discharge contains elements capable of producing septic poisoning. I have come to regard this coryza as an unfa- vorable symptom. The clear serum which runs over the lip never causes death ; but the fact that it sometimes pro- duces excoriation and ulceration of the tissues with which it comes in contact, indicates that there are nasal and pharyngeal changes which may destroy life ; especially is this the case in young children. Sloughing ulcers sometimes develop in the mouth and throat ; and, when they do occur, the patient is said to have ulcerative stomatitis ; but these ulcerations are really due to a peculiarity of the scarlatina poison. Under such circumstances, your patient may go on through the period of eruption, enter the stage of desquamation, and then rapidly sink and die, with symptoms similar to those which attend diphtheria. Although the odor of the breath may very closely resemble that noticed in some cases of diph- SEQUKL.E. '.V2l tlit'iia, tlifiT is no (li|ililliiTitic I'Midaiion present. Wln-ii diphtlit'iia docs occur, it is (Irvch^iifd as ii coinijlicatioii or siHiiit'la ; it (Iocs not Ix'loiiii; to the' I't-gular liistoiy of scarhi- tina, and is an ••nlir»'l\" ditVfi-<-nl disease, dcjx'ndiiiL;- ujtoii an cntin-iy dilVcicnt poison, wJiich makes its upjx-aiance alter the scarlet fever ])oison lias s])ent itsell*. Reniend)er that scailalina and di)>hiheria are distinct dis(:'ases, and cannot he develo})ed the one from tiieotiier, and tliat the condition I have l)een descrihiiii;-, whicii resembles di])lit]ie- ria, is siin])ly a scarlatinal coryza which indicates the exist- ence of slou,!j;hini; phar3ii,i^itis. Scarlatina ma}' also be miide to run an irregular course by the development of intlammation of the internal eai*. This intlammation extends from the throat ii]) the Kusla- cliian tube, involves the middle ear, and gives ris(^ to a train of symptoms, such as intense pain, delirium, and rolling of the head, all of which suggest the ])resence of acute meningi- tis. I recall several instances in whicli the diagnosis of acute meningitis was made, where from the after history of the case there was no question but that the symptoms were due to such an intlammation of the middle and internal ear. AVhen such an intlammation occurs, you should be prepared to relieve 3"our patient. The method of ])rocedure for the relief of this condition you will learn from lectures in an- other department of medicine. All these dilTering conditions I have been describing are usually spoken of as complications of scarlet fever, but I believe them to be nothing more than a part of the regular history of the disease. We tind the same thing true in re- gard to many other diseases. CoMPLiCATioxs AXD Sequel.e. — I coine now to speak of those conditions which may be regarded as the sequehc or complications of scarlatina. The most common sequtda is anasarca. The anasarca of scarlatina usually ap})ears at the time the patient is convalescing, during the ])eriod of desquamation, or just as desquamation is being com])leted. It has been connnonly believed i)y the ]»rofession that ana- sarca is due to some exposure to the inlluence of cold during this period. It is quite possible that the chanixcs in the 21 322 SCAELET FEVER. kidney wliicli give rise to the anasarca may sometimes be produced by the influence of cokl, and undoubtedly ana- sarca is occasionally developed in this manner, but in the majority of cases it is due to some peculiarity in the scarlet fever i)oison, or to some peculiar atmospherical condition. During some years anasarca is a very common sequela of scarlet fever ; while during other years we have equally severe cases of the disease, and yet scarcely a case of ana- sarca is seen. While we recognize the fact that it is possible for kidney lesions to be developed which shall give rise to anasarca in consequence of exposure to cold, it is also of importance that we recognize the fact that the lesions and the anasarca may be developed independent of such exposure. The anasarca first shows itself on the face, and from the face it extends over the entire body, and if it becomes general you will usually have more or less ascites developed. In most cases, at the time or previous to the occurrence of the anasarca, you will have certain premonitory symptoms, and it is of great importance that you should be familiar with these symptoms, and be on the watch for their appear- ance. For two or three days previous to their development a certain restlessness will be noticed, with nausea and vomit- ing. These symptoms are almost universally present. The nausea and vomiting so commonly present during the earlier periods of the disease have subsided, and now, during the period of desquamation or perhaps after it has been completed, the vomiting returns. The patient has some pain in the head, has loss of appetite, is annoyed by the light, does not sleep well, and the temperature is raised perhaps two or three degrees. When your patient com- plains in this manner during the desquamative stage of scar- let fever, your suspicions should be aroused, and if you have not already examined his urine you should do so at once. It will usually be found scanty and high-colored, will contain albumen and casts of the exudative variety, and perhaps blood-casts. Occasionally, epithelial casts are found; usually, however, these casts are not seen until later during the disease. If you have made previous examina- tions of the urine before the development of these symp- SEQCTEL.E. 323 toms you may liiive found renal ('])ifli(>limn, wliidi an' usually found in an}' seven* case of scarlet Icvei-; but mow there an? ])n'sent casts which indicate tin? (\\ist«'nc(' of :in active intlainniatory process in the uriiiift-rous tubules. It is not the ('])itht'lial desquamation oi" ihc tubules, wiiich oc- curs in connt'ction with thi- (li'S(|uaination which is takiu;; place over the riitiif sui facr of flu' Inxly ; but it is a distinct sequela of the disease, which shows itself in the form of a tubular uephiitls. It is ])()ssible to have a i)arenchymatous nephiitis devehqied in coiise([Ueiice of exposure to cold durinii" this sfauv c)f scarlet fever, but this nephritis is due to the direct elfect of a ])oison which is acting upon the se- creting portion of the kidnevs. After the anasarca has been present two or three days, if the case is to have a favorable termination, the anasarca will begin to decline, will be less and less marked about the face and feet, the tendency to stupor which has accom- panied it will begin to disappear ; and as the dropsy sub- sides, and the patient is not so lethargic, the appetite be- gins to return, the urine increases in quantity, the albumen diminishes, the casts disappear, and convalescence is fully established. Anasarca may have been developed, all the symptoms have disa]>peared, and the patient have recov- ered within two weeks from the commencement of the at- tack. Such anasarca is due to a simple catarrhal inflam- mation of the uriniferous tubules, and as complete recovery may take place as after an ordinary catarrhal inflammation affecting the bronchial tubes. If, however, after the anasarca is developed, the case is to go on to an unfavorable termination, the anasarca instead of diminishing will increase, the face will become more and more puffy, the legs more and more crdematous, the abdomen more and more distended, the ])ulse more and more fn'ciuent and feeble, the temperature mure and more elevati-d, until a condition of coma is finally reached, which condition is sometimes preceded by convulsions, and followed bv death. I have given you a brief outline of the usual course of a case of scarlatinal nephiitis. wli-'iher it goes on to recovery or to an unfavorable termination. 324 SCARLET FEVER. It is possible for bronchitis or pneumonia to occur as a complication of scarlet fever, but they are of rare occur- rence. As I have already stated anasarca is the most com- mon sequela, and if you will remember when and why it appears you will rarely fail to recognize its occurrence. Another sequela of scarlatina is inflammation of the serous memhranes. The serous membrane most liable to be involved is the endocardium, and this inflammation may pass unrecognized unless you are on the watch for its oc- currence, for there may be no rational symptoms present. Endocarditis, when it does occur, is liable to be ulceratim in character. As the result of such ulcerative endocarditis you may have septic symptoms developed, or embolism oc- curring in consequence of the removal of a portion of mate- rial from the ulcerated valve, and a subsequent plugging up of an arterial twig in some distant part of the body. If a portion is removed and carried by the circulation into the brain, and has been lodged in one of the cerebral vessels, it will give rise to sudden coma, and unless you have been very closely watching your patient you may be at a loss to account for the sudden development of the embolic symx3- toms in a patient who seemed to be doing well. If the endocarditis is not of the ulcerative variety, the patient apparently recovers and you discharge him as cured of his scarlet fever. Two or three months after his dis- charge, he comes back to you complaining of shortness of breath, and probably you will suspect and search for chronic kidney disease and find no evidence of its existence, but you will find the signs of chronic endocarditis, the result of the acute endocarditis, which you had failed to recognize. Inflammation of the pericardium may occur as a compli- cation of scarlet fever, but it does so much less frequently than inflammation of the endocardium. Inflammation of tlie pleura, and occasionally inflammation of the peritoneum is met with as a sequela of this disease. I have seen death caused by an acute peritonitis which occurred as a sequela to scarlet fever, but if peritonitis does occur it is much more likely to be subacute in character. It is possible to have peritonitis developed as a sequela to scarlet fever and to sp:quel/E. 325 be ontin^ly rocovorod from. T liavo had two patients re- cover wlu) liad ascites, tlie result of subacute jn'ritoiiitis as a sequela of scarlet fever. Klieumatisni may be developed during the d«'squamative period of scarlet fever. Under such circumstances it assumes the ordinary a])pearances of inflammatory rheumatism. Quite rapidly it invades one joint after another, the joints become red, swollen, and painful, the temjx'rature rises, and the pulse becomes accelerated; but the attack is of sliort du- ration, usually does not last more tlian four or five days. It is not a serious sequela, and complete recovery usually occurs within ten or fourt>^is. :{-i7 resemble tluit of scarlatiun, yet the dcvelopiueuL of the lir^t vesicle settles the question. The ap]ieiinince of enjlhema bears a closer resemblance to a perfi'ctly developed scarlatina eruption than does any other eru})tive disease. It is not, however, present on the extremities, neck, and portions of the trunk, and spreads in a very irregular manner ; whereas in scarlatina such is not the case. I5ur if, on account of the scantiness of the scarla- tina eruption, any doubt arises as to the nature of the erup- tion, remember that in scarlatina the throat symptoms are rarely absent, that usually tlie tongue presents the straw- berry appearance, and that at an early period there is usually some swelling of the cervical glands. In those cases in which, during the early part of the disease, it is impossible to make a differential diagnosis, when the period of desquamation is reached the diagnosis will be readily made. The differential diagnosis between roseola and a very mild form of scarlatina is sometimes attended with great difhculty. If scarlatina is prevailing, and a child has an eruption which lasts for two or three days, then disappears, and is not followed by desquamation, you very natui-ally come to the conclusion that the case is one of scarlatina ; and yet the sequela proves that the case was one of roseola. Such a form of roseola sometimes prevails epidemically, and attacks the children in a certain locality, wh.'ther they have or have not had scarlatina. Under such circumstances, adults and children are said to have had a second attack of scarlet fever. In making a differential diagnosis between this form of roseola and scarlatina you must be guided by the duration of the eruption and by the character of the throat symi>- toms. In sctirlatina the posterior part of the pharynx is affected, while in roseola the redness is confined to the an- terior portion; besides, the throat affection in roseola is much milde-r tha-n in scarlatina. One can hardly mistake erysipelas for scarlatina, for erysipelas comnuMices at one point and from that ix>int gradually extends ; there is also marked a^denui of the con- 328 SCARLET FEVER. nective tissue, and there is a very marked difference in the constitutional symptoms of the two diseases. There are malignant cases of scarlet fever in which no eruption appears ; they prove rapidly fatal. In such cases, you must be guided in your differential diagnosis by the fact that an epidemic of scarlet fever is prevailing (which is usually the case), by the rapid development of the disease, by the very high range of temperature, and by the very grave nervous phenomena ; all of which cau only be ac- counted for on the ground that your patient is overwhelmed b}' some ver}'" active blood-poisoning. In no other infectious disease do we have such violent sjnuptoms, nor does death take j)lace in so short a time. In this class of cases you should frequently examine the entire surface of the body, for the eruption is sometimes very transient, perhaps a]3pearing only for a few hours on the neck or extremities. It is sometimes difficult to draw the line of distinction between scarlatina without an erup- tion, with swelling of the cervical glands and ulceration of the throat, and diphtheria. If a patient has swelling of the cervical glands and well-marked febrile symptoms, which have come on graduall}^, that is, have been two or three days developing, and yet no scarlatina eruption has ap- peared, but a gangrenous ulceration has developed involv- ing the tonsils, the posterior wall of the pharynx, and the anterior pillar of the soft palate, if scarlet fever is prevailing in the locality it is very difficult to decide between it and diphtheria. There can be no doubt but that scarlatina poison may excite a tubular nephritis without an eruption appearing upon the surface of the body, or without any of the other ordinary symptoms of scarlatina. Prognosis. — The prognosis in scarlet fever is always un- certain. It will be influenced more by the character of the prevailing epidemic than by any other circumstance. According to statistics, the rate of mortality ranges from one death in five to one in twenty. Some epidemics are very mild. During one epidemic, in one month, I treated fifty cases of scarlet fever, with only two deaths. During the PfiTiio month of \ho followiiin* y»':ir, I tivatcd twi^nty riisfs with si'vt'ii (l«'ath:3. In iniikiiii^ your prognosis you must always tak.' into account tlio type of the prevailing disease. Evi'u when the disease is mild in character, and is running a i)t'rfectly regular course, dangerous symptoms nuiy sud- denly arise without an}^ assignable cause. The conditions of a favorable ]irognosis are as follows : when th<^ eruption a])pears within fortv-eight hours from the eoiniuencement of the attack, and ra])idly completes its course, reaching its maximum on the second day ; when the throat symptoms are mild, little difficulty being experienced in swallowing ; when the cervical glands an? but slightly enlarged ; when the temperature does not rise higher than 104° F., and the pulse beats only 120 per minute ; when the cerebral S3^mptoms are not severe, -and are of short duration ; and when the disappearance of the eruption is attended by a steady decline in temperature. Even if there i3 a slight affection of the joints and a moderately severe nephritis during the period of desquamation, a favorable termination may be predicted. The nephritic symptoms will almost always entirely disap]>ear during the third or fourth week. The conditions for an unfavorable prognosis are: when the disease pursues an irregular course ; when tln^ temi)era- ture rises above lO.j"" F., with dyspnoea and extrenu' fre- quency of the pulse ; when sym])toms of collapse come on, attended by a cold surface and a small pulse ; when the eruption assumes a livid hue, and there are abundant IhMuor- rhages in the skin ; whi'ii iilctTative ]ihai} iigitis is present, especially wlieu it extends to the nasal passages, accom- panied b}' copious coryza and infiltration of the glands and tissues of the neck ; when severe nervous symptoms are de- veloped with tyi)hoid sym]itoms ; when there is persistent and long-continued vcmiiting, with diarrhoea coming on at the commencement of the attack ; when the nephritic symp- toms are early present, and there is general drops}', exces- sive ha^maturia, or almost complete sup])ression of urine, with high temperature. The occurrence of any of the more serious com])lications to which I have already refern.'d, such as ])neumonia. diph- 330 SCARLET FETEE. tlieria, pericarditis, oedema glottidis, etc., always renders the prognosis bad. Before making your prognosis, decide whether the scarlet fever is regular or irregular in its course, and if irregular, what are the causes of the irregularity. By so doing, you will be greatly aided in making your prognosis. It is also important to determine your patient's power of resisting disease. Favorable hygienic surroundings, good nursing, and well- directed medical treatment will greatly lessen the death-rate in scarlet fever epidemics, and these should be considered elements of prognosis. Patients with scarlet fever do better when left to themselves than when badly nursed, or when under the care of unskilful medical attendants. Age is an important element of prognosis. The period of greatest mortality is from infancy to five years of age. Bej^ond this period until adult life, the prog- nosis is decidedly better. In adults, the mortality is great- est in 23regnant women, and those who are suffering from some organic disease, especially some disease of the heart or kidneys. Treat.alejSTT. — In connection with the treatment of this affection, the first question that presents itself relates to pro'pliylaxis or x>reT>entlon. The projyhylaxis of scarlet fever is a system of the strict- est quarantine. The sick must be removed from the healthy. As in other exanthematous fevers, all useless articles of fur- niture must be removed from the sick-room. Fresh air renders the contagion of scarlet fever less powerful ; there- fore, free ventilation is of the utmost importance. All the clothes and excretions of the patient should be disinfected in the same manner as in typhoid fever. To prevent the dissemination of the dusty particles of the desquamating epidermis, during the period of desquamation the surface of the body should be frequently sponged, and after each sponging the surface should be rubbed with olive oil. Those convalescing from this disease should not be allowed to leave their apartment until desquamation is completed, which usually requires at least three weeks after the com- TKKAT.MKXT. ^^l iiitMicvnionl of the ])('1M(kI of (l('sati(>nt should have a warm bath once or twice during the day, tlie sni'lace of tlio body being well washed with car- bolized soap. The baths hasten the process of desquamation and aid in bringing the skin into a healthy condition as rapidl}- as possible ; the kidneys will also be relieved, and you may prevent serious lesions from these organs. Such general means as are applicable in the treatment of all fevers may be employed. If the temperature of the patient rises above 103° F., certainly if it rises above 104° F., it is impor- tant that some measures be resorted to for its reduction. The temperature should never be allowed to remain at 104° F. longer than twenty-four hours. The means which are to be employed to accomplish this reduction are the antipyretic measures already referred to, such as the application of cold to the surface by means of sponging and baths, and the administration of large doses of quinine. There is a strong prejudice against the application of cold to the surface of the body in scarlet fever. I am by no means certain that cold baths are always safe, or that in all cases the application of cold to the surface is judicious treatment. At the present day, we are told that the kidneys will be most readily relieved of the scarlet fever poison when cold is used for the purpose of reducing the temperature, and that we should make use of this agent rather than permit the case to go on without effecting such a reduction. It is claimed that when the temperature of a patient is kept below 103° F., scarlatina nephritis rarely occurs. This statement is not sustained by facts ; it has been found that kidney complications are as extensive in the cases where cold is employed as in those cases where the temperature ranges higher and cold to the surface is not employed. We should be governed by the same rules in the appli- cation of cold to the surface in scarlet fever as govern us in the treatment of typhus and typhoid fevers. With regard to the use of quinine as an antipyretic, I need add nothing to what has already been said in connec- tion with its antipyretic power in the treatment of other TUEATMENT. 'yV-^ ft>v.Ms. It has tlie same pow.'r (tf reducing teniporatiiit' in scarh't fever tliat it lias in typhoid h'ver. Unless the tfiujx'rature in a ease of searh't fever ranges above 105° F., do not apply cold to the siuiace, noi- give quinine in anliiiyretic doses. With sucii a lenipeniture there will prol)al)ly be delirium, but it must be regarded as one of the phenomena of the disease, requiring no sjx'cial treatment. If the tem])eratur(^ rises above lO.j" F., perhai)S reaches 10(3' F. or 107° F., and the patient numifests the nervous phenomena which have been referred to, such as restlessness, tossing, blueness of the surface, tendency to coma, etc., your duty is to reduce the tem])erature either b}- the a])plication of cold to the surface or by the admin- istration of one or two antipyretic doses of (piinine. In all cases, let the patient be sponged frequently with tepid water, and if there is intense burning of the surface, add a saline to the water. Sponging in this manner will give the patient very great comfort. Some have advised that the surface be anointed with oil for the relief of the burn- ing. My own experience has led me to rely upon simple tepid saline water. I have found that it gives patients greater relief, is more easily a]q3lied, and in its use is more agreeable than any of the substances which have been used for this ]niiiiose. I have not found that the application of oil to tlie surface has any elfect in controlling the temi)era- ture, nor does it seem to have any effect on the process of des(iuaniation,and as soon as desquamation commenc(>s, tlie process should be assisted by fre([uent washings with soap and water. For the throat com])lications, whieh will give you more or less trouV)le in all severe cases, es})ecially when there is much enlargement of the glands at the angle of the jaw, causing difficulty in swallowing, leeches were formerly em))loyed, but their use has now been almost en- tirely abandoned. The vitality of the patient is lessened by their use, and on this account they are contra-indicated. Of all the remedies which I have em])]oyed for the relief of throat complications, I think <-old carbonic acid water the best. Whether it does more than all'ord relief, I am not able to say, but I am certain that cold carbonic acid waii-r 334 SCARLET FEVER. or pieces of ice held in the month, and brought as much as j)ossible in contact with the swollen mucous membrane of the throat, when used early, afford most marked relief. In the advanced stages of the disease, where there is great infiltration of the glands and tissues about the neck, cold api»lications do not afford the same relief as when they are used in the early stage; then cloths wrung out in tepid water and applied to the surface seem to be of ser- vice. During this stage, hot applications are generally much more agreeable to the patient. You may cover the hot cloths witli oil-silk. These applications will not hasten the suppurative process, unless suppuration is already established. While using hot applications externally, warm water gargles and steam inhalations may be used internally. Of these methods of treating throat affections, adopt the one which seems to you to be the most rational plan of treatment. In scarlet fever I favor the use of hot rather than cold applications. Whichever you use, use it to the exclusion of the other ; either cold internally and externally, or heat internally and externally. There are different opinions in regard to the action of heat and cold. Some claim that their action is the same. The superficial and deep ulcers which are sometimes seen in the throat of scarlet fever patients can best be treated by spraying them with carbolic acid, muriated tincture of iron, chlorate of potash, tannic acid, or any of that class of reme- dies. Whatever remedy you may choose, it can be much more successfully applied by means of spray than by a camel' s-hair brush or a probang. Such local remedies thus applied afford great relief. The pain from these ulcerations is sometimes very severe, and you will be obliged to resort to some measure for its relief. Bromide of potassium, ether, and other anodyne applications in the form of spray may be made with satisfactory results. In a certain class of cases, where there is marked disturb- ance of the nervous system, accompanied by great depres- sion of the vital and feeble heart action, you will be obliged early to resort to the use of stimulants. It is not necessary to wait until a certain stage of the eruption or of the dis- TREATMENT. .^:?.T ease is rracln'd l)i'fui(' cMiiimt'iiciiiir tlu-ir :iJi. It may be in'cfssary to rrsort to tlu-ir use within twdvt' lioiirs, or even within a less time, I'loin th<' conunrnctMncnt of llie attack, ill soMif cases 3''()n will r.-ly almost cntin-ly on tlio btMirlicial t'lVt'ct that may bf itroducrd by the free and rarly administration of stimulants. Tlu' aj)])roach of kidiu'V sf- quela in scarlet fever will be indicated by the drvehtpm.-ni of tliose pi'emonitory symj)toms which precede the ana- sarca; and whenever snch symptoms are develojx-d. you should ap})ly dry or wet cups, according to the c(»nilition of tlie ])atient, over the region of tlie kidneys, upon either side of tlie spine. Apply thiee or four cups on each side, and follow their application with hot fomentations over tlie kidneys. At tln^ same time raise the temperature of the sick-room to 73° F. or 74° F., cover the body of the ])atient with flannel, administer hot-air or warm baths, and early commence the administration of diuretics. Of these, digi- talis wdll act most favorably. If the anasarca does not dis- appear under the influence of the digitalis and the other means employed, calomel may be combined with the digi- talis, and its use continued for a few days. Why the action of diuretics is increased by having a mercurial com- bined with them I am unable to say ; but the fact is well established that, in certain cases — when the patient is going on from bad to worse, when the anasarca is increasing, the tendency to coma is becoming more and more marked, indi- cating an unfavorable termination to the case, and cu])s have been a])])lied, hot baths, and diuretics em]»loyed with no satisfactory^ result — if small doses of calomel aie cdm- bined with tlie diuretics, and their use continued for two or three days, th«' entire ]>hase of tlie case may be changed. In conjunction with the measures recommended, let the patient drink as freely as ])o-^sible of water. If convulsions occur, or threatening symi)toms indicating the apjuoach of convulsions, are developed, you will be justilied in resort- ing to the use of opium, either h3])odermically or by the mouth. Fnder such circumstances the elTect of o]>inm is ofteu most satisfactoiy. ll luit only an-'sts the c(.iivulsive tendencies, but produces tiie most profuse diaphoresis, and 336 SCARLET FEVER. aids in restoring the renal functions. With this chass of patients I am confident that I have saved life by the timely use of opium. In my published articles on Bright' s disease I have very fully discussed the subject, and given the rea- sons for its administration. It is unnecessary for me to detain you with the special treatment of the different complications wliich I have stated as liable to occur in scarlet fever. The treatment of each complication will be hidicated by the character and severity of the complication. There are many other minor points in the management of this disease. I have given you an outline which I think will enable you to fully appreciate the general indications, and I must leave many of the details of treatment to your own study and experience. LECTURE XXIX. MEASLES. 3forb id A natomy. — Etiology. — Symptoms. ^YE now come to the study of another exantliematous fever, namely, measles or niheoJa. This is of much more frequent occurrence tlum any of the fevers which have been engaging our attention. It is a disease from which few per- sons escape. It is essentially a disease of cliildliood, but it may occur at any age ; it is, however, less liable to occur in young infants than in children after the period of dentition. A second attack is of rare occurrence. It is characterized by an eruption of red spots, accompanied by a catarrh of the mucous membrane of the air-passages, and a more or less severe fever. It may prevail as an e])idemic or endemic disease, and not infrequently there are sporadic cases of measles. Morbid Axatomy.— The anatomical lesions of measles, with the exception of the eru])tion, are similar to those of small-pox and scarlatina. There are the same changes in the blood ; it is dark-colored and flnid, poor in fibrin, and in severe cases shows a tendency to infiltrate the tissues. The number of red globules are diminished, and the white ones are increased. There is the same tendency to congestion of the internal organs. The spleen and liver are moderately enlarged. The mucous membrane of the nose, ])liaryn.\', larynx, and larger bronchi, as well as the conjunctivae, are more or less intensely congested, and ])ri',sent all the ana- 2-2 338 MEASLES. tomical changes of acute catarrh. In the majority of instances this catarrh is most severe just before and during the early period of the eruption; generally, it begins to dis- appear when the eruption has reached its height, and within two or three days entirely disappears. Where death has resulted from measles, in the majority of autopsies you will find evidences of capillary bronchitis, and not infre- quently evidences of catarrhal pneumonia. Strictly speak- ing, these are not anatomical lesions of measles, but complications ; they are, however, such frequent attendants of this disease, that they almost become a part of its his- tory. Catarrhal affections of the respiratory organs are rather characteristic of the measles. The eruption of measles is papular ; the papules first show themselves upon the face, especiallj^ upon the chin ; gradually they extend to all parts of the body, until lastly they are seen upon the back of the hands. When the eruption is well developed the spots are slightly elevated, and have a diameter varying from one-tentli to one-twentieth of an inch ; in form they are crescent-shaped, their margins are sharply defined, usuall}^ their color is of a bright red, sometimes shading off into blue. In most cases the spots are distinct and sepa- rated from each other by pale tracts of skin ; the}^ may become confluent, and thus give to the surface an uniform redness. When this occurs the surface presents an appear- ance similar to that seen in scarlatina. The earlier papule in each spot usually occupies the place of a hair-follicle. The spots disappear on pressure, but immediately return when the pressure is removed. Sometimes each spot con- tains several papules. The diversity in form and appearance of measle spots in different cases depends upon deviations in size, elevation, and grouping of the papules. When the spots assume a dark-red color, and do not disappear on pressure, capillary hemorrhages have taken place into the papules, and the eruption is called hemorrhagic. When the eruption is very abundant, little vesicles sometimes appear upon the papules, especially upon the trunk when there has been profuse perspiration. As soon as the spots have reached their maximum of development, their color KTIOT.OCV. n^O l)(\u-iiis to fndc ; iln' fadiinj; is ])ro^ivssi\'t', llu^ ct'iih'"- of tin* S})urs loii^ii'cst rt'taiii llii-ir icdm-ss; (lie clcvalioiis subside witli loss of color. In a varyiiiLT liiiH', rioiu oiw to live days, the sjK)|s fiilii'"-! y disaj)])i'ai\ li'a\iiii: a y<'ll<»\\i^li oi' Ihow iii-li stain. This staiiiiiiii; is due to jiit^iin'iilatiMii of the skin, and is sonictimcs visible for two weeks. Ivxfdiialion of tl ]>i- denuis or desciuamalion lakes |)la('e only u])mii (he sid'S of the nieasle s])ots ; it is never so extensive as in scarlet U'Vi'V. The skin does not desquamate in layers, but in line brown scales. It may commence before (he rednessof the .Mii]tlioii disa})])ears, but it does not usually occur until the eiuji- tion lias entirely faded. In most cases the period of des- quamation is short, rarely lasting a week. Etiology. — As n^g'ards theeti(^lostion but that the disease caji ])e con- veyed in i'lothing, or, in otli'i- woids, that it is a portable 340 MEASLES. disease. I regard the infection of measles as more tena- cious, so to si)eak, than that of small-pox or scarlet fever. That is, a person not protected when exposed to measles is much more certain to contract the disease than is an unpro- tected person to contract small-pox or scarlet fever, the same circumstances surrounding the exposure. It is pos- sible for the infection to be conveyed from one place to another in clothing and in fluids. I know of one instance in which it was brought to a family in cow's milk. The exact nature of this poison is still unknown. It has been claimed that a certain cell has been found, a cell Avith a tail-like end, movable and colorless, which has the power of developing measles, but these statements have never been substantiated, and like the theory that the syj)hilitic cell was the active agent in the development of syphilis, this theory of development still lacks facts to sustain it. The microscope has not as yet revealed the contagion of this disease. All that can be said vdth positiveness concern- ing its nature is, that there is an impalpable virus which may be conveyed from' an affected to an unaffected person, and when received into the body of an individual who is not protected from the contagion by a previous attack, after a certain period, varying in length from eight to four- teen days, it produces the phenomena which characterize the disease. Some claim that the poison may remain sixteen days in the system before the phenomena of the disease are developed. One case is recorded in which the disease is said to have been developed fifty days after exposure. This period is termed the " period of incubation," audits average duration is eight days. During this period the poison remains latent, giving its possessor no knowledge of its presence. In most cases a slight exposure is sufficient to induce the disease ; in some cases it is contracted only after prolonged exposure. Susceptibility to this contagion is almost universal. All classes are equally subject to the infection. Second attacks are exceedingly rare. symi'thms. 341 Till' cxnct tiiut' ill tlic course of iIk* disease wln-n nwasl^'S is most infectious is not drliuili'ly detcrniincd. Sialistics furnish almost absolute jtroof that it ma> infect throUL^h- out its entire course, in the ])recursory, eru})tive, and des- (luamative stage. Sv.MP'ro>[S. — Nfeiisles, like t jic < >t lier exaut hemat:itit'iit to cough pt'rlia])S for two or tliivc (Itiys without ('X])i'('t()ration, or any att('ini)t at I'XjjfC- loration. During this jii-iiod tlir ])ulst' will raiig<' from 100 (o 120 bi-ats }HT iiiiimh'. aii0' F. or 107 F. As soon as the ernjiiion begins to decline, a marked eil'ect will be ])roduced, and usually the tem])era- ture falls two or three degrees. As the decline in the erup- tion goes on. tlie temperature gra and is a v<'rv uiifavoial)!.' \y\u- of lli.- disoaso. At lirst the eni))ti(Hi ]»rt>s<'nts tlif suiiif appearance as the onliiiaiy erui)ti()ii of luraslcs; but, aftn- tlir fever lias coiitimu'd a few days, it assumes a daik color, the patient hfcomes restless, the ton.«;iie dry, tli. iv may be voniitin^^ and diai-- rhani, and, if death occurs, at the ])ost-ni()rteni examination 3'ou will lind that the anatomiT-al lesions very closely re- semble those found at the ])ost-morteni examinati(ui of one who has died from tyjOioid fever, such as changes in the s])leen and elevation of Peyer's ])atclies. These cases are also known by the term " black measles." We have, then, two forms of black mr'asles — one in which the erujttion consists of petechial s})Ots scattered over the surface, and dependent upon a hemorrhagic tendency ; in the other form the eruption assumes a dark appearance, on account of changes wMiich have occurred in tht? blood, the result of a very high degree of temperature at an eaily })erio(l of the attack. I have thus l)iieny spoken to you of the most frequent irregularities in the course of this disease. There is always more or less danger connected with any of the more severe forms of irregular develo})Uient. Although measles is usu- ally not a disease of much severit}^ yet you must remember that, however mild the ty])e may be, the disease is liable to be complicated, and the most fretpient complications are to be found in tlie respiratory organs. CoMi'LiCATioxs.— Of these the most important is ca])illary bronchitis. You will rarely have a case of measles without more or less bronchial catarrh, but the bronchial catarrh which ordinarily attends it is not of much conse([uence. When, however, you lind that the broiu-hitis is l)ecoming cai)illary, you must recognize the fact that the patient is in great danger. Ui)on auscultation, if instead of loud, sonorous rales, which indicate that the catarrh is conlined to the larger bronchial tubes, you have line crackling sounds, accompanied l)y aii entire loss of or an extremely feeble vesi<,'ular murmur, you may be certain that the ca- tarrhal intlammation has extended into the finer bronchial tul)es, and when, in connection with this disease, these are 346 MEASLES. invaded, you should remember that there is always great danger of the plugging up of the fine bronchial tubes. Tliis will almost certainly be followed by a lobular collapse, and a subsequent development of lobular pneumonia. A catari'hal pneumonia which complicates measles is always attended with great danger. As a rule, it attacks bofli lower lobes at the same time, especially their dorsal asjject, while in the upper lobes only a few tubes are involved. This complication may occur at any time during the course of measles, but it is more liable to occur just after the eruptive stage. Its development always increases the fever in proj)ortion to the extent of lung involved. Desquamative nephritis may occur as a complication, but is not of as frequent occurrence as in scarlet fever. You will rarely have anasarca or the other attendants of scar- latinal nephritis. Secondary meningitis not infrequently occurs as a com- plication in measles. When it does occur, it is developed during the period in which the eruption is disappearing. It is more likely to occur in this disease than in scarlet fever. In connection with measles you will have what may be regarded as a sequela, a mild form of oj^hthalmia. This ophthalmiamay considerably inconvenience the patient, and lead to permanent injury of the eyes. It is especially im- portant that you should remember that it appears during the convalescing period, that it is a conjunctivitis, and usually entirely disappears if the eyes are frequently bathed with warm water and properly protected from the light, Otorrhoea, or inflammation of the external ear, is another complication, or rather sequela of measles. It most com- monly appears in those j)atients who have what is called a strumous diathesis, have phthisical parents, are themselves badly nourished, and have suffered from a severe form of measles. This otorrhoea is sometimes very obstinate, and if it jdelds to treatment, does so very tardily. In adults, acute miliary tuberculosis not infrequently occurs as a sequela of measles. This is the unqualified statement of the books. COMPLICATIONS. IM? Williiii till' jxist two y.'Mis I liiiv.' s.'.'ii two ciiscs of wli:it, pivvioiis to death, smut'd to he acute tiil)erculosis, and when the autop^}' was made, throughout the lun^: sub- stance here and thei-e were little i)oints or ii(mIu1<'> which presented tlie usu:d ai)}iearance of niiliary tuberch-s, l)Ut, when niicroscoi)ically examined, they were found to he points of vesicular itiieiuiionia. These two patients really died I'roni i)neumonia, and not from acute tul)ercuh>sis, although the lungs presenttnl the a})pearances ordinarily seen in connection wdth acute tuberculosis. The gross ap])ea ranee of the lungs so closely resembles lungs that are the seat of acute tuberculosis, that it is diffi- cult with the naked eye to distinguish tlie one from the other. The mucous membrane of the intestinal canal may also become tlie seat of important complications in measles. A mild form of gastric catarrh is of quite frequent occurrence, but is rarely serious in character. Severe intestinal catarrhs, giving rise to troublesome diarrhoea and dysentery, are sometimes very serious complications, especial I3' in very young and feeble children. Occasionally malignant e})i- demics of measles prevail, during which fatal results are chiefly due to intestinal catarrhs. Diphtheria does not so frequently comi)licate measles as it does scarlet fever. It generally makes its ai)pearance at the acme of the eruption, and when severe its occurrence is marked by a raj)id rise in temi)erature. The symptoms of the di])htii(^ria are the same as when it occurs as a ])rimary disease. Inspection shows the dii)htheritic exudation on the tonsils and pharynx, accom])anied by all the atti'Fidant phenomena of ordinary dii)htiieria. Sometimes the diph- theritic exudation appears on the labia of the female, and on the genitals of the male. It must always be regarded as a serious complication. Not unfrequently measles leaves the patient in a state of general ill-health. Especially is this the case in scrofulous and racliitic children. LECTURE XXX. MEASLES. Differential Diagnosis. — Prognosis. — Treatment. — Rose- ola. — Miliary Fever. We will continue the liistoiy of measles, and tliis morn- ing I invite your attention to its differential diagnosis. DiFFEKENTiAL DIAGNOSIS. — Ordinarily, when the erup- tion is well delined, the diagnosis of measles is not difficult. In some cases, however, the ernption presents an appear- ance which closely resembles that of the eruption of scarlet fever and roseola. As I have already stated, in nearly every case of measles the catarrhal symptoms j)recede and accompany the pre- cursory stage, and increase in severity during the period of eruption. The presence or absence of these catarrhal symptoms will enable you in the majority of cases to make a differential diagnosis. It has been said that the line of distinction between measles and scarlet fever may be easily drawn ; that if in scarlet fever 3^011 j)ass your finger-nail lightly over any por- tion of the surface of the body, a white line will remain, which will immediately again become red. Whereas in measles no mark will usually be left ; but, if a white line does remain, the color produced is more permanent than in scarlet fever. In well-marked cases this appearance may settle the question of diagnosis, but in those cases in which the eruption of measles closely resembles that of scarlatina, DIFFERENTIA T. DIAriXOSIS. — rPvOONOSIS. 349 W(» are c(nni)t'llrani<'(l by eatanlial syiii))- toiiis. In tyi)hus fevi-r, (|uiti' frfi|ii<'iitly, ihtvoiis symit- toms are present, such as dfliiium, ])rostration. and t'-ii- dency to coma. Such symptoms are only met with in the liemorrliagic or tyi)hoid variety of measles. Before the aj)- pearance of the erui)tion a careful examination of the mu- cous membrane of the pluuynx will settle the question of diagnosis. In measles the mucous surface will be more or less intensely injected ; in t\plius fever it will not be so injected. The difTereutial diagnosis between measles and small-pox has already been considered. There will certainly lie no difficulty in making a diagnosis, if you wait until the third day of the eruption ; then the small-pox vesicle is formed. The same is true of varicella and other vesicular diseases. The eruption of measles differs from that of roseola. In measles it is partially confluent, in roseola it is non-contlu- ent. In roseola the mucous membrane of the fauces is not intensely injected. In measles the fever runs a characteris- tic course. If the temperature is normal, if the eruption on the trunk is of a bright red color, if the surface is smooth, and if catarrhal symptoms are absent, you may exclude measles. The non-contagious charactearance of the eruption, measles may l.)e mistaken for an ordinary in- fluenza. PiioGXOSis. — The prognosis in uncom]>licated meash's is always good. Any irregularity in its dev.'h)iiment, and dentition in children, may render the prognosis unfavora- ble. In the hemorrhagic, in the ulcerative, and in the ty- 350 MEASLES. phoid variety, or black measles, as it is termed, the prog- nosis is grave. Measles occurring in pregnancy almost invariably' prove fatal. Ill severe cases, the deviations from the typical course of the disease which render the prognosis unfavorable are a temperature of 105° F. or 106° F., during the period of ini- tiatory fever, a retardation or an irregular! tj^ in the appear- ance of the eruption at the beginning of the eruptive stage, and the occurrence of complications, especially broncho- pneumonia, croupous laryngitis, and diphtheria. Profuse hemorrhages from the mucous surfaces during any period of the fever, render the prognosis unfavorable. The hygienic surroundings of the patient greatly influence the prognosis. The prognosis also depends upon the age of the patient ; the rate of mortality is much greater among adults than children. The character of the prevailing epidemic deter- mines to a very great degree the prognosis. When measles is developed in one who is suffering from a severe chronic disease, especially some organic disease of the lungs, the prognosis is unfavorable. The patient will not probably die during the active period of the measles, but the chronic pulmonary disease may terminate fatally from the effect produced by the sequelae of measles. For instance, a person has evidences of consolidation about the apex of the lung, a condition which justifies a favorable prognosis ; let measles be developed in this same person, and capillary bronchitis, terminating in a more or less ex- tensive pneumonia, will probably occur, from which acute phthisis may be developed. In measles, death rarely occurs during the first w^eek of the disease ; it usually takes place during the second week ; if serious complications occur, it may take place later in the disease. TiiEATMEisTT, — The prophylactic treatment of measles con- sists in isolating the affected person. When the disease runs its regular course, the principal duty of the physician is to watch for and guard against the occurrence of pulmonary complications. As regards treat- TnKATMKNT. :?."!l moTif, all tliat is necessary is to place the paticul in a larLj*', well-vciitilatt'd room, with the t<'m])<'ratun' of (;:{ V. or (').")' F. Tin' (lift should I)'' milk. Tln' room should bf dark»'in'd, so tliat the coiigest<'(l conjuucllx ;r may not Ix* exposed to light. If tlu' patient comiilains of itchinLi: and huininL; of tlie surface, he maybe frt'(|U"'ntly s])om;t'd with b'pid watri-, this causes an alleviation of tin- itching and buining, and reduces the tem]ierature. In an ordinary case this is all that will bt? required. Hot drinks or stimulants have no power to liasten the a))pearanc<' of the eruption; the admin- istration of the latter may be followed by very injuri<»u3 results ; convulsions ma^' occur and death ensue. In an ordinary case, stimulants should never be adminis- tered during the initiatory i)eriod of the fever, unless there is some special indication for their use, such as gn'at pros- tration, or bronchial complication ; then they may sometimes be used with benefit. Covering the patient with heavy clothing does not hasten the appearance of the eruption. The greatest cleanliness should be observed ; besides, there should be free ventilation, avoiding all draughts in the sick-room. If there is thirst, cold water may be freely taken in small quantities at a time. If the case is severe, and the temperature rises to 103° F. or J 04° F., it may be reduced by fn.'qiiently sponging the sur- face with tepid or cold water. German writers recommend the cold batli in the treatment of measles. I should hesitate to place a ])atient with measles in a cold bath, on account of the great tendency in this disease to pulmonary complica- tions. Only a few days since I saw a child sick with measles, who had been treated with cold baths for the reduction of tempei-ature. I found the physical evidences of extensive lobular pneumonias, which the attending physician said had l)e»'n developed within the previous twenty-four hours, so that there was little doubt l)ut that the\' were developed subsequent to the baths. My own experience leads me in the treatment of measles to employ quinine as an antipyretic, in preference to cold to the surface, either by baths or ])a(ks. 352 MEASLES. You will recollect I stated that tlie post-pliaiyngeal catarrh is liable to extend into the larynx and bronchial tubes and give rise to bronchitis. One of the most impor- tant duties of the pli3'sician is to watch for the occurrence of this complication ; he should frequently examine the chest, and wlien the bronchitis is found to have reached the capillaiy tubes, should immediatly commence treatment for its relief. I have found the inhalation of steam to afford the greatest relief and best control the bronchial inflamma- tion. As soon as I find that the larynx has become so in- volved as to interfere w^itli the respiration of the patient, and there is danger of croupous laryngitis, I immediately order vaj)or inhalations and insist upon their continuance until the laryngeal symptoms shall have subsided. Some- times this subsidence will take place within two or three hours, and, again, not until after two or three days. I de- sire to impress upon you the value of vapor inhalations in the treatment of the laryngeal and bronchial complications of measles. I have come to regard them as of great value. When catarrhal pneumonia is developed it is to be treated in the same manner as catarrhal pneumonia developed un- der any other circumstances ; the patient should be sustained by the free use of stimulants. Pulmonary complications in measles are often the result of exposure to sudden changes in temperature ; the severity of catarrhal symptoms will alwaj^s be increased by such ex- posure, therefore it is of great importance in the manage- ment of a case of any type of measles that the patient should be protected against such exposure. When there is great restlessness during the fever of in- vasion, or during the early period of the eruptive stage, small doses of opium, in the form of Dover's powder, may be administered with marked benefit. The management of the different varieties of measles will be indicated by the general condition of the patient. In the ulcerative, hemorrhagic, and typhoid varieties, the free administration of stimulants should be early commenced. Usually in these varieties there is great prostration, and the thing to be accomplished is the support of your patient. OKiniAN' MKASI.KS. — MoKlUD AXAToMY. '.l^u^ GiKMAN Mi;a>ij>, or HjntJeinic Roseola. — Before leiiviii'; the subject of inetislt's I will call your aftcution to an alTcc- tion which has recently received the name of (IrniKin measles. It is C()niim»nly known liy llie term ro.^tula. or mock iiirash's. It has Ijecn reii;anle(l by some as a inodilied form of measles; by others as a niodilied form of scarh-f fever; again it has been thought to be a combination of th«' two diseases. Some writers maintain thai we are not justilit-d in calling this type of measles an independent and specific disease, but that it may endjiace any blotchy exanthemata, from the appearance of which we are unable to determine what we shall call the disease ; whether scarlet fever, or measles, or urticaria, etc. Later German writers regard it as an indejx.'iuh'nt all'ec- tion, a specific, acute, and contagious eruptive fever, and have given to it the name of rubeola. I am disposed to regard it only as a different tyix.* of measles from that which ordinarily prevails, and by way of distinction will call it German measles., ov epidemic roseola. MoKBiD Anatomy. — This affection must be regarded as one of the mildest of eruptive fevers. It lias prevailed epi- demically and endemically. The study of its morbid anat- omy has been almost exclusively restricted to the eruption. This is an exanthemata consisting of irregular spots, orhy- persemic blotches, varying in size from a pin's head to a large pea, usually slightly elevated, so that when i\\o hand passes over them the surface of the skin feels somewhat rough. Sometimes these spots occasion intense itching; they are (juite distinctly separated by healthy skin, and disappear under pressure. As a rule, even at the acme of the development of the eruption, their color is a '' jiale rose red," paler than the intense red of the erui)tion of scarlet fever, or the peculiar bluish hue of the eru])tion in sev«»re cases of measles. The eruption can readily l)e recognized. It is seen upon all parts of the body, but is most abundant upon the face and trunk. The spots are usually discrete ; they often lie crowded closely together, but they are not confluent, 23 354 MEASLES. The eruption is exceedingly fugitive, rarely remaining visible more than twenty -four or forty-eight hours. It may continue visible for three or four days. The period of its most marked development may be only a few hours — twelve hours is the limit. In some cases there is slight desquama- tion ; in most cases the eruption disappears, and leaves no trace, except in occasional instances, when there is a tran- sient and yellowish discoloration of the skin. Some writers affirm that the eruption may disappear and reappear alter- nately for several days, and when it has finally disappeared the disease has terminated, and there is nothing to fear from complications or sequelse. In certain rare cases vesi- cles resembling miliaria may be developed upon the hyper- ?emic spots, especially upon the back ; doubtless these are chiefly due to external conditions. Etiology. — Doubtless this disease is a contagious affec- tion. Nothing is known concerning the nature of its con- tagion. It is essentially a disease of childhood. In persons more than forty years of age its development is of very rare occurrence. It is conveyed from one person to another in the same manner as measles. It has been thought by some that women were more susceptible than men to the influ- ence of the contagion, and that high atmospheric tempera- ture has a great influence in its development. Symptoms. — Epidemic roseola is so mild an affection, that it is questionable whether it has an invasive stage. The duration of the stage of incubation has not been deter- mined. Generally, the symptoms which manifest them- selves two or three days before the appearance of the erup- tion are much less marked than they are in any other eruptive fever. Perhaps in many cases they escape notice. Quite frequently the eruption is the first symptom of the disease. In some cases there may be nothing more than a feeling of discomfort. In other cases the disease may be ushered in by vomiting, diarrhoea, and convulsions. In many cases, immediately^ preceding the eruption, and accompanying its appearance, there is well-marked fever^ headache, loss of appetite, and sometimes noticeable pros- tration. When the eruption is regular in its appearance SYMPTOMS. :V)r> it MiT.-cts first til.' facr imd scmIj), ih.-n <:i:i(lii;illy ••xt.-iids downward over tlif trunk and rxircniilirs. I'snally, the dt'Vflopinent and s))t'cd of tlir ciuiytion is ra])id, ])rrliai»s no more tlian two or three days beini? occMijiied in its l)assa<;(' ov(M- the entin^ body. Its duiation ui)on anyone part of tli.> body before it be^jins to disa].i)rar is not more than from twelve to twentj^-four hours. Within forty-ci-^lit hours it lias almost entirely disajipeared. In the majority of cases the temp«>ratnre does not rise more than lOOA^ F. to 101^° F. above the normal standard. It may rise from 102° F. to 104 F.° During the second day of the disease the temperature begins to fall. Sometimes it reachos the normal standard within twelvt^ hours, occasionally not nntil the third day. Sometimes it reaches it by crisis, at other times by gradual descent. The i)ulse increases and diminishes in frequency accord- ing to the rise and fall of temperature. The tongue is usually covered with a whitish coating, is dotted here and there with red and swollen i)apilhe. The mucous membrane of the fauces is generally congested, and the tonsils moderately swollen ; there may be some soreness of the throat. The mucous membrane of the air-passages is usually in a condition of mild catarrh, consequently at the onset of the disease sneezing and coughing are frequently pres- ent, ]>ut they are less marked and are of shorter duration than in the ordinary t^^pe of true measles. Suifusion of the e^-es with congestion of the conjunctival vessels is rarely present ; there maybe a slight degree of photo])liobia. The face and e3'elids are usually slightly swollen at the time the eruption makes its appearance, but this swelling rapidly disappears. In most cases, there is moderate swelling of the lymphatic glands of the neck, and enlargement of the glands at the nape of the neck. Moderate enlargement of the occipital glands may continue for a number of days. Sup])urafion of lymphatic glands has not been observed. The urine is usually normal ; it may, however, contain an abnormal amount of the chlorides. 356 MEASLES. You liave already learned tlie fact, that wlien this dis- ease runs its regular course, it is exceedingly mild in char- acter. So mild, that children generally dislike to remain in bed, and prefer to be out-of-doors and at play. Differential Diagnosis.— One of the prominent fea- tures of this disease is the close resemblance which its eruption bears to that of measles. In certain cases it may be impossible by the eruption alone to make a differential diagnosis. When the eruption of measles is not typically developed, a complete history of the case must be taken into consideration. When this has been done, usually there is no great difficulty in arriving at a correct diagnosis. Perhaps, that which will best aid you in making a dif- ferential diagnosis between roseola and measles is the fact that an attack of one does not protect against the other, any more than does an attack of varicella protect an indi- vidual from an attack of variola. This fact certainly establishes the non-identity of the two diseases. It has been questioned whether a person may not have a second attack of epidemic roseola. The latest observations go to prove that a second attack of roseola is of as rare occurrence as a second attack of measles or scarlet fever. Again, the evidence seems most conclusive that an attack of this disease does not protect an individual against the contagion of scarlet fever; nor does an attack of scarlet fever protect one against the contagion of roseola. An in- dividual may have an attack of German measles very soon after he has been ill with measles or scarlet fever. Prognosis. — The prognosis is always good. Complica- tions rarely occur. When they do, they are usually pul- monary affections. Treatment. — The treatment of this affection simply con- sists in protection against exposure. Tepid sponging will relieve troublesome itching, and reduce fever. Regulate the diet, and carefully watch the catarrh of the air-pas- sages. In some cases, a mild course of tonic treatment may be beneficial. As a rule, convalescence is rapid, and is completed without hindrance. MORBID AN'AT(»MV. 357 MILIARY FEVER. Tliis form of fever c;iniu)l strictly be ref^arded as a coii- tui^ious disease, but it so frtH[iit'ntly i)revails in (ujiinection with measles and scarlet fever, and lias a})i)arently so many elements of contagion, tliat 1 lia\ •■ inchub'd it in tlif list of contagious fevers. Some deny its existence as a distinct fever. \Vi it. is have described it under the names of auflontina, stKhtnd cx(in- t/icma, miliaria alba, etc. I shall adopt the name of miliary fever. Several diseases which are accompanied by sweating, and which exhibit a tendency to the formation of miliary vesicles, have been called miliary fever. L'ntil the occur- rence t>f the severe ei)idemic of the disease known as the "English Sweating Sickness," its specific type was not rec- ognized. It luis prevailed epidemically over limited areas, in Belgium, France, England, Germany, Italy, and Austria. In some of these epidemics one-fifth to one-tenth i)er cent, of the whole population of the invaded district has been at- tacked by the disease. The average duration of the epi- demics has been from three to four weeks, occasionally they have lasted from three to four montlis. MoKHin Anatomy. — Few j)ost-mortem examinations have been made, and those few have failed to reveal any charac- teristic lesion. During life the blood is thin, of a l)right-red color, and coagulates imperfectly ; after death it is thin and dark- colored. Generally, the internal organs present evidences of hyper- jomia. The mucous membrane of the air- passages is red and frequently covered with reddish mucus. The lungs and liver are generally filled with blood ; th(» latter is soft«'r than normal. The spleen is always enlarged and soft. Some observers have reported the kidneys to be in a normal condition ; other observers have reported them to be in a condition of congestion. The mucous membrane of the stomach and intestines is usually re(lden»'d, and presents here and there red spots. Occasionally these spots are very 358 MILIAEY FEVEE. numerous, and vesicles are sometimes seen in the small in- testines. By some these vesicles have been supposed to be swollen, solitary follicles ; by others they have been thought to be distinct miliary vesicles, similar to those which are seen upon the surface of the body. Superficial ulcers are sometimes seen, especially in the region of the ilio-csecal valve. The miliary vesicles which are seen upon the surface of the body, and the cutaneous eruption, are developed because the secretion of the sudoriferous glands cannot escape. The escape of the contents of these glands may not take place for two reasons : First, the gland-ducts may become obstructed. Second, the secretion may be so abun- dant that it cannot be transmitted by the gland-duct. In either case, the secretion emerges under the epidermis around the sweat-duct, and, as the scales are lifted uid, a small clear vesicle is formed. The liquid contained in the vesicle at first is transparent, has an acid reaction, and is said to contain free nuclei-cells, which have three or more nuclei ; these nuclei remain visible after the cell membrane has been destroyed by the addition of acetic acid. It has been claimed that the virus of the disease is con- tained in these polynucleated cells. After death, the skin becomes oedematous, and very soon the odor of decomposi- tion is perceivable. Etiology. ^ — It was formerly supposed that miliary fever was indirectly induced by scarlatina, the puerperal con- dition, variola, vaccinia, typhus fever, and other diseases, and that it was not a distinct disease arising from some constitutional cause. The prevalence of this fever in con- nection with these diseases gave rise to this supposition. Epidemics of this disease have generally prevailed during the spring and summer months ; from this fact one would be led to think that there is some atmospheric condition peculiar to these months. Again, the disease has most fre- quently appeared in warm, moist weather, and from this fact it has been supposed that some peculiar condition of the soil is necessary to its development. Certain epidemics ETIOLi)(;V. 359 Imvt' sliowii a close connection uiili coiifaminations of the soil, such as arise from nc^lfct of «lraina^<', collections of refuse, etc. Doubtless, such coiKlitions of the soil may in- crease its severily, iiml cause ii lo prevail more extensively, but facts do not jJiove tliiit, direcily oi- iiKlirtM-tl}', thi-y cause its (leveloiuu<'nt. The (lis.-ase u-iially :ii lacks healfliy adults, and occurs more freiiuently amoni; females than males. It attacks all classes, and its spread does not seem to be affected by crowding. It can hardly b(^ regarded as a contagious disease, in tiie sense that it can be communicated directly from tiie sick to the well. It does not seem to be well established that the disease can be develo])ed by inoculation with the contents of the vesicle, notwithstanding it has been supi)osed that certain cells in the fluid hold the contagion of the disease. Theinfn^tiuenc}' of the simultaneous occurrence of miliary fever, with epidemics of measles or scarlet fever, is unfavor- able to the theory that there is a specific relationship be- tween the poisons of these diseases. The view that there is an intimate relationshi}) between cholera and miliary fever has been accepted by some wri- ters, and the accession of the latter during the course of the former has been supposed to exert a lavorai)le influence over the course of the disease ; the opposite, however, does not appear to hold good, but, on the contrary, favors a fatal termination. Much remains to be learned in regard to the relationship existing between miliary fever and the other diseases which we have mentioned. The etiology seems to be mainly speculative and theo- retical. Symptoms, — The average dumtion of the disease is from five to eight days. It has three stages : First, ///c .vA///t o/" inrasi Ejiidomic Fcvor which prpviiilinl in the City of New York during the Suninier iind Fnll of 17'J."». New York, 17%. Beli.INI's, Laiuentus. a Mcchuuical Account of FeverH. Done into KngliHh. London, 17'20. Bennett, Dk. John Ht'oiies. Clinical Lectures on the Principles and Practice of Me«licine. New York. Wm. Wood «k Co., 1872. Beuenol'Ieh. M. Adkikn. Traitt!- des Fitivres Intermittcntea et Remittcntes. Paris, l^tio. Bert, Patl. Chalenr .\nimalc. Bibliographie. Nouveau Dictionnaire de Medecine ct de Chirurgic. Tome Hixioine. Paris, 18'>0. Beunauh M. Ci.. Physiologie et Pathologi*' dn Systi-me Nerveux. Paris, 1858. Bevan, Dr. Roijeut. De Scarlatina. Edinburgh, 1H0;{. 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PAOK Algid variety of pernicious fever 157, 158 Alkalies in the treatment of typhoid fever 77 Antipyretics in the treatment of simple remittent fever 140-148 " " " typhoid fever 00-73 " " " typho-malarial fever l!»S-200 Arrangement of sick-room in the treatment of measles 351 *' " " simple remittent fever 140 " " " typhoid fever 04 " " " typhus fever 347 Arthritic pains in relapsing fever 201 Astringents in the treatment of typhoid fever 77 Bibliography 365-384 Bilions remittent fever 141 Black vomit as a symptom of yellow fever 90 Blood, changes in the, in measles 337 " " miliary fever 357 •' *' pernicious fever 149 " " relapsing fever 258 ♦' " simple remittent fever 132 «« " typhoid fever 7, 8 " " typho-malarial fever 182 " " typhns fever 206 " " yellow fever 88 Bloodletting in pemicions fever 104 " typhoid fever 03 Brain, changes in the, in pernicious fever 151 " " scarlet fever 308 " •' tyiihoid fever 12 *' " typhus fever 207, 208 " " yellow fever 87 Bronzed liver in simple remittent fever 133 Cathartics in the treatment of dengue fever 173 •' " pemiciouH fever , 1<54 ♦' " typhoid fever 81 386 ii^DEX. PAGE Chronic malarial infection 173-180 " " definition of 173 «« «* differential diagnosis of 177 ♦« '« etiology of , 174 «« " morbid anatomy of 174 « " " " heart 174 " " " " liver 174 ti " • " " kidneys 174 « " " " spleen 174 " " prognosis of 178 «» " symptoms of 174-177 « " " diarrhoea 175 « " " gastro- enteritis 175 «« " " hemiplegia 175 " " '« hemorrhage 176 " " " hypochondriasis 176 " " " local anaesthesia 175 " " " melancholia 176 " " '• neuralgia 176 «' " treatment of 179,180 Citrate of iron and quinine in the treatment of dengue fever 173 Cod-liver oil " " chronic malarial infection . . 179 Colchicum " " dengue fever 172 Cold applications " " measles 351 " *' " scarlet fever 333 " " " simple remittent fever 148 " «' " typhoid fever.. 67-70 " " " typho-malarial fever 201 '♦ " " typhus fever 249 Collapse in pernicious tever 156 Colliquative variety of pernicious fever 158 Coma vigil in typhus fever 220 Comatose variety of pernicious fever 153 Contagion in measles "^^ " relapsing fever 260 *' scarlet fever 308 " small-pox 273 " typhoid fever 21 " typhus fever 212-214 " yellow fever 90-92 Convulsions in pernicious fever 155 " scarlet fever 315 " typhoid fever 37 Delirious variety of pernicious fever 154, 155 Delirium in pernicious fever 15^ " relapsing fever 261 " scarlet fever 312 INDEX. 387 PAoa Delirium in Btimll-pox 2''' tyi>hi)i(l fcvor :t">--'''' *' tyi>ho-nuvl!iiial fovor "'«' " typhus fever 'J"20-J'Jw " yellow fever '^^ Dengue fever Hi!) 17:? " etiolopyof H>'J-170 " definition of ^''•* " differential diagnosis of . . . . ' ' ~ " morbid anatomy of "•'•^ " prognosis of ' '*' " symptoms of ' '^'~' '•' " '' enlargement of lymphatic glands 170 " " headache 1~0 " " period of incubation 170 «« " pulse 1^*^ «' " skin 1~<^ •' ' * temperature 1 ' *^ »« " tongue I'l " treatment of 1 12. li-? " " calomel in the 1 ' '•' «' " cathai-tics in the 1 ••' «» ♦* citrate of iron and quinine in the 1 ' -^ ♦• " colchicum in the ^ ' - «» " diet in the l~-5 «* " emetics in the ''3 «« " sulphate of quinine in the 1 <"J Diaphoretics in the treatment of typhoid fever I^-^ Diarrhcea in chronic malarial infection • ' •» " relapsing fever - '^ " typhoid fever ''^ " typho-malarial fever 188-191 Diet in dengue fever ^ y' " measles "■_J_ typhoid fever ' " tvpho malarial fever - " " typhus fever ~'^^ Differential diagnosis of chronic malarial infection ^ >' " •' dengue fever ' ' ~ i« " epidfroic roseola ''•'■* »» •' measles '*' - " «' miliary fever •"'•'- ♦» »' pernicious fever 159-16w «4 " relapsing fever -'*■* " " scarlet fever 32<>-3M •♦ «' simple intermittent fever !-•> « •; simple remittent fever 1*'~. l** «» " small-pox 2y4-288 388 INDEX. PAGE Differeutial diaguosis of typhoid fever 45-49 " " typho-malarial fever 194-196 " " typhus fever 282-239 " " yellow fever 100 Digitalis in the treatment of typhus fever 253 Disinfectants in the treatment of typhoid fever 63 Dry cups " " " 79 Emaciation in typhoid fever 38 Emetics in the treatment of dengue fever 172 " " pernicious fever 164 " " typhoid fever 63 Epidemic roseola 353-356 " differential diagnosis of 354 " etiology of 354 " morbid anatomy of 353 " prognosis of 355 " symptoms of 355, 356 " treatment of 356 Epistaxis as a symptom of typhoid fever 170 Eruption of dengue fever 169-171 ' ' epidemic roseola 353 " measles 341 " miliary fever 358-360 ' ' relapsing fever 262 " scarlet fever 313 small-pox 270-273, 277-284 " typhoid fever 42-43 " typhus fever 219-225 Etiology of chronic malarial infection 174 " dengue fever 169, 170 " epidemic roseola 354 " measles 339-341 ' ' miliary fever 358, 359 " pernicious fever 152 " relapsing fever 258-260 ' ' scarlet fever 308-31 1 ' ' simple intermittent fever 120 " " remittent fever 134-136 " smaU-pox 273-275 " typhoid fever 20-26 " typho-malarial fever 186 " typhus fever 211-216 " yellow fever • • 88-93 Fevers, classification of 5-7 ' ' contagious 5 " dengue 169-173 INDEX. ''^^ ■■Aiii: .... 5 Fevers, endLinic ^ " epidomio . ^ 1 -O " introduction to " ""^''^7^ ;;;':m-:5ni5 " njoasles ^ " niiu.-^nmtic coutagioua • • • ' ., ... .\ni--iM ""^'"'^^ . 14S-ir.H " pcrniciou.s o-,n...'r,7 " relapsintr "J^^J^^j - sourlot. ...^ •••••• ^,,^_j,4 " simi>le mtormittent ,.,o . .a .^^ . l.>f5-14o «• " remvttcnt „ „ 2»iH-302 " small-pox ^_^^ ;; ^yphoid. ;. ■::■.:■.;■; 181-202 " typho-inalarial ,. / , 20.)-2.»a *^'V^^ 85-107 " yellow 2^, Fresh air in the treatment of typhus fever ■'Oil Gangrene of tonsils in scarlet fever i -- 'i ^C Gastro-enteric variety of pernicious fever I'J''' ^^ Gastro-enteritis in chronic malarial infection • '•' , .... 3j3-.3oI> German measles Glandular enlargements in typhus fever Glandular inflammation in scarlet fever Headache in dengue fever ' ... o oOO " miliary fever . . , l.)4 " pernicious lever " scarlet fever ' "_ typhoid fever ^ - ^^^ " typhus fever ~ ' /' Heart, changes in the, in chronic malarial infection 174 n " relapsing fever *^*" 4. " typhoid fever ^' '^ n " typhomalarial fever '' ^ . "07 II " typhus fever *■"' a » yellow fever 80. H7 Hemiplegia in chronic malarial infection '^ Hemorrhage in chronic malarial infection »» pernicious fever ' ' «« typhoid fever, from intestines ., .i " larvnx • '- ,.,,,„," 19:1 " typho-malana. fever Hydrate of chloral in typh.iid fewr " " typhus fever 87 Hypertcathesia in typhoid fever Hypochondriasia in chronic malarial infection 390 INDEX. PAGE Hypodermic injections of opium in pernicious fever 164-1 G5 " " sulphate of quinine in pernicious fever 164-105 Icteric variety of pernicious fever 158-159 Infantile remittent fever 141, 143 Infarctions in the kidneys in typhoid fever 99 " " lungs in yellow fever 87 " " spleen in pernicious fever 151 Inoculation 293-295 Intestines, lesions of the, in relapsing fever 257 " " simple remittent fever 134 " " typhoid fever 14-18 " " typho-malcorial fever 183-185 " " typhus fever 208 Intestinal hemorrhage in typhoid fever 31, 33 Iodide of iron in chronic malarial infection 179 Iron cough in measles •. 342 Jaundice in bilious remittent fever 141 " pernicious fever 158-159 " relapsing fever 261 " yellow fever 98 Kidneys, changes in the, in chronic malarial infection 174 " " pernicious fever 153 " " relapsing fever 257 " " scarlet fever 307 " " typhoid fever 9 " " typho-malarial fever 183 " *' typhus fever 207 " " yellow fever 87 Laryngitis, in typhoid fever 11 '' typhus fever 330 Liver, changes in the, in chronic malarial infection , . 174 " " measles 337 " " pernicious fever 151 " " relapsing fever 257 " " scarlet fever 308 " " simple remittent fever 133 " " typhoid fever 8-9 " " typho-malarial fever 183 " " typhus fever 206 " " yellow fever 85,86 Lungs, changes in the, in ijernicious fever 152 " " measles 338 " " typhoid fever 10,11 " " typho-malarial fever 183 INDEX. 391 PAOB Lungs, changes in the, in typhus fever "'' " " yellow fever "' Lymphatic ghuids, eulargemcnt of, in douguo fever HO :^Ialarial fevers, uitrwluction to 100-118 Masked intermittent fever '"^ ' Measles «' complications of " differential diagnosis of '"**' " etiology of 3:{9-:m " morbid anatomy of :3:57-339 '» " blood changes ^''' " '» eruption '^'^ " " liver ^■^'^ n »« lungs "^'^^ " «« skin ^'^^ " " spleen '^■^' " period of incubation **"*" •' prognosis of " symptoms of 341-;J48 " " desquamation •'*■' " " eruption '^'^^ ■w " iron cough '^'^^ »« •' irregularities '^"^ oil " " premomtorj- '^'*'^ «« " pulse 343,344 «» " temperature '^^•^' '^^ " " tongue '^^^ " treatment of '^^^' '^'p *' '' arrangement of sick-room 3ol " " cold applications '^'^ diet. ;.")! «« " opium •^•"*"' ♦ » " sponging '^"'^ «« <' stimulants •'•^'' "'••'■^ " «« sulphate of quinine •^■'^ «« " vapor inhalations •'•'■' *« " ventilation '^•'' Melancholia in chronic malarial infection ^ '^ Meningitis in typhus fever *-'^" Mercury in the treatment of dengue fever 1 ' '- n " simple remittent fever 14i> " •« typho-raalarial fever 201 Mesenteric glands, changes in the, in typh(Md fever 18-20 i» " '• typho-malarial fever 1^» Miliary fever " " complications of "'"' • ' " differential diagnosis of '^'^•' 392 IXDEX. PAGE Miliary fever, duration of 359 " etiology of 358, 359 " " morbid anatomy of 357,358 " " prognosis of 362 " " relapses in 361 " " symptoms of 359-362 " " " desquamation 3G2 " '* " eruption 360 " " " headache 360 " " " pain, epigastric 360 " " " " precordial 360 " " " pulse 360 " " " rapid respiration 360 " " " stages 359 " *' " temperature 360 " " urine 361 " " " vomiting 361 '' " treatment of 362, 363 Morbid anatomy of, chronic malarial infection 174 " " dengue fever 169 " " epidemic roseola 353 " " measles 337-339 " " miliary fever 357 " " pernicious fever 149-152 " " relapsing fever 256-258 " " scarletfever 305-308 " " simple intermittent fever 119 " " simple remittent fever 132-134 " small-pox 269-273 " '« typhoid fever 7-21 " " typho-malarial fever 182-186 " " typhusfever 205-211 " " yeUow fever 85-88 Morphine, hypodermic injections of, in pernicious fever 164, 165 " " " simple remittent fever 148 " " " typhoid fever 79 Mucous membrane, changes in the, in relapsing fever 287 '• " " scarletfever 306 " " " yellow fever 86 Muscles, changes in the, in simple remittent fever 134 " " " tyiihoid fever 12,13 " " " typhusfever 211 *' paralysis of, in typhoid fever 36 " " typhusfever 223 Neuralgia, in chronic malarial infection 176 Opium in the treatment of measles ;^1 INDEX. 39:i TAOE Opium ill the treatment of pernicious fever •'''^ " " nimplo remittent fever l'--'7 •' " typhoid fever 77-71), H2 «« " typho-malarial fever 2'^0 «« " typhus fever '-•'•* Pain in the epigastrium in simple remittent fever '•' ' Parenchymatous de-jencrations lu typhus fever 2(H> Period of incubation in dengue fever ^ •*' " ♦' measles ■'■' " " scarlet fever •" * '• " email-pox "-"' typhus fever -'•' Pernicious fever '"* ' " definition of '"'"^ " dilferential diagnosis of l.)9-lti"<. " etiology of ''*^ " morbid anatomy of ^ l!)-l)v • ' " blood changes 1 '!• «» " brain ^"'^ «* " kidneys l''~ t< " liver 1"*^ » " lungs 1 ''2 a " spinal cord l'*l «« " spleen 1">1 " prognosis of ^^'■^' ^'''^ " symptoms of 1.)~-1.j!) " " algid variety li»7, l-'''^ " " colliquative variety l-^S *» " comatose " ^•''•^ " " delirious " 1"> •, !•'>•"> " " gastro-enteric " l."), ITdj »» " icteric " loM-l.V.) *« " premonitory 1'- " treatment of ir,:j-l(;,S «' " bleeding 1'"' ^ " " cathartics '•" " «' depletion l*'^ '• treatment of, emetics 1*'1> l'"'-* it " hypodermic injections of opium and ipiin- ine I'Jt-l';^ " " opium ^''* «t «« stimulants "•' «* " sulphate of quinine ^''* ♦ t " Warl)erg's tincture '*'''» . • « 111 " varieties of Phlegmasia dolcns in typhus fever -| Phosphorus '" " "'' 394 INDEX. PAGE Photophobia in relapsing fever 2G1 Physiognomy in dengue fever 170 " pernicious fever 158 " small-pox 276 " typhoid fever 29, 30 Premonitory symptoms in measles 341 " pernicious fever 152 " scarlet fever 311-312 ' ' simple remittent 136 " small pox 275 " typhoid fever 27 " typho- malarial fever 187 " typhus fever 217 " yellow fever 93 Prognosis in chronic malarial infection 178 dengue fever 172 epidemic roseola 355 measles 349 miliary fever 362 pernicious fever 162, 163 relapsing fever 265 scarlet fever 328-330 simple intermittent fever 126 simple remittent fever 143-144 small-ix)x 286-288 typhoid fever 50-60 typho-malarial fever 196-198 typhus fever , 239-243 yellow fever 102 Pulse in dengue fever 170 measles 343-344 miliary fever 368 pernicious fever •. 153-159 relapsing fever 261 scarlet fever 311, 316 simple remittent fever 137 small-pox 276 typhoid fever 40-42 typho-malarial fever 189-191 typhus fever 219-223 yellow fever 95 Relapses in miliary fever 362 " relapsing fever 262 ' ' typhoid fever 58-60 '' typhus fever 232 Relapsing fever 256-267 " comijlications of 264 I^'DEX. I-AIIE ... '-2t;4 2.')S-2t50 no5 Relapsing fover, differential (li!igna>53 " morbid anatomy of *"' "'' u •' blo.Kl -"'^ «< " heart -'" o-,7 I. '• mtestines ~ ' »» " kidneys liver fy tt " mucous membrane *"' ' »« " spleen " . , 2<;5 ' ' projmosia of . f ....260-2(3-1 " symptoms or " " arthritic pains "*'■ Til " " delirium ~"^ 'Til «« " diarrhcea ~"'- 'Vil n " eruption " o(;i »« " jaundice " '« " photophobia -^'■ " " pulse ~**^ oi;i " " temperature ""'^ . . Til " " vomiting -"^ " treatment of Respiration in typhus fever Salivarj' glands, cfhanges in the, in typhoid fever on*. qo« _,,^. 304— O'J'i Scarlet fever " complications of , ^ .^. f 304 »' dehuition or " differential diagnosis of o-o-o-o ,. , , 308-311 " etiology of «• morbid anatomy of 305-308 u " brain ^^^ »i " diphtheria ^^^ ear =^07 (( " gangrene of tonsils 30f> <( " glandular intlamination -^O'l u «' kidneys ^^^ ti " liver •^'^ (( »« mucous merabranea '^00 " skin i^Oo " period of incubation _ ^ » « periods of ,, : ,,f 32M-:W0 " protmosis of ,, \ 323-325 " sequela; ' , 311-326 " symptoms of _ _ »4 " con\'ul.'i;x. ;{07 Simple remittent fever, treatment of, arrangomont of sick-rnum Mtl *' " cold 14H «» " mercury 1'*'^ «« " moriihino 14H " " sulphate of quinine 1 "5 Skin, appearance of, in dontruc fever 1»>1)-1 <() " measles •""- " miliary fever '^^^ " pernicious fever ir),{-l.)7 «' relapsing fever "''^ ♦' scarlet fever '*"■* " simple intermittent fever 1-* " simple remittent fever I'll " small-pox -''' ~^ «« typhoid fever •*-' -^^ «' typho-malarial fever '^'^ *' typhus fever ~ ' •''-"' " yellow fever '^ „ ,, „ 2G8-303 Small-pox «' complications of " differential diagnosis of ~i^ '^' eruption of 270-273 " etiology of "''^ -"^ ' ' inoculation m *" " morbid anatomy or ~ ' 071; " period of incubation of *" "■' ,, ■ f 2sr.-2.s8 " procrnosis ot " symptoms of "^ " " convulsions *' •t " delirium ^~'' «» " eruption -.n-^ «t " pain in the back and head ~ ' " . 07'; « " phvaiognomv ~ «* " premonitory ~^ ' *« " pulse ~'* «» " skin -i(--.-*4 *» " temperature ~"* <■'■ " vomitmg *■ ' " treatment of '" " - " . .. 2!»."i-;j(Kl ' ' vaccination Somnolence in typhoid fever ' "' " typhus fever -" Spleen, changes in the, in chronic malarial infection l ' * •' measles ' »« pfrnicious fever '■" «• relapsing fever "^ ' «» simple remittent fever l-*^*' " typhoid fever ^ 898 rNDEX. PAGE Spleen, changes in the, in typho-malarial fever 183 " typhus fever 206 " yellow fever 88 Spontaneous origin of typhoid fever 21 Stimulants in measles 352 " pernicious fever 167 " typhoid fever 73, 74 ' ' typho-malarial fever 200 ' ' typhus fever 250-252 Stomach, changes in the, in simple remittent fever 134 " typhoid fever 13 Sulphate of quinine in chronic malarial infection ISO " " " dengue fever 173 " " " measles 351 " " " pernicious fever 164, 165 " " " simple intermittent fever 128 " " " simple remittent fever 146 " " " typhoid fever 71-73 " " " typho-malarial fever 1 98, 199 " " " typhus fever 248 Suppression of urine in yellow fever 97 Symptoms of, chronic malarial infection , 174-177 " dengue fever 170-172 " epidemic roseola 355, 356 " measles 341-348 " miliary fever 359-362 '• pernicious fever 152-159 " relapsing fever 260-264 " scarlet fever 311-326 " simple intermittent fever 120-125 " simple remittent fever 136-142 " small-pox 275-284 " typhoid fever 27-45 " typho-malarial fever 187-194 " typhus fever 217-229 " yellow fever 93-100 Tetanus in pernicious fever 155 Temperature in dengue fever 170 ' ' measles .... 343 '♦ miliary fever 360 " pernicious fever, algid variety 157 " " colliquative variety 158 " " comatose " 153 " " delirious " 155 " " gastro-enteric " 156 " " icteric " 159 *' relapsing fever 261 FM»i:\'. 309 Tcmpemturo in scarlet fever :tl 1 , JIKJ " simple intermittent fever l'^"J. 1-1 " eiinplo remittent fever 1-17 * ' smallpox 'iir, " typhoid fever :«•, 40 " typbo-malarial fever IW, I'lO " tyi.lmfl fever :!1H, '-.".':{ yellow fever 'S.\ dl Tents in the treatment of tyi>hns fever ~ 11' Thrombi in the heart in typlioiil fever 10 " veins in typhoid fever 207 Tongue, appearance of, in dengne fever 171 " " measles '^44 " " pemicions fever l'>7 "■ " scarlet fever '512 " " simple intermittent fever 123 " " typhoid fever -50 «« " typho-malarial fever 1><^, 101 " " typhus fever 21H " " yellow fever -'O Tracheotomy in the treatment of typhoid fever ^0 Treatment of chronic malarial infection 1 7'.>. 1 sO " dengue fever 1 (J 1 i^J " epidemic roseola •^•*'' •' measles ;}50-:r)2 " miliary fever •^"2, '503 " pemicions fever KJM-ltJS " relapsing fever 2111! •' scarlet fever :{:}0-:};{<> " simple intermittent fever 12()-i:?0 *' simple remittent fever Mo-HH smail-pox 2M!»-21)2 ♦♦ typhoid fever •'1-H4 *' typho malarial fever lN!)-'202 " typhus fever 2 \:\'2r>r, " yellow fever 10.{-10<5 Turpentine in the treatment of typhoid fever 78 " " " typho-malarial fever 201 Tympanitis in typhoid fever '^'5 Typhoid fever "-'^* " differential diagnosis of 4')-49 " duration of •'•^ •' etiology of 20-20 • ' morbid anatomy of 7-20 " •' blluiio 7y " " opium 77-H2 " " Btimnlaiits 7;$^ 74 *' '■ siilplmti- of qniniiio 71-7:$ ** ■ ■ tracheotomy HO " ■■ tnn)cntiiie 7s " " vapor iuhahitions 7!l Typho-malarial fever lsl-'2(i'J " definition of \<^\ " ditforential diag^nosis of l!(4-lfl(.» " duration of ISO *' etiolo{ry of 18G " morbid anatomy of 1 H2_187 J ]oo-;{02 Urine, clianges in tlie, in tyithus fivtr •' " yoUtnv fever ^"i Vaocinfition i, J.j-.JOO VuUriiin in the treiitnient of typhus fever '■i'>'-' Vjijiur inliahitions in the treatment «>( mcnalcs :{•>- typhoid fever Vari<.l..i.l Vomitinjr in miliary fever •'"^ pernicious fever l-'U 1'*!' " relapsing fever 2(51 " scarlet fever •' ' ^ " simple intermittent fever !-■• " " remittent fever '•'' !sniall-pox ~''"' ** yellow fever •"' Wurbery's tincture, formula for 1'''^ Yellow fever 8.")-10ri '• definition of ^^ " differential diagnosis of l'"l " etiolof^y of H8-9:t " morbid anatomy of 80-^ blood changes B8 " " brain ^"t " •« heart 8f!. ST " " kidneys ST " " liver ■"^•'' " " lungs sT " " mucous membrane S(; " " skin ^^ «« " spleen 8s " symptoms of ilo-lOO " " black vomit '•"> «« " delirium W «* " jaundice OS '* " pulse y"» " " temperature 5»:5, !)l " " tongue i"' " " urine -'T *' " voniitiiiLT !•(> prognosis of If- treatment of 1(i.'.-Hm; ^ 14 DAY USE RETURN TO DESK FROM WHICH BORROWED This book IS due on the last date stamped below, or on the date to which renewed. Renewed books are subjea to immediate recall. MAY 2 ly^^'- „ 11 n O ^v^s'b^6« DUE SHp24iqfin SuDjC.. ISMsediaieiy RETURNED -BIOLO^ 3Y SEPS 'Ol TIMP ! ?Dll7-rsrO)V^I Un.vt«£og^'^.nia r