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HANDBOOK 



OF 



PE ACTIO Ali: : MEDICINE 



BT 

Dr. HERMANN EIOHHORST, 

PROFESSOR OF SPECIAL PATHOLOOT AND THERAPEUTICS AND DIRECTOR OF THS 

UNIVBRSITT MEDICAL CLINIC IN ZURICH 



VOLUME IV. 

DISEASES OF THE BLOOD AND NUTRITION. AND INFECTIOUS 

DISEASES 




SEVENTY-FOUR WOOD ENQRAVINaS 



NEW YORK 

WILLIAM WOOD & COMPANY 

i386 

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■ • 



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• • ■ ■ • • • 
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COVTBIOBT BT 

WIU^AM WOOD S: COMPANY. 

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V.4. 



TABLE OF CONTENTS, 



DISEASES OF THE BLOOD AND NUTRITION, AND 

INFECTIOUS DISEASES. 

SECTION VIII, 

DISEASES OF THE BLOOD AND THE BLOOD-PRODUCING 

ORGANS. 



PART I. 

DffiBASBS OF THE BLOOD, 

1. LeuksBmia, . . \ 

2. PseudoleuksBmia, 
8. Melaxuemia. . 
4. Anadmia. -Chloroctis, . 
6. Progressive pernicious anaeinia, . 

6. Purpura simplex, 

7. Purpura rheumatica. 

8. Purpura hemorrhagica, 

9. Scurvy, 
10. Heemophilia, 



PART II 

Diseases of the Spleen, 

1. Acute enlargement of the spleen, . 

2. Chronic enlargement of the spleen, 
8. Inflammation of the splenic capsule. 

4. Hemorrhagic infarction of the spleen and' inflammation 

spleen. Splenitis, . 

5. Waxy degeneration of the spleen, . 

6. Tumors of the spleen, . 

7. Parasites of the spleen, 

8. Rupture of the spleen, . 

9. Changes in position of the spleen, . 



Perisplenitis, 



or 



I he 



SECTION IX. 



Diseases of Nutrition, 
1. Obesity. Polysarcia. 

3. Gout. Arthritis uraticu, 
8. Diabetes mellitus. 

Appendix. Mellituria, 

4. Diabetes insipidus, . 
6. Rickets, . 

6. Osteomalacia, 

7. Arthritis deformans. 



PAOB 

1-40 
1-10 
10-11 
11-14 
14-19 
19-27 
27 
27-28 
28-81 
81-37 
87-40 



40-50 

40-48 

48-45 

45 

45-47 
47-48 

48 
48-49 

49 
49-50 



'^l-OS 
51-57 
57-68 
88-81 
81-82 
82-a5 

av.94 

94-96 
96-98 



IT 



TABLE OF GONTXSTTS. 



SECTION X. 



INFECTIOUS DISEASES. 
A. liffTBcmous D18KA8IS WITH Typical Localization, 



PAOK 

99-265 



PART I. 



1. Aom IKFCCTIOU8 EXANTHKMATA. 

I. M«m1mi, . 

9. HonrUtltiA, . 

9. Rcvtheln, . 

4. Typliuti rt»Yer, 

ft. Kry»i\t0\9m, 

jt. I!frpt»» facialH, . 

<». II«ir|K«» pn>K«'i>itHUH, 
<l. ll««r|Htii phHrviiKi''. . 
0, linriMm liuryiiKUi, . 
7. KMffUi iiillUrK 

H. Hlflllll'|M>«, 

10, VnrM^llA. . 



. 99-152 

99-107 

. 107-116 

116-118 

. lia-134 

124-130 

. 130-1:^5 

130-131 

. 131-134 

134 

. 134-135 

135 

135 

136-145 

. 145-150 

150-152 



TART 11. 

ifUfHimHV** fl|toie4Ml6M lHVOt«VtN(» TIIK M(.)TOR APPARATUS (JOINTS OR 

M(^MU.M). . 152-159 

I AmiM* HrMiMilnr rlit>uiiiii(Uii), ..... 1.52-158 

i, < })ti«'iilif MfMoiilfir rht>uiiiAU»iu. .158-159 

. Mi««NiUt#r rtM>UiiiiiUiilii. 159 



I'AUT 111. 



If^^lN-'M^'f'* lMt)l»4t)lM> iMVol.VINd Tllie UUHH) AND BLOOD-PRODUaNO 

|l^l4i»}0, ........ ]55~?II 

, Mh(h/N, 

B llff* mijMn, . . ..... 



159-167 
167-176 
176-177 



PAUT !V 



I^P¥4^i^M*^ Miiii»4tiiMi UVMi.viNu title Uicmimuatury Apparatus. 
f/\tmi^tm ♦•HHnli, ..... 



. 178-187 
178-184 

. 184-185 
185-187 



PAHT V. 

|4|^f|i.f(//M M^f>^4AM |»iVM|.VIMi IMtD iMUKnTIVK APPARATUS, 






. 187-239 
187-190 

. 190-191 
191-215 

. 215-222 
222-237 

. 287-289 



TABLE OF CONTENTS. 



PART VI. 

Infectious Diseases Involvino the Sexual Apparatus^ 

1. Gonorrhoea. ...... 

2. Soft chancre, . . ... 



PAOS 

. 289-258 

289-252 

. 252-258 



PART VII. 

iNFEcnous Diseases Involvino the Nervous Apparatus, 

1. Epidemic cerebro-spinal meningitis, 

2. Simple cerebro-eplnal meningitis. 



. 258-265 

258-264 

.. 264-265 



B. Infectious Diseases with Variable Localization, 



265-402 



PART I. 

Tuberculosis, ....... 

1. Pulmonary phthisis, .... 

2. Laryngeal pnthisis, ..... 
Appendix. Tuberculosis of the nose, 

3. Pharyngeal phthisis, ..... 
Appendix. Tuberculosis of the tongue, lips, mucous 

of the cheeks, oesophagus, and stomach, . 

4. Intestinal phthisis, ..... 
Appendix. Tuberculosis of the rectum, 

5. Chronic ulcerative tuberculosis of the urinary organs, 

6. Solitary tuberculosis of the viscera, 

a. Solitary tubercle of the brain, 

b. Solitary tubercle of the spinal cord, 

c. Solitary tuberoie of the spleen, 

d. Solitary tubercle of the liver, 

e. Solitary tubercle of the heart muscle, * 

7. Oeneral miliary tuberculosis, 

8. Tubercular meningitis, .... 

9. Tubercular peritonitis, 

10. Scrofula, ...... 



membrane 



265-824 
265-294 
294-297 
297 
297-299 

299 

299-803 

802 

802-806 

807 

807 

807 

807 

307 

807 

807-818 

814-817 

817-318 

818-824 



PART II. 

Syphilis, ......... 

1. Acquired syphilis in the primary and secondary stages, 

2. Tertiary syphilis of the skin, muscles, fasciae, joints, and bones, 
8. Syphilis of the nose, 
4. Syphilis of the larynx, 
6. Syphilis of the trachea and bronchi, 

6. Syphilis of the lun^s, . 
Appendix. Syphilis of the mamma, 

7. Syphilis of the digestive tract. 
Syphilis of ttie buccal cavity. 
Syphilis of the tongue, 
Syphilis of the pharynx. 
Syphilis of the salivary glands, 
Syphilis of the oesophagus. 
Syphilis of the stomach, 
Syphilis of the intestines, . 
Syphilis of the rectum, 

8. Syphilis of the liver. 
Appendix. Syphilis of the pancreas, 

9. Syphilis of the spleen, 

10. Syphilis of the kidnevs, 

11. Syphilis of the sexual organs. 
Syphilis of the testes, . 
Syphilis of the penis. 



824-868 

325-341 

341-343 

343-344 

345-348 

348 

348-350 

350 

850-351 

350 

850 

350 

351 

351 

351 

351 

851 

851-:^53 

353 

353-354 

354-855 

8:»5 

355 

855 



TABLE or OONTENTS. 



Byphilin of 
BypiiiJiM of 
Hyphilii) of 
HyphiliH of 
19. HypljiliM of 
Byphilb of 
HyphiliH of 
Hy phi liti of 

13. Byphiliii of 

14. Hyphilis of 

15. HyphiHiiof 

16. Uereditary 



the epididymis, 

the Tan deferens, 

the Belli iiial vesiclet, 

the proHtate, 

the rinnilHtory organs 

the liiNirt iniiscle, 

tlie endooardium, 

the arteries, 

the hrain, . 

tlie spinal cord, 

the peripheral nerves, 

syphilis, 



PAOK 

855 
855 
855 
855 
8.55 
855 
«55 
3.55 
855-862 
862-363 
.*)63 

363-368 



PABT m. 



Lbprosy, . 



PABT IV. 



DiPilTHiBRIA, . 

1. Diphtheria of ^he 
9. Diphtheria of the 
8. Diphtlieria of the 
4. Diphtheria of the 
6. Diphtheria of the 

6. Diphtlieria of the 

7. Diphtheria of the 

8. Diphtheria of the 



phamyx, 
larynx, • 
noee, 

oesophagus, 
stomach, • 
intestines, 
bile passages, 
urinary passages, 



C. ZOONOBRB, . ' . 

1. Trichinosis, 

d. Anthrax, 

8. Olanders, . 

4. Actinomycosis, 

0. Houth-and-hoof disease, 

6. Hydrophobia, 



. 868-371 



871-890 

872-881 

881-388 

888-889 

889 

889-;{90 

890 

890 

890 

890-402 
890-397 
897-398 
898-400 
400 
400-401 
401-402 



HANDBOOK 



OP 



PRACTICAL MEDICINE. 



SECTION YIIL 



DISEASES OF THE BLOOD AND THE HEMATOPOIETIC 

ORGANS. 

PART I. 
DISEASES OF THE BLOOD. 

1. LeukcBmia. LeucocythcBmia. 

I. Etiology. — Leaksamia consists of a constantly increasing excess 
of white blood-globules in the blood, with progressive diminution in the 
number of red blood-globules. 

We distinguish splenic, lymphatic, and myelogenic leukssmia, ac- 
cording as the spleen, lymphatic glands, or medulla of the bones form 
the starting-point of the disease. As a rule, we have to deal with mixed 
forms of the disease, although the organs concerned in the production 
of blood are often affected in very different degrees. 

B^hier also recognizes enteric leukadmia, in which the follicular apparatus of 
the intestines is said to form the starting-point of the disease. In Behier's case 
the spleen and lymphatic glands were unchanged, while extensive hyperplastic 
changes were visible in the lymph gland apparatus of the intestines, but no ex- 
amination of the medulla of the bones was made, so that the case was possibly 
myelogenic in its origin. 

Neumann has shown that in the m^'ority, perhaps in all, of the cases the me- 
dulla of the bones is the primary starting-point, but the changes are rarely lim- 
ited to this part. Splenic lymphatic changes supervene in the majority of cases. 

Leukaomia is more frequent in men (among 200 cases, 135 males, 65 
females). 

1 



3 DISEASES OF THE BLOOD. 

Tha disease ocours usually between the twentieth and fiftieth years, 
the maiimum occurring in males in the third decennium^ in females in 
tha fourth decenuium. It is also ^observed in children and old people 
(oldest case at seventy-three years). In childhood it is more frequent 
between the seventh and fourteenth years. 

There is no doubt that the laboring classes are attacked with special 
frequency. 

In not a few cases no exciting cause is demonstrable. The disease 
sometimes follows injuries to the spleen and bones. Mursick reported 
a case of acute development of leuKsemia five days after amputation of 
the thigh. 

The disease has also been attributed occasionally to bodily and men- 
tal strain^ grief, care, and excitement, and alcoholic excesses. 

Pregnancy, delivery, and mei^^trual disturbances are supposed to be 
etiologically related to leukaemia, and Paterson states that in such cases 
the morbid changes may run a very acute course. 

The disease has also been observed after chronic diarrhoea, and in 
rachitic and scrofulous children. 

It may also follow infectious diseases. Chief among these is malaria, 
particularly irregular, chronic cases. Syphilis sometimes acts as a cause, 
especially nereditary syphilis in children. Immermann observed a case 
of^myelogenic leukaemia after typhoid fever. Diphtheria is also said to 
be an occasional etiological factor. Whether progressive pernicious anae- 
mia should be included amon^ the causes is still doubtful. Two cases 
have been reported in which tnis disease was converted into leukaemia. 

Hereditary influences seem to have been potent in a few cases. 

Casati observed Bplenic leukaemia in a Rirl whose grandmother and father had 
suffered from the same disease. Biermer observed it in two sisters, set. three years 
and four and one-half vears, Senator in twins, set. one and one-half years. 

The disease ocours m animals (dog, horse, cow, pig). 

II. Symptoms. — The most striking symntoms are the changes in the 
blood. All other symptoms may occur unaer other circumstances, par- 
ticularly in anaemic conditions. To examine the blood, the tip of the 
finder, after having been cleaned, is pricked with a needle, a small drop 
of blood received upon a clean cover glass, and this placed upon an object 
^lass. If the surfaces of the glass are clean, the blood will be distributed 
in a uniform layer. 

The blood often presents macroscopic peculiarities. It is unusually 
light and watery, sometimes chocolate-brown or yeast colored, and co- 
agulates slowly. If a larger amount is removed by cupping, white streaks 
and dots are noticed on the clot, or it is covered with a whitish gra^ 
layer, which consists of white blood-globules. Under the microscope it 
is found that, instead of the normal proportion of white blood-globules 
(1 to 350-600 red blood-globules), they are increased to such an extent 
that they sometimes equal, or even exceed, the red blood-globules. In 
a few very advanced cases, a certain amount of care was reauisite in order 
to discover any red blood-globules. Even in less advancea cases, the mi- 
croscopic appearances are very characteristic (vide Pig. 1). 

Three principal forms of white blood-globules are visible. One form 
is smaller than the red blood-globulos ana contains a single nucleus sur- 
rounded by a narrow zone of protoplasm. The latter is sonietimes so 
small in amount that the cell looks like a free nucleus. These white 



DISEASES or TBS BLOOD. 

blood-globules resemble the parenchyma cells of the lymphatic glfti 
and abound jd leukeemia of a predominantly lymphatic character. 

A second form of white blood-globules exceeds the red onea in size. 
They contain generally three or four nuclei, sometimoB are grouped to- 
gether like a clover leaf, and often present constrictiona. This form re- 
setn lilea the cells of the splenic pulp, are especially numeroua in leukEemia 
of s predominantly splenic character, and are probably derived m great 
part from the spleen. 

Finally, Moalor called attention to white blood-globules which con- 
'l drope offat. They are said to be derived from the medulla of the 
"1, and to be characteristic of myelogenic leukaemia. Much more 




ichll'lly IrmptiBlic). Ealnr^ed 4.V) times. 

characteristic of the latter form, however, are the so-called tranaition 
celts of E, Neumann. These are imperfectly developed red blood- 
fflobules which still contaiu a large nucleus, wuile the zonal portion ia 
noinogQueous and colored. 

Various forrna of wlijte blood-globulea are tound even in the blood of healthy 
ladividuaU. Tliis sliould be expected d priori ia kulueinia. because, as a geoeral 
tiling, wti do not observe pure forma of lyinphatic, aptenic, or mjeloji^nic leu- 
kiBmui. Etpceiit investii^tions have shown, Iiuvrever. that the foTia of the wbJUi 
blood-glob II Ira is not a positive indication of tlieir place of origin, and that a stlU 
larger viiriety of these cells may be distinguished by staining with aniline. 

The red blood-globules are sometimes very much diminiahed in nam* 




« DIBEA0E8 OF THS BLOOD. 

Im, and they may even be reduced to half a million in one cnbic milli- 
metre (normally five millions). Their number may vary greatly in 
different examinations. They may be pale and abnormal in shape (pear 
shaped, club shaped, etc.)> so-called poikilocytosis. 

The frequent spontaneous hemorrhages of leuksBmia furnish abundant mate- 
rial for ezc^mination. The blood is not infrequently cloudy, milky, or pus-like. 
It readUy decomposes and becomes acid, probably as the result of the formation 
of glyoerm-phosphoric acid from the lecithin contained in it. The specific gravity 
is diminished to 1.086 to 1.049 (normally 1.055). It possesses slight tendency to 
coagulation. According to Bockendahl and Landwehr, this is owing to the 
large proportion of peptone which is said to be derived from the white blood- 
globules. If the blood is allowed to stand in a test-tube, the lowest layer of 
sediment, consisting of red globules, is diminished, the middle layer of white 
globules is unusuaUv lar^. The longer the blood is aUowed to stand the more 
abundant the crystals which are deposited YCharoot-Neumann crystals). Zenker 
attributes their origin to the white blood-gloDules in and upon which he has found 
them (vide Fig. 2). 

The amoeboid movements of the white blood-globules are sometimes dimin- 
ished or lost. According to Birk, they produce no fibrin ferment. Jssderholm 
reports a case in which many of them were filled with fine fat granules, so that 
the nucleus was often concealed. If the disease has been preceded by intermit- 
tent fever, they sometimes contain pigment granules 
Yjq 2 (melanoleukssniia). In one case, Friedreich observed 

amoeboid movements of the red blood-globules. In 

©Jf tA i some cases, there is a large number of protoplasm 

wH| granules (hsematoblasts), often aggregated in groups. 

^^^ Unusually small red blood-globules (microcvtes) have 

M . _ been repeatedly seen. A few writers claim that 

I ^S^ ^^ schizomycetes are present in the blood. 

XI ^gP JH Quincke found only one-third of the normal 

' ^^ amount of hsBmoglobin in the blood, but, accord- 

ing to Laacher, the quantity in the individual red 
Leukffimio oryBtals from the blood-globules is unchanged, 
blood, partlr fr^, iMitly in- LeuksBmic blood contains substances which ap> 

cloeedinwhlteblood-globulet. pear to be derived, in great part, from the blood- 
After Zenker. producing organs. We may mention hypoxan thin, 

xanthin, glutin, lecithin, formic acid, lactic acid, suc- 
cinic acid, peptone, traces of leucin, and a phosphorus-containing organic acid 
probably glycerin-phosphoric acid). Hypoxanthin and glutin are characteristic 
of leuksBmia. The former has been found in healthy blood, but only after stand- 
ing for some time. It is pi*obably derived in great part from the spleen, but 
may also be found in lymphatic leukaemia. Neumann and Salkowski are in- 
clined to attribute the presence of glutin to changes in the medulla of the bones. 

Kext in clinical importance to the abnormalities of the blood are the 
local changes in the blood-producing organs. 

Changes in the spleen are the most constant. The organ is usually 
very mucn enlarged, and is sometimes tender on pressure. Peritonitic 
friction murmurs are sometimes felt on palpation of the spleen, and 
auscultation reveals vascular murmurs, coincident with the pulso, and 
similar in character to uterine murmurs. The spleen may be so large as 
to displace adjacent organs, and to give rise to rupture and death from 
perforation-peritonitis. The organ constantly increases in size, though 
temporary diminution sometimes occurs after obstinate diarrhoea and 
profuse hemorrhages. 

The enlarged lymphatic glands may attain the size of a fist or even 
more, and often protrude under the skin as flat prominence-. In the 
neck, they give rise to great deformity and interfere with the mobility 
of the head and neck. Large glands are often observed i!i tlio 
axilljB and inguinal folds. The cervical and submaxillary glands are 






\ 



. DffiEABES OF THE BLOOD. 5 

first attacked. As a rnle, the tumors are not tender on preB8are> and, 
unlike scrofulous glands, the orerlying skin is not reddened or adherent; j 
furthermore, the swelling is generally flatter and softer. As the disease 
adTances, the consistence of the tumors not infrequently increases. 
Caseation and suppuration are extremely rare in leuksemic lymphatic 
glands. 

The spleen and glands are often enlarged long before the blood 
xmdergoes leuksBmic changes. 

The internal lymphatic glands often undergo hyperplasia. Swelling 
of the tracheal and bronchial glands is sometimes shown by slight pro- 
minence of the manubrium sterni and dulness on percussion, or by the 
signs of tracheal or bronchial stenosis, as the result of compression (in- 
spiratory retraction of the intercostal spaces, stenotic murmurs, cyan- 
osis, objective and subjective dyspnoea). Pressure upon the oesophagus 
may interfere with deglutition. Dome authors have attributed attacks of 
palpitation to compression of the pneumogastric. Compression of the 
recurrent laryngeal is followed by paralysis of the vocal cords. On 
pressing the hand deep in the abdomen, the mesenteric and retroperi- 
toneal glands may be felt as nodular tumors. 

Enlargement of the tonsils, thyroid gland, and even of the persistent thymus 
gland is observed in some patients. Hyperplasia of the lymph foliiclee at 
the haae of the tongue has also been noticed. 

AAection of the medulla of the bones is sometimes, though not 
constantly, manifested by pain over the bones^articularly the sternum 
and spine, and occasionally the long bones. We sometimes find slight 
depressions in the bones, and soft, yielding places. 

Less important symptoms are presented by the urine. Its amount 
is generally normal, though it is sometimes increased or diminished. 
It IS often pale and has an acid reaction. The specific gravity is generally 
unchanged. It sometimes contains shining crystals of pure uric acid, 
and deposits a uric-acid sediment. The amount of urea may be in- 
creased or diminished; its amount probably increases with the decree of 
cachexia. The amount of uric acid is increased. In healthy individu- 
als the proportion of uric acid to urea is 1 : 50-80; in leukaemia, Salkowski 
found it 1 : 16. According to Fleischer and Penzoldt, the excretion 
of phosphoric and sulphuric acids is increased, that of lime un- 
changed. Salkowski discovered traces of formic acid, and diminution 
of oxalic acid. The urine sometimes contains small amounts of albumin, 
and occasionally casts. According to some authors, an abundant sedi- 
ment of round cells indicates lymphomatous deposits in the kidneys (?). 

R. Liebreich showed that the retina presents characteristic changes 
(retinitis leucaemica) in one-fourth or one third of the cases. 

The retina is often pale, and has an orange-yellow color. The veins are wide, 
sinuous, and rosy red; in places they are bordered with white. The retinal 
arteries are narrow and pale yellow. The retina is sometimes cloudy; the 
boundaries of the papilla may be indistinct, especially on the nasal side. There 
are more or less numerous reiinal iiemorrhages. Special attention is merited by 
prominent yellow patches, which are not infrequently surrounded by a red ring 
of extravasation of blood. Leber states that they are found particularly in the 
perif>heral portions of the retina between the equator and ora serrata, next in the 
vicinity of the macula lutea. Visual disturbances may be entirely absent, but 
if the macula lutea i<) affected, the interference with vision may attract atten* 
tlon before the other symptoms. 






DI8SASJC8 OF THB BLOOD. 

Barer phenomena are hemorrha^^ into the vitreous, or hemorrhages and Ivm* 
jdiomatous formations in the choroid and iris. Leber has described exophtluil- 
mns and large lymphomatous formations in the eyelids. Birk has observed 
bilateral exophthalmus as the result of lymphomata in the posterior portions 
of the orbits. Similar gprowths may develop in the lachrymal glands. The de- 
velopment of cataract is sometimes attributed to leukaamia. 

Auditory disturbances have been observed in leuksBmia^ and in one 
case Pulitzer found lymphomatous deposits in both labyrinths. 

A rare but charactenstic sign is the appearance of leukasmic tumora 
in the skin and epididymis. 

A series of other symptoms may develop which are the result of 
ansBmia, rather than of the leuksomia. 

The first symptoms generally consist of increasing pallor and feeble- 
ness. Other patients complain, at an early period, of stitches in the 
splenic region and of occasional attacks of fever. 

When the patients come under our observation^ they generally attract 
attention by the striking pallor of the skin and mucous niembranes. ' 
The coinplexion is often dirty gray; in a few cases, the skin is jaun- 
diced. The pauniculus adiposus is sometimes very well developed, but 
in the later stages it undergoes emaciation. There is often an unusual 
tendency to sweating, occasionally hectic night sweats. Furunculosis 
or the development of bullous and pustular eruptions has also been de- 
scribed. Cutaneous oedema is observed not inirequently, at first tem- 
porarily, later permanently. 

The bodily temperature is not infrequently elevated, the type of 
fever being irregular. The pulse is usually soft and accelerated. Many 
patients complain of dyspnoea, which is often noticeable objectively. 
This is the result of the diminution in the number of red blood- 
globules, the interference of the splenic tumor with the movements of 
the diaphragm and thorax, feebleness of the heart, and sometimes of 
compression of the trachea or bronchi by the enlarged thyroid, thymus, 
or lymphatic glands. 

The sensorium may remain entirely intact. In some patients, how- 
ever, delirium sets in, terminating in mania, and must oe regarded as 
the result of defective nutrition oi the brain. 

There is a tendency to catarrh of the air passages, and pneumonia 
is not an infrequent fatal complication. In later stages, serous fluid 
may accumulate in the pleural cavities. 

Pettenkof er and Yoit found that, despite the diminished number of red blood- 
globules, tbe absorption of oxygen and excretion of carbonic acid remained nor- 
mal. The excretion of water and urea was greater at night than during the day, 
unlike what obtains in healthy individuals. 

Anaemic systolic murmurs are heard not infrequently over the heart. 
The organ is often dilated, particularly the right half, and is pushed 
upwards by the enlarged spleen. Attacks of palpitation sometimes 
occur spontaneously or after slight causes. The jugular vein may be 
distended occasionally on one side alone, as the result of compression 
by enlarged glands. Tiie venous pulse is often present. 

Appetite is generally lost, while thirst is often increased. The par- 
otid and submaxillary glands are sometimes increased in size, as the 
result of lymphomatous deposits. Leukaemic stomatitis and pharyngitis 
may set in and render deglutition painful. A feeling of pressure in tho 



DISEASES OF THE BliOOD. J 

siomachi ernctations, and vomiting are not inf reanent. A more serious 
symptom is obstinate diarrhoea ; this proves fatal in some cases. Vir- 
chow f oand a large amount of leucin and tyrosin in the passages. The 
liver is almost always enlarged, as the result of lymphomatous infiltra- 
tions. Ascites develops occasionally. 

Priapism has been observed in a number of cases. 

A noteworthy symptom is the tendency to hemorrhages. These may 
take place beneath the skin, into the muscles, or from the mouth, nose, 
air passages, gastro-intestinal tract, and ^enito-urinary apparatus. Kuest- 
ner described a case in which sudden hemorrhage into the abdominal 
muscles produced symptoms of peritonitis, and terminated fatally^ 
Hemorrhages into the brain produce the ordinary symptoms of cerebral 
apoplexy. Pepper observed sudden deafness as the result of hemor- 
rhage into the ear. 

In one case, Eisenlohr described bulbar symptoms. May reported peripheral 
facial paralysis as the result of lymphomatous infiltration of the sheath of the 
nerve. 

The disease is generally chronic, and. may even last eight years. 

The average duration is one to two years. Acute cases have also 
been reported. In one case death occurred upon the eighteenth day of 
the disease ; in another, upon the twenty-fifth day. 

Steinberg and Schultze noticed a cadaverous odor several hours before 
death, and the rapid occurrence of emphysema of the skin and internal 
organs soon after death. 

Death may be the result of increasing marasmus, or of unforeseen 
complications ^pneumonia, hemorrhage, rupture of the suprarenal cap- 
wiles, cerebral hemorrhage, etc. ). Friedlaender reported a case in which 
the signs of cerebral tumor appeared, as the result of lymphomatous new- 
formations in the brain. 

III. Anatomical Changes. — Lymphomatous new-formations in 
leuksemia occur either as true hyperplasisB in localities which contain 
lymph follicles, or they develop independently of them in a heteroplastic 
manner. Thev appear to have a double mode of development. In 
part they are the result of abnormally profuse diapedesis and extravasa- 
tion of white blood-globules from the vessels, in part of proliferation of 
pre-existing connective-tissue cells. They appear as a diffuse infiltra- 
tion or as nodular formations. The latter may be so small as to resemble 
tubercles, but they are hardly ever cheesy ana do not contain tubercle 
bacilli. 

The peripheral lymphatic glands often form large tumors, which are 
white or speckled grayish red on section. In recent cases, they are soft 
and succulent; in older ones, they are harder. They depend on hyper- 
plasia of the cellular elements, particularly of the cortical substance ; 
this is followed by increase of the interstitial connective tissue and 
increased consistence of the tumor. 

The pericardial cavity generally contains serous transudation, 
which is occasionally sauguinolent, as the result of hemorrhages. 

Nodular or more diffuse lymphomata may be found beneath the epi- 
cardinm, generally in the immediate vicinity of the vessels. 

The left heart is usually empty. The blood contained in the right 
heart sometimes looks exactly like pus ; there is an unusually small 
amount of blood in the venas cavsd, and in all the other organs. 



h DISEASES OF THE BLOOD. 

As a rnle, the heart muscle is pale, occasionally infiltrated with small 
hemorrhages and fatty in places, it may also contain lymphomatous 
new«formations. 

The plearal cavities generally contain transudation. In two cases^ I 
found lymphomatous growths in the pleura, in one case in a diffuse, in 
the other in a nodular form. Similar growths may occur on the epiglot- 
tis, beneath the mucous membrane of the larynx, trachea, and bronchi, in 
the pulmonary interstitial tissue and alveoli. Boettcher described degen- 
eration of the lymphomata and rupture into the bronchi, giving rise to 
the formation of a cavity. The tracheal and bronchial glands are con- 
verted not infrequently into tumors as largo as a fist. The thyroid and 
thymus glands may also be very much enlarged and infiltrated with 
lymphomata. 

Ascitic fiui4 is often found in the abdomen, and the peritoneum is 
sometimes strewn with nodular or diffuse lymphomata. 

The spleen often occupies the larger part of the abdominal cavity. 
In Sixer's case it weighed 16j^ pounds, and was 37 cm. long, 25 cm. 
broad. It is often adherent to adjacent organs. The capsule is gene- 
rally thickened, as hard as cartilage in places, and not infrequently pos- 
sesses villous appendages. The,consistence varies, being softer in recent 
cases, harder in older ones ; it varies according as the hyperplasia affects 
the cellular or also the connective- tissue constituents. The appearance 
of a cut section of the spleen also varies. In some cases, there is simple 
hyperplasia of the splenic pulp; in others, there is hyperplasia of the 
follicles, which may attain the size of a walnut and have a round, elon- 
gated or caudate shape, or the trabeculsB may be hyperplastic. The organ 
sometimes presents a speckled, granite-like appearance. Hemorrhagic 
infarctions, and, if the disease has been preceded by intermittent fever, 
an unusual amount of pigment have also oeen found, Yirchow mentions 
the formation of an abscess as a rare phenomenon. 

Microscopical examination of the spleen does not disclose any abnormal con- 
stituents. 

Chemical examinations of the organ have not furnished the same results. In 
2,600 grams of splenic tissue, Salkow^ski and Stern found large amounts of pepto- 
noid bodies, 0.238 hypoxanthin, 0.134 of other xanthin substances, 0.420 ty rosin, 
succinic acid doubtful, no uric acid. In 1,400 grams of splenic tissue, Boecicedahl 
and Landwehr found: peptones, 15.5 grams; lactic acid, 0. 16; succinic acid. 0.029; 
xanthin, 0,548 ; leucin m large amounts ; no hypoxanthin, uric acid, or tyrosin. 

The liver is generally very large^ and its weight may increase to 10 
kilograms. The periportal glands are generally considerably enlarged. 
Upon section, the interlobular tissue is found more or less diffusely infil- 
trated with lymphomata, or wo find very small nodules or firm nodes 
which have produced atrophy of the adjacent hepatic cells, so that in 
places only pigment detritus remains. If the liver is exposed to the air, 
the cut surface sometimes becomes covered with tyrosin crystals. On 
microscopical examination, the finer blood-vessels are not infrequently 
found to be almost entirely filled with white blood-globules, and their 
walls are often infiltrated with leucocytes. Cirrhosis of the liver is a 
rare complication of leukaemia. 

According to Salkowskl, chemical examination of the liver furnished the fol- 
lowing results : 



DISKA8S8 OF THS BLOOD. 9 

2,500 grams liver. 

83 peptonoid subBtances. 
1.718 tyrosin. 
0.864 leucin. 
0.2426 hypoxanthin. 
0.538 other xanthin substances. 
0.0852 succinic acid. 

The stomach and intestines may also contain lymphomatous new- 
formations which form large prominences on the mucous membrane^ and, 
in places, may surround the intestines like a ring. The lymphomata may 
"Start from the lymph follicles, or they may be heteroplastic. When 
they undergo ulceration, as in Friedreich's case, they may be mistaken 
for the lesions of typhoid fever. 

The pancreas likewise may contain lymphomata. 

The mesenteric and retroperitoneal glands may be very large. Vir- 
chow reported a case in which the pelvic glanas were so large as to 
incarcerate^ as it were, the pelvic organs. 

The kidneys are often infiltrated with lymphomatous masses. They 
generally start from the surface, and are particularly numerous in the 
cortex. The kidneys sometimes contain uric-acid concretions. Under 
the microscope the accumulations of leukocytes are found to be espe- 
cially abundant in the neighborhood of thQ vessels and glomeruli. A 
rare complication is waxy degeneration of the kidneys. 

The suprarenal capsules are sometimes increasea in size to such an 
extent by the development of lymphomata that they may undergo 
rupture. 

The meninges and brain do not escape similar changes. Hemor- 
rhages are frequent in these parts. 

The larger retinal vessels have been found dilated and sinuous, the adventitia 
infiltrated with round cells; the smaller vessels present fatty degeneration, vari- 
cose dilatation and distention with round cells. The previously mentioned white 
patches consist in small part of sclerotic, hypertrophic nerve fibres and accumu- 
lations of granulo-fatty cells in the outer layers of the retina, in great part of an 
accumulation of leukocytes, mingled with red blood-globules, oimilar changes 
are found in the choroid, and even in the iris. 

The medulla of the bones always presents changes, to which Neu- 
mann has applied the terms lymphoid and pyoid. In the former, the 
medulla is gelatinous and red, and sometimes contains extravasations of 
blood; in the latter, the leucocytes have increased in number, and the 
medulla is opaque, grayish, pus-like. In both forms the fat cells disap- 
pear and are replaced by round cells. Waldstein observed nuclear 
fission in some oi the large, mono-nuclear cells of the medulla. Neu- 
mann noticed profuse infiltration of the smaller arteries with round 
cells. Numerous Charcot-Neumann crystals are deposited on exposing 
the medulla to the air. The bone tissue is generally rarefied, although 
Henck observed osteo-sclerosis in one case. 

No cases of leukaemia are known in which the blood-producing organs 
were intact. 

IV. Diagnosis. — With the aid of the microscope the diagnosis of 
leukaemia is easy. The temporary increase of white blood-globules (leu- 
cocytosis) observed after eating, in fasting and marantic individuals, 
during pregnancy an^ infectious diseases does not reach such a high 
grade, and is not permanent. 



10 DIBXiJBES OF THE BLOOD. 

V. PBOON08I8. — The prognosis is unfavorable. Cases of improve- 
ment or recovery are very rare, and even these are not undoubted. 

VI. Trbatmbnt. — We may recommend nutritious, light food, and 
country air. Niemeyer obtained tem{)orary effects from cold-water 
treatment. In addition, we may order iron. Quinine, and cod-liver oil, 
and good effects are said to have been obtainea from arsenic and phos- 
phorus. 

Many authors employ local treatment, i. $., directed aminst the 
splenic enlargement. ^ Mosler recommends large, continued doses of 
quinine, alternating with eucalyptus and piperin. Others employ sub- 
cutaneous injections of ergotin or arsenic in the region of the spleen, or 
inject these substances directly into the spleen. According to Mosler, 
injections into the spleen should not be made unless the marasmus is not 
too far advanced, there is no tendency to hemorrhage, and the spleen is 
not too soft. An ice-bag should be applied over the spleen after each 
injection. Gold douches and compression, faradization, galvanisation^ 
and galvano-puncture of the spleen nave also been emfdoyed. 

Bplenotomy is contra-indicated in this disease, inasmuch as all the patients 
(10) oied immediately after the operation. 

2. PseudoleukcBtnia. 

(Hodgkin's Disease. Adenie. Malignant lymphoma. Lymphosarcoma.) 

I. Etiology. — Pseudoleuksemia and leukaemia agree in their clinical 
and anatomical relations, except that, in the former disease, there is no 
increase of the white blood-globules in the blood. 

Very little is known concerning its causes. Among those mentioned 
are intermittent fever, acquired and hereditary svphilis, scrofula, rickets, 
chronic diarrhoea, and alcoholic excesses. The disease sometimes follows 
otorrhoea, chronic coryza, or dacryo-cystitis, the adjacent glands being 
first affected, and the glandular hyperplasia then becoming general. In 
many cases no cause can be discovered. 

It is more frequent in males, and from the ages of twenty to thirty 
years and fifty to sixty years. The laboring cla^s are more frequently 
attacked than the upper classes. 

II. Anatomical Changes.— The anatomical changes, with the ex- 
ception of the blood, are entirely similar to those of leukaemia. The 
enlarged lymphatic glands may be soft (hyperplasia of the round cells) 
or hard (also increase of the connective tissue). Caseation, suppura- 
tion, or waxy degeneration are observed in rare cases. 

III. Symptoms. — The disease generally begins with swelling of the 
cervical glands. Then other glands become swollen, either in the imme- 
diate vicinity or in remote parts (axilla, inguinal region). The process 
sometimes begins with anginal disturbances and lymphomatous degener- 
ation of the tonsils. The scene mav also open with enlargement of the 
spleen, followed by swelling of the internal and external lymphatic 
glands. 

Anaemia soon develops, and is followed by all the symptoms men- 
tioned under the head of leukaemia. 

In the blood the microscope shows more or less diminution in the 
number of red blood-globules (poikilocytosis), n^krocytes, and numer- 
ous elementary granules. 



I o ns 



lis, 

P 

■ ml 

th 



pear 
|^F_»r6<i 

I ' are I 
sol 

I «h 



mSEABBfl or THE BLOOD. 

The disease generally nine a more rapid conrBB than leiifcBemia, h 
oocasioaally lasts several years. Febrile phenomena are sometimet 
DOticeablej particularly when new glands become aSected. 

The pressure of the glands on adjacent organs may give rise 
I complications, such as circumscribed oedema, paralyais of the recur-^ 
mt laryngeal nerve, tracheal and bronchial steuosis, icterus. Lscites, etc. 
lu some cases the disease is converted gradually into lenktemia. 
ime writers regard both diseases as identical, and believe that on 
nt of the more rapid erowth of the glands in iiseudoleukiBmia the 
lymph tracts are occluded, and the passage of white blood-globules 
into the blood thus jireveuted. Cohulieim s opinion, that pseudoleii- 
IlKmia is an acute leuks^mia in which death occurs before an excess of 
leucocytes enters the blood from the swollen glands, is disproved by tlifr 
fact that the disease sometimes persists as such for several years. 

IV. DiAGSosis AND PBOQNOSis. — M'ith the aid of the microscope^ 
it is easy to diagnose the disease, and to distinguish it from leuktemia. 
The prognosis is as unfavorable as in the latter affection, 

V. Treatment. — The causal indications (intermittent fever, sj-phi- 
lis, scrofula, rickets) should first be met. Cod-liver oil, potaaamm 
iodide, iron, and iodide of iron have been recommended in the treat- 

lent of the disease itself. The experience of Billroth and Czerny war- 
ints the administration of arsenic internally, and in the form of injec- 
ions into the glands. Trial may also be made of inunctions of green 
nap. Sapo vind., 3iv.-xij., is dissolved in a little lukewarm water, 
rubbed twice a week (for twenty minutes) into the back and limbs, and 
then washed off with water. M. Meyer caused enlarged glands to dis- 
appear by the action of the faradic current. The splenic enlargement 
treated iu the same way as in leukiemia. 

3. Jfelanmntia. 

I. Etioloov. — In this disease, the blood contains granules of black ' 
or blackish pigment. 

Intermittent fever, of severe types, is the sole known cause of the 
melanffimia. It is moat frequent in the pernicious intermittents of the 
tropics, but occurs occasionally in the fever of our own latitude. The 
development of melanieniia depends on the severity of the infection, 
rather than upon the duration of the fever. Hence it is more fre- 
quent in certain epidemics. 

II. Symptoms. — The chief feature is the appearance of dark pig- 
ment granules in the blood. These are free in the plasma, or inclosed 
in round oells, or in spindle-shaped cells which resemble the endothe- 
linm of the splenic veins, or they are contained in loiig. hyaline coagula. 
Finally, they may form long cylindrical structures, which sometimes ap- 
pear fractnred at one end or on both sides (vide Fig. S). The granules 
RTe deep black, reddish-brown, or yellowish. The older, black particles 
' «iat for a long time the action of mineral actds and caustic alkalies ; 

10 younger ones grow pale very rapidly under their action. 
The majority of granules are inclosed in round cells, in which 
kensie recently detected amceboid movements. The coagula which 
Bometimes found, consist of an albuminoid substance which dis- 
solves in alkalies, and sets free the pigment granules. It is questionable 
whether the clots are precipitates of fibrin from the blood, or album!- 
lids derived from the destroyed red blood -glohtilos. The pigment 



TWkm* 






■BKCraBniBr, and wru 
oC^ iSwd-globak^ ud 



Ift Mat OBB^ As pipBHC Aafp^M w? npHflf after the eea»- 
tiM «( M «iHk tf fc«c^ iifimi lilN the next alUek. In other 
^1^ ik antes M ite hlM^ lir ■■■>■ and aontha. MdaB«iu« n 
■^ a^i^Mk 4ad ijk «at* neopiiable after microocopic 
ife &IH& it m jMBcnUT MnoHatnd with impoTentt- 
Nd A lafi VkmtiffBhaim (oUfrocjtluBnia) and tiot infre- 
- - HP «f tlMr vhitr plobal» (lettcocTtiMu). 
Al«iril>f>, the resah in great port 0< UkB i 




«i||» Dlxltitlirlllin. . .. 
UilnlllK I'llliiiiiiil. AIMr 

(if llhi |ilt(Mii>iil< lulu tLo mpiUiirieB of rsrions regions of th« 

iMi ii*ln>n crRV nr grayish- vel low color. 
' nhii li-'i'ii dlMorvcii 'wii ilio iwrt of the cerebral, 
i», Imt it in iloiibtful whether the greater 
iMniil fovor or lht> Bcootitinrv nieiaQferaia, 

nii|il(>iitH iit (|iit>Hiti>ii muv occur in perni- 

uul i'i>-r\lH)iiig ri 1(^1 1) I lit' milt. 

ntl »vin|'loiuii lire hoiHhiclio and vertigo; 
iiiiml i<(i't> iiri< ouiiviiNians tttiil paraljseB, 

.'iiill. (rmn iHU'liisiiiTi of the cerebral capjl- 

iMil iMUKiiiiliu'v oxtntvasHtioiis of blood. 

iliiiiiilii iif tlio portnl vein are Baid to gire 

1.1. |ikM'lUiiiltlii >viu{>tomB. and ascites. 



I 
I 



DISEASES OF THE BLOOD. 13 

Pigment emboli of the finer renal vessels cause anuria^ albuminuria^ 
fmd haematuria. Basch described a case in which the urine contained 
clamps of pigment, and similar ones were found in the blood. 

in. Anatomical Changes. — The characteristic changes in the 
blood are recognizable in the dead body. 

The largest amount of pigment is contained in the spleen ; in rare 
cases, it is comparatively free, while the liver is very rich in pigment. 
The medulla of the bones, lymphatic glands, brain, kidneys, and skin 
also contain an abundance of pigment, and a smaller amount is also 
found in other organs (gastro-intestinal walls, pancreas, and lungs). 

The spleen is generally enlarged as the result of the intermittent 
fever, and is soft or firm, according to the duration of the primary dis- 
ease. Its appearance varies according to the amount of pigment which 
it contains. It is either speckled dark-brown or black, or has a diffuse 
black or slate color. 

In the spleen, the pigment is inclosed, in great part, in round cells. Spindle 
cells, clots containing pigment granules, and free pigment are also found. The 
latter is most abundant in the blood spaces of the spleen itself, whence it passes 
into the surrounding pulp, particularly into the round cells. The Malpighian 
foUicles are unaffected. 

The periportal glands are not infrequently loaded with melanin. 
The large amount of pigment in the portal vein is evidently derived 
from the spleen. The liver is often swollen and not infrequently indu- 
rated. On section, it has a steel-gray color in places. 

The interlobular branches of the portal vein are filled with pigment. The pig- 
ment then passes through the intralobular vessels to the central veins, and a part- 
then passes into the inferior vena cava, right heart, lungs, and general arterial 
circulation. In this manner, pigment may also accumulate in the branches of 
the hepatic artery. A portion is probably carried by the amoeboid round cells into 
the connective tissue surrounding the vessels. The liver cells are generally free, 
but Yirchow found pigment in them. 

The kidneys present black dots and streaks, the former correspond- 
ing to the glomeruli filled with pigment, the latter to the afferent ves- 
sels. Frerichs occasionally observed pigment in the urinary tubules. 

In the brain, the cortex is affected almost exclusively, and assumes a 
chocolate-brown or graphite appearance. The medullary substance has 
a brilliant white color by contrast, but here and there it contains black- 
ish streaks (pigment in the vessels). Small extravasations of blood are 
sometimes observed as the result of the pigment emboli. 

The medulla of the bones has a brown, gray, or blackish color, and 
is usually poor in fat. 

The pigment is undoubtedly the result of excessive destruction of red blood- 
|;lobules. Since melansemia is absent in other infectious di^easas, an injurious 
mfluence upon the red blood-globules must be attributed to the malarial poison. 
Th«^ destruction of the red blood-globules is supposed by some to take place in the 
spleen, by others in the liver. According to Arnstein and Welsch, it takes place 
in the vessels themselves, and is deposited secondarily in the spleen and other 
organs. 

IV. Diagnosis, Prognosis, Treatment. — The diagnosis can be 
easily and certainly made with the aid of the microscope. The prog- 
nosis is generally grave on account of the severity of the primary disease. . 



14* 



DI8EA8B8 OF THB BLOOD. 



It should be treated prophylactically and causally with large doses ol 
quinine ( 3 ss.-i. daily), continued lor a long time; otherwise purely 
symptomatic treatment. 

4. Chlorosis. 

( ChlorcBmia. ChlorancBmia. ) 

I. Etiolooy. — Chlorosis is an extremely frequent disease of the 
female sex. It is very rare in men, and some writers deny, though im- 
properly, its occurrence in the male sex. The affected males are gener- 
ally slender and of a feminine type. 

The disease generally develops at the |)eriod of puberty (fourteenth 
to twenty-fourth years). It is not so very infrequent in children, and in 
exceptional cases develops at the age of thirty years or later. 

Chlorosis is an exquisitely hereditary and congenital disease. Vir- 
chow showed that it is the result of imperfect development of the vascu- 
lar apparatus (hypoplasia), which may or may not be associated with 
feebleness of the entire body and hypoi)lasia of the sexual apparatus. 

Chlorosis is often hereditary in families which also suffer from phthi- 
sis, cancer, and nervous diseases. 

In many cases, certain auxiliary factors produce complete development 
of the latent germs of the disease. Such factors mav also produce the 
disease in the absence of hereditary and congenital predisposition to 
chlorosis (acquired form). These include psychical conditions: excessive 
study, grief, nomesickness, etc. In others, physical factors are at fault, 
for example, sedentary habits, confinement in close, poorly ventilated 
rooms, working in factories, insufficient nourishment, etc. It sometimes 
follows vital losses, such as those connected with child-bed, lactation, or 
masturbation. 

The constitution is not such an important factor as is generally be- 
lieved, since delicate and feeble girls are not the only ones affected. The 
Eatients almost always suffer from menstrual disturbances, but we must 
e on our ^uard against mistaking cause and effect. Kiemeyer states 
that all gins who menstruate at the twelfth or thirteenth year, before 
the development of the breasts and pubis, become affected with chlorosis. 

The frequency of the disease is constantly increasing. This is partly the re- 
sult of the perverse bodily and mental training incident to modem civilization. 

II. Symptoms. — The symptoms generally develop gradually. They 
occasionally be^in immediately after the first menstrual i)eriod. The 
patients gener^ly seek medical advice on account of subjective com- 
plaints: general feebleness and lack of desire to work, drowsiness, rheum- 
atoid pains, dyspnoea, palpitation, gastric disturbances, etc. In other 
patients, the menses first become irregular, scanty, and painful, or cease 
entirely. In rarer cases the individual feels quite well, out has a pale, 
miserable appearance. 

The pale color of the skin is one of the most consfant and earliest 
symptoms. It appears earliest and most markedly on the lobe of the 
ear. The cheeks ^so lose their red color and the mucous membranes 
(conjunctiva, lips, gums, and remainder of buccal mucous membrane) 
become pale-rea or yellowish-red. In some patients the entire face has 
a sallow or greenish-yellow color, and in brunettes it is sometimes a dirty 
pale gray. 



or TBB BIXWD. 

I The sclera ie often bluiab-white, and the subconjuDctival fat p^ I 
lUow. 

The amount of [ligment sometimes diminiahes in the skin, and even 
lu the hairs, either in patches or difFnsely. The nails generally have a 
deathly pale color on account of the diminished redness of the nail bed. 

The integument is generally dry, has very little tendency to perspire, 
and often desquamates. 

Certain cnlorotics, however, have a blooming compleiion, as the I 
resnit of dilatation of the subcutaneous veaaels in the face. Others blush 
deeply with every bodily or emotional excitement, evidently from hyper- 
exctiability of the vaao-motorB. 

The panniculns adiposus ie often nnoanally well developed. If it 
disappears very rapidly, a suspicion of the existence of some wasting dis- 
eaBeYdenerally phthisis) must be aroused, 

(Edema develops occasionally ; it is generally very alight, affects the 
ankles or lids, and disappears at night. In rare cases more extensive 
and permanent cedema of the legs is observed. The oedema is owing to 
the fact that the changes in the blood disturb the nutrition of the walla 
of the vessels, and render them abnormally permeable. 

If the finger is pricked with a needle, the blood generally flows 
freely, so that it does not seem to be diminished In this disease. But, as 
a rule, it is pale red, serous, and watery. Under the microscope, the red 
blood -globules often seem, even without careful measurement, to bo di- 
minished in number. They are often very pale and exhibit but little 
tendency to assume the nummular arrangement. Blood-globules of 
very large dimensions often alternate wltji extremely small ones. Changes 
in the shape are also very frequent. The globules are constricted, pear- 
8haj)ed, or entirely irregular (poikilocytosis). In not a few cases the 
white blood -globules are diminislied in number. In some cases there 
arc numerous protoplasm granules, occasionally aggregated into large 
heaps. 

Accurate count has ahoira that the a 
anchauKed. nometiiiies diminished. Ii 
blood-globules in one cub. vara, (normally 4,430,000). 

Even the amount of bsnioglohin rnav be unchauged. though, as a rule, it ii 
diminished (sixtf-eeven per cent of the iiormal, on the average, in twenty-four 1 
cases examined by Laacher), a 

Duncan noticed that if the red globules are placed in a solution of sodium 1 
chloride, they lose their coloring matter more readily than the blood -globules of | 
healthyindividuata. I 

The amount of iron in the blood is diminiebed. The blood serum may be UO. I 
changed, or the proportion of ^bumln may be increased or diminished. 

The temperatnre of the body is almost always unchanged. There 
are occasionally slight elevations in temperature (39.8° in the rectnm is 
not infrequent, according to Molli^re, and may be relieved by quinine). 

The majority of patients complain of a subjective feeling of coldness, 
The pulse is usually soft, accelerated, and its rapidity often varies 
greatly in consequence of bodily or mental exertion. 

Aa' a rule, the patients exhibit a disinclination to mental or bodily I 
work. They have a tired expression of the face, and often sleep during 
the day, while at night they toss about reBtleaslv in bed. 

The mood is irritable, capricious, and tearful. The patients often 
oomplain of shortness of breath which is increased by movement. They 
^tto^nfreqnently hoarse, and in such cases the laryngoscope shows 




16 DISEASES OF THE BLOOD. 

striking pallor and dryness of the laryngeal tissues. Catarrhs of the 
deeper air pass^es are not infrequent^ and their development is eyi* 
dently favored by the diminishcld powers of resistance of the system. 

The breasts become very flabby and diminish in size; not infrequently 
they contain hard spots which may occupy the entire gland. 

The majority of patients are annoyed by palpitation, which develops 
spontaneously or after mental or bodilv effort. The vigorous action of 
tne heart is often visible over several intercostal spaces. The right, 
rarely the left, ventricle is often dilated (ansemic dilatation). Systolic 
murmurs are often audible over one or several, or even all the valves. U 
the heart's action is very vigorous, the second pulmonale sound is often 
intensified temporarily, thus arousing the suspicion oi mitral insuffi- 
ciency. The differentiation between the two conditions sometimes re- 
quires prolonged observation. 

Dilatation of the right ventricle may be the result of nutritive disturbances: 
of the heart muscle, to which the thin-walled right ventricle is most apt to yi^d. 
The murmurs are probably dependent on the same cause, inasmuch as the im* 
properly nourished heart muscle is incapable of regular vibrations during con- 
traction. The systolic sound is always heard in addition to the murmur. The 
murmur is rarely musical, nor does it often give rise to thrill. It is heard most 
frequently over the pulmonary valve, next over the mitral and tricuspids, rarely 
over the aortic valves. 

Accidental diastolic murmurs ai*e heard in rare cases. 

In not a few cases, the carotids pulsate vigorously, and the cardiac 
svstolic sound is often converted, in these vessels, into a murmur. A 
snort, low systolic sound may be heard over the smaller arteries, and on 
pressure is converted into a compression murmur; on increased pressure, 
into a pressure sound. 

The bruit de diable is often heard over the bulb of the internal 
jugulars (between the sternal and clavicular portions of the stemo- 
mastoid, immediately above the sterno-clavicular joint); but this is also 
found, at times, in healthy individuals. The murmur is sometimes con- 
veyed across the manubrium along the right border of the sternum. 

The bruit de diable mav be sighing, roaring, sawing, or whistling. It is not 
infrequently felt as a thrill. It increases in the erect position, in deep inspiration 
and slight rotation of the head towards the opposite side, and is generally louder 
on the right side than on the left. This is owing to the fact that the ri^ht in- 
ternal jui^ular runs a more vertical course to the heart, so that a more vigorons- 
whirl is formed within its bulb than in the left jugular. Compression of the peri- 
pheral portion of the vein causes disappearance of the murmur, on account of 
mterruption to the blood supply. The murmur may be so loud that it is heard by" 
the patients as an annoying roaring in the head. 

Similar murmurs are sometimes heard over the crural vein, immediately 
below Poupart's ligament, but these increase during expiration; in rare cases,, 
they are heard over the subclavian or even the facial vein. 

The cervical veins are generally but slightly filled. They sometimes 
manifest a negative venous pulsation. 

Chlorotics very often suffer from goitre, but I have never been able 
to hear a murmur over the tumor. It disappears as the primary chloro- 
sis is relieved. It is also said that the patients may suffer from exoph- 
thalmus. 

Persistent factor ex ore is observed not infrequently in chlorotics*. 
Anorexia is a frequent symptom, but sometimes we notice bulimia, in-^ 



DISEASES OF THE BLOOD. 17 

creased thirst, or a desire for peculiar articles (pica). Many complain 
of gastric distention, violent pain in the stomachy eructations^ and 
Yomiting. Constipation is quite a constant symptom. 

The urine is generally light-colored, watery, and of low specific 
gravity. The urea and unc acid may be diminished. The urine often 
contains traces of albumin, but no casts. 

Disturbances of menstruation are very common. In the majority of 
cases, the menses remain entirely absent. In others, they occur reg- 
ularly, but are attended with violent pain, last only a few hours, and the 
fluid has more of a mucoid than bloody appearance. The menses may 
also be very irregular, and finally they majr be very profuse. 

Complications of a functional or organic character are observed very 
often. The former include nervous disturbances, such as spinal irrita- 
tion, neurasthenia, cephalalgia, neuralgias, more rarely spasms and 
paralyses. The latter are particularly apt to develop when, as is not un- 
common^ chlorosis is followed by hysteria. 

Among the various forms of neuralgia, . particular attention is 
merited by gastralria, since chlorosis creates a predisposition to round 
nicer of the stomach. 

Chlorotics often suffer from ieucorrhcsa, and examination with the 
speculum may disclose erosions and ulcerations of the vaginal mucous 
membrane and portio vaginalis. 

Virchow emphasizes the tendency of chlorotics to endocarditic 
changes. Cases of venous thrombosis have also been described, perhaps 
as the result of fatty degeneration of the endothelium. 

Bepeated epistaxis is often observed. 

Finally^ chlorosis creates a certain predisposition to pulmonary 
phthisis. 

In three cases, (lowers observed optio neuritis and neuro-retinitis, which im- 
proved after the administration of iron. Pallor of the fundus is a common symp- 
tom of chlorosis. 

The duration and course of the disease depend upon its causes. If 
dependent on hereditary and congenital influences, frequent relapses 
must be expected, and certain symptems may persist permanently. In 
other cases, it may be relieved in a few weeks. 

III. Anatomical Changes. — Death occurs only from intercurrent 
diseases, so that very little opportunity is afforded for post-mortem ex- 
aminations. 

Increased development of the adipose tissue is often noticeable, not 
alone in the panniculus adiposus, but also the subepicardial and omental 
fat. The internal organs are generally pale. 

The pale, often fiabby heart is unusually small, but the right ventri- 
cle is often dilated in comparison with the other cavities. The endocar- 
dium is delicate, transparent, and bluish-white. In places it contains 
slightly elevated, light-yellow patches, which correspond to fatty degen- 
eration. Streaks ox fatty degeneration are also often found in the h^aat 
muscle. 

The aorta is likewise unusually small and delicate, and occasionally is 
not larger than the crural artery of a healthy individual. Its walls are 
often very delicate and distensiole. The intima has a bluish appearance 
and presents yellowish elevations. The microscope shows fatty degene- 
ration in the intima and tunica media. The intercostid arteries are very 



18 DISEABES OF THE BLOOD. 

often given ofp irregularly from the aorta. Similar changes are observed 
in other arteries. 

There may be defective development of the sexual apparatus., though 
this is not constant. 

Patty degeneration may develop in the liver, kidneys, pancreas, and 
the glandular cells of the gastro-intestinal tract. 

Nothing is known with certainty concerning the nature of the dis- 
ease. We re^rd it as a primary affection of tne blood-producing or- 
gans, which gives rise to the production of a diminished number of red 
blood-globules containing a diminished amount of hsemoglobin. We 
confess, however, that we possess no positive proof in support of this 
hypothesis. 

IV. Diagnosis. — The diagnosis is easy, but it must be remembered 
that chlorosis sometimes occurs in individuals with a ruddy complexion. 

The disease is distinguished from secondary anaemias by the fact that 
chlorosis is a primary condition. Under certain circumstances, how- 
ever — for example, latent phthisis and cancer — secondary anaemia may be 
mistaken for primary sclerosis. We should be on our guard, therefore, 
when chlorosis develops in a woman with a phthisical family historv, and 
when it is attended by rapid emaciation and night sweats. 

It is distinguished from progressive pernicious anaemia by its amena- 
bility to treatment, the absence of orolonged febrile movement and of 
retinal hemorrhages. 

Chlorosis is differentiated from chronic nephritis, in those cases in 
which oedema and slight albuminuria are present, by the absence of casts 
in the urine. 

V. Prognosis. — The prognosis is always good as regards danger to 
life. The symptoms can be rapidly relieved in the majority of cases, 
but it is often impossible to prevent relapses. 

VI. Treatment. — The treatment consists mainly of rational bodily 
and mental regimen. But although fresh air is very necessary for the pa- 
tients, we should not, at the start recommend long walks, since these 
often do more harm than good. Exercise in the open air should never 
be carried to such an extent as to tire the patient. Cold rubbings are 
useful iu order to make the body more resistant, A change of air is gen- 
erally beneficial. In some cases such simple measures, attended with re- 
moval of the etiological factors, will suffice to effect a cure. 

Among the medicinal agents the most important are the ferruginous 
preparations. 

We agree with those writers who recommend long-continued and large dosee 
of iron. 

Almost every practitioner has a favorite iron preparation. Our own prefer- 
ence is for Blaud's pills. 

The various preparations may be arranged in the following order, with regard 
to readiness of assimilation: ferrum redactum, ferrum lacticum, ferrum pulver- 
atum Tgr. iss. three hours after meals), tinct. ferri pomata, tinct. ferri acetici, 
tinct. ferri chlorid. (90 drops 1. 1. d.). 

In some individuals, the mildest preparations produce gastric symptoms. In 
such cases, iron has been used subcutcuieously, especially ferrum oxydat. dialysat., 
ferrum pyrophosphorio c. ammonio citrico (1:6), ferrum pyrophosphoric. c. na- 
trio citrico (1 : 6), one syringeful subcutaneously . The solutions should be freshly 
prepared, since f un^ are apt to form in them, and often lead to the development 
of an abscess after injection. 

Iron is absorbed to a very slight extent in the ^astro-intestinal tract, so that 
some writers think it acts by producing hyperssmia of the mucous membrane, 
and thus favoring the absorption of food. 



DISEASES OF THE BLOOD. 19 

Iron waters and baths are also employed in many cases. Ziemssen 
reports favorable results from the administration of haemoglobin loz- 
enges. 

If the patient also exhibits evidences of scrofula, we should order 
iodine in combination with iron, for example, ferrum iodat. saccharat. 
{^T, iss. every two hours), syrup, ferri iodia. ( 3 ss. t. i. d.), etc. Cod- 
liver oil should also be administered ( I ss. morning and evening). In a 
number of cases I have obtained remarkably good results from the use 
of Kissingen water, together with baths. 

If gastric symptoms are present from the start, we must be very 
careful in the use of ferruginous preparations. Gastric digestion may 
be improved by the administration of hydrochloric acid (gtt. v. in half 
a wineglassful of lukewarm water one-half hour after dinner and supper). 
If gastrointestinal peristalsis is inactive, we may order the bitters, for 
example, tinct. chinsB comp. ( 3 i. t. i. d. ), elix. aurant. comp. ( 3 i. 
t. i. d.), strychnin, nitricum (gr. f, pulv, althaese, q. s. ut ft. pil. No. 
XV. D. S. One pill t. i. d.), etc. 

In some cases, the symptoms disappear rapidly after a happy mar- 
riage, but in other cases women become profoundly chlorotic after 
marriage. 

6. Progressive Pernicious Ancemia. 

{Essential Pernicious Ancemia. Idiopathic Ancsmia. Ancematosis.) 

I. Etiology. — The disease is characterized by increasing impover- 
ishment of the blood, which increases almost uninterruptedly to a fatal 
termination. 

In the minority of cases, it develops without any demonstrable cause 
(idiopathic or primary form); in others it follows certain injurious influ- 
ences (deuteropathic or symptomatic form). But we would relegate to 
the category oi pernicious anaemia only those cases in which there is a 
striking disproportion between the cause and effect. Hence a sort of 
predisposition is necessary in order that progressive pernicious ansemia 
may develop. 

The secondary form may result from mental strain; excessive bodily 
labor may act in the same way. In some cases, it is the result of living 
in unhealthy rooms, working in overcrowded factories, and insufficient 
food. The disease sometimes develops during pregnancy or after con- 
finement. It occasionally follows diarrhoea, vomiting, repeated epis- 
taxis, vital losses, and tjrphoid fever. 

It is most frequent from the twentieth to sixtieth years; in very 
rare cases, it occurs during childhood. 

The geographical distribution of the disease varies remarkably. It is especially 
frequent in Switzerland, i)articularly in Zurich and its vicinity. Even in Zurich 
ils frequency varies greatly at different times. Numerous cases have been ob- 
served in England, France, and Sweden, while Italy, Spain, and Russia escape 
almost entirely. 

n. Stmptoks. — The clinical history depends entirely on the intensity 
of the impoverishment of the blood. 

The disease generally begins gradually. The patients grow tired, 
and perspire after slight exertion; they are short of breath, suffer from 

falpitation, perhaps complain of dizziness, and grow paler day by day. 
'inally they are unable to leave the bed. 



20 DI5EA8E OF THE BLOOD. 

Among the manifest symptoms^ the chief attention is attracted by 
the intense pallor of the face and mucous membranes. The sclera is not 
infrequently icteric in color. 

Jaundice is a rare sjmptom. In a few cases, the skin assumed a gray or 
brownish color, as in Addison's disease. 

The cutaneous secretions are diminished^ so that the skin appears 
dry. The nutrition of the hairs is sometimes impaired. They become 
brittle^ destitute of gloss, and fall out. In one case, I observed nutri- 
tive changes in the nails: they were thickened and fissured, and crum- 
bled off ^t the free edges. 

Hemorrhages under the skin are not infrequent. They generally^ 
occur earliest and most abundantly upon the lower limbs, are usually 
about the size of a pin's head (petechiae), rarely they cover a large sur- 
face (ecchymoses) or have a swollen appearance (ecchymomata). They 
are sometimes shaped like stripes (vibices), generally as the result of the 
pressure of folds of the clothing. 

Punctate hemorrhages may also occur upon the mucous membranes 
(scleral conjunctiva and buccal mucous membrane). 

(Edema is a frequent symptom. It does not always appear first in 
the lower limbs, but occasionally in the face. At a later period, also, 
the face may be swollen into a shapeless mass, while the oedema of the 
limbs is very slight. (Edema of the conjunctiva (chemosis) is frequent. 
At the beginning of the disease, the oedema may be temporary. At a 
later period, it becomes permanent, and is associated with slight serous 
accumulations in the serous cavities. This symptom is probably the re- 
sult of nutritive disturbances in the walls of the vessels. 

The subcutaneous .adipose tissue is often unusually abundant; in. 
other cases, it is more or less atrophied. The physique is generally 
slight, but robust persons may also be affected. Some oi the bones may 
be tender on pressure. In rarer cases, tliere are pains in the -muscles. 

The bodily temperature may be normal during the entire course of 
the disease. In other cases there are elevations of temperature (40° 0. 
or more), of a continuous, remittent, or irregular type. 

The pulse is generallv soft and accelerated. 

The subjective complaints of the patient consist chiefly of a feeling- 
of great weakness. Palpitation, obscuration of vision, dizziness, nausea, 
and syncope often set in as soon as the patient attempts to pass from the 
recumbent to the erect position. Many also appear to suffer from 
mental weakness. They he in an apathetic manner, as if half asleep, 
sometimes mutter to themselves, and answer questions after a long in- 
terval, as if the meaning of the question were only understood gradually. 
Some complain of obstinate insomnia, anxiety, a feeling of constriction 
in the chest, etc. 

The sensorium is sometimes unaffected almost to the last moment. 
In others, there is increasing somnolence with a dreamy condition, in 
which life is gradually extinguished. In still others, delirium and 
maniacal attacks are observed, and thev must be carefully guarded in 
order to prevent them doing injury to tnemselves or those about them. 

There is often persistent insomnia. The patients are sleepy in the 
day, but at night they toss to and fro, moan, and talk to themselves. 

The respiratory organs are unaffected. Attacks of dyspnoea may 
develop spontaneously or after excitement, and are the effect of anasmia. 



SUBASIS OF THS BLOOD. 

e is also ft tendenoy to ojilstaxis, which may be repeated, increaswV 
^e anffimia, and occusionally ie directly dangeroue to life. f 

The circulatoy organs rarely escape tunctional distil rhancea. In 
isny, attacks of palpitation occur epontaneously or after slight excite- 
leut. The movemeutti of the heart are then unusually vigurnue, but 
^e subjective symptoms may also exist without inoreiisad heart's action. 
Not infrequently there is aligh*. dilatation of the heart, usually the right 
Bide alone, occasionally al-o the left. The first heart sound is ofteu 
converted into a systolic murmur, which may be beard over one or all 
( the cardiac orifices. In rare casBSj we bear diastolic murmurs of ■_ 
lurcly accidental character. 

The carotids generally pulsate vigoroasly, and systolic marmura ( 




^. 



epherlwl mion>cyi«a. Bolarged 000 timet. 

~oft«n heard over them. A short arterial sound may also be heard in 
peripheral arteries (bmchiul, axillary, radial). 

The bruit de diable over t!ie jugular vein is a constant svmptom. 
Trae or negative venous puke b often visible in the external jagulars. 
The bruit de diable may also be heard in the crural vein, but, unr 
like tliat in the jugulars, it grows feebler during inspiration, stronger 1 
during expiration. ■ I 

If the finger is pricked with a needle, the blood flows freely. As a 
rnle, it is lignt colored, sometimes of an amber yellow. Coagulation 
may take place very slowly. The white blood-globules are generally 
very scanty. The so-called }irotopliism granules (elementary granules, 
imatoblusts) are present in small numbers. The number of red blood- 



22 DI8BASE6 OF THE BLOOD. 

globules is rery mnch diminished. Ejellberg found in one case only 
671,000 inl cub. mm. (normally 4,000,000 to 5,000,000). The red blood- 
globules are pale, irregular in shape, and vary in size. They are ellii>tical, 
provided with prolongations, pear-shaped, etc. (vide Fig. 4) (poikilocv- 
tosis). As a rule, their dimensions are increased (8-9 // instead of 7.6 fj). 
Not a few attain a diameter of 15 pi (giant blood-globules). In addition, 
there are others which are unusually small (microcytes), and these are 
either umbilicated or spherical. The former are intensely red and 
glistening, and are rather rare. Their diameter generally yaries from 
3-4 pi. very fine drops of a haemoglobin color are sometimes found. 
The red blood-globules are generally isolated, rarely arranged in 
columns. Stellate shapes are rarely observed. 

In one case the blood had a reddish-brown or a ooffee-like color, in mottier 
it was unusually dark. Strieker describes brownish blood-globules. The hmno- 

flobin has been found separated from the stroma and aocnmwlatiwl in drops. 
Ilz mentions amoeboid movements of the red blood-globules. • A few nudeafeed 
red globules have also been observed. 

The changes described may also occur in other farms of ansdmia. Franken- 
haeuser described, in the blood of pregnant women suffering from progranive 
pemidons anaemia, spherical movaole bodies with a switiging lash, wGkdi are 
supposed to have entered the blood from the liver and to oonstitute a osrtain 
stage of development of leptothriz (?). In three of mv cases these bodies wars 
also noticeable, but I could arrive at no oonclusion with regard to their natars. 
In one case Quincke found that the blood amounted to ^, in another to iM$ 
of the weight of the body (normally 8^. 

In one case Fraenkei found that 100 parts of the blood, four days befovsd«ath» 
contained 11.57 solid matters, of which 1.81 were nitrogen (15.M)( nitmen 
in the dried blood). Healthy blood gave the following figures: in XOO parts M.M 
solid matters, d.27% nitrogen, ld.l7j( nitrogen in the dried blood. 

Disturbances of the digestive organs are observed almost constantly. 
Hemorrhages from the gums and small ulcers upon the buccal mucous 
membrane have been observed in several cases. The majority of pa» 
tients complain of anorexia and fcetor ex ore. Sometimes there is 
insatiable bulimia and the feeling of thirst is occasionally increased. 
Complaint is often made of pain and pressure in the gastric region, a 
burning feeling, eructations. Vomiting is frequent, and hnmatemesis 
is observed occasionally. The latter may continue for a long time, and 
rapidly exhaust the patient. Diarrhoea^ sometimes of a bloo^ charaoter, 
is a frequent symptom. 

The liver and spleen are generally normal in size; in advanced cases, 
they are sometimes slightly enlarged. The liver may be very tender on 
pressure. 

The urine is passed in large (j^uantities, but there may be striking 
variations on successive days. It is sometimes very dark, the specific 
gravity is normal, the reaction always acid. 

Chemical examination of the urine furnishes varying results. The urea is 
sometimes diminished, sometimes increased; sodium chloride is almost always 
diminished. Increase of the amount of indican haH been noticed. 

Albuminuria is rare; Laacher observed peptonuria. Hoffmann found lactic 
acid in the urine and an increased amount of kreatinin. Hsdmaturia has been 
observed occasionaUy. 

The nervous system is very often affected. Twitehings, paretic and 
paralytic conditions, and parsBsthesiso are not unusual, but generally only 
temporary. 



DISBASBS OF THE BLOOD. 



The neiree of special sense may be involved. The p 



Iwcome deaf, lose smell itnd taste, • 



mplain of E 



iuddonly 



in Bume of the nerves of special sense. Sudden blindness develops occa- 
donally, and is sometimes the result of retinal hemorrhages. 

Vision is often intact despite the almost constant occurrence of reti- 
nal changes. The latter consist mainly of hemorrhages, which ara > 
Eometimea present in astonishing numbers (vide Fig. 5). Thuj vary.g 
greatly in size, but are sometimea almost as large as the optic diso.* 




t Retinal uhsiuMS In proBreaslTB pemlcloUH Mteinlft. 

Llghl CDDtn la tbn heinorrbiucei. A((«r gulucke. 
icy are most abundant in the neighborhood of the papilla. They are 
DCrally streaked, and often radiate towards tho napilla. The recent 
ea are ruby-red, the older ones bmwnish-red, the latter not infre- 
ently containing a light-yellow centre. Large numbers aomelimes 
pear Ruddenlv in the course of a single day, but they may be absorbed 
a relatively short time (two to three weeks). 



m 



24 DISEASES OF THE BLOOD. 

The retina sometimes contains yellow patches similar to those found 
in Bright^s disease. 

(Edema and symptoms of stasis in the retina and papilla are observed much 
less frequently. The retina assumes a veiled, reddish-gray appearance, the bor- 
ders of the disk are indistinct, the papilla prominent, and the retinal veins dis- 
tended and sinuous, while the arteries are very narrow. 

The disease sometimes lasts only a few weeks. In other cases^ life is 
prolonged for months, sometimes even for years. The subacute and 
chronic cases often present remissions and exacerbations, but, as a rule, 
the disease terminates fatally. 

A few cases of the conversion of progressive pemicioot anssmia into other 
diseases have been reoorted. For example, it has been followed by the symp- 
toms of myeloRenic leuksBmia, or of sarcomatoeis of the bones. In one of my 
cases it was followed by a beginning cancer of the pylorus. As the ansBmia had 
existed for a year, and the cancer was just beginning, it would be irrational to 
regard the anssmia as the result of the cancer. Another of my cases was com- 
plicated during the course of the disease by lympho-sarcoma of the mesenteric 
and retro-peritoneal glands. 

In some cases death follows the gradual extinction of all the func- 
tions, in others a rise of temperature occurs for days or hours before 
death. But sometimes the temperature falls to a very marked extent 
(25.8° C). The cutaneous perspiration sometimes has a cadarerous 
odor for a few hours before death. 

III. Anatomical Changes. — The integument remains extremely 
pale. The panniculus adiposus may be unusually developed^ and there 
is sometimes an increase of fat in the internal organs, particularly be- 
neath the epicardium and in the mesentery. The muscles are pale, and 
sometimes very dry. 

Under the microscope, the muscles are generaUy found to be intact. Berger 
found ooUoid degeneration of these organs. MueUer describes fatty degeneratk>n 
of the diaphrastn and intercostal muscles. £. Fraenkel noticed a larape amount 
of yr]Yow <)nd brown pigment in the ocular muscles; the muscular fibres wiere 
< loiid.v iiiiil Kianular. 

The serous cavities contain moderate amounts of transudation of an 
amber yellow. It is occasionally sanguinolent or icteric. 

Hemorrhages are noticed upon the skin, in the muscles, the mucous 
membranes, serous membranes, and the interstitial tissue of many 
organs. They are generally small, often punctate, rarely of large size. 
They are sometimes so large, however, as to give rise during life to hes- 
moptysis, hsematuria, or nasmatemesis, although no bleeding vessel can 
bo found after death. 

The internal organs are unusually pale, the cavities of the heart are 
almost empty, or contain small quantities of watery blood, which is 
either entirely fluid or deposits scanty thin clots. The latter sometimes 
have an icteric color. 

In one case, the blood in the dead bodv had an acid reaction. According to 
Quincke, the specific gravity is 1038.2 (normaUy 1055). 

The heart is sometimes unusually small, sometimes it is dilated, par- 
ticularly the right ventricle. Hypertrophic changes may also be noticed. 
The heart muscle is generally pale and brittle. If the epicardium is 
thin, yellow patches sometimes can be seen shining through, and these 
are seen still better under the endocardium. They are most abundant 



DTBBABES OF THE BLOOD. 

frtbe left heart, particularly in the papillary museSescfthe mitral Talves. ' 
Aev are often bo namerous that tlie heart muscle has a butter-yellow, 
speclcled, marbled appearance, and are found to correspond to marked 
fatty degeneration of the muscular fibres. The fat is generally arranged 
in coarse granules; one part of a fibre may be affected, while adjacent 
part* are intact. Nuclear proliferation is absent, but there are often 
small interstitial hemorrhages. These appearances are rarely absent in 



The endocardium is thin and transparent, and occasionally presents 
hemorrhages, alight fatty degeneration and atheromatous changea. The 
Talvniar apparatus is always intact. 

The aorta is generally normal. In a few cases it has been found to 
be narrow, or to present fatty degeneration and atheroma. 

The respiratory organs are little changed. Small hemorrhages into 
the lungs have been observed, and oocaaionolly cedema of the glottis. 

The spleen is generally normal in size, but slight enlargement is not 
very rare. In the latter event, the parenchyma is firm and tough, i 
Hemorrhages into the organ have also been reported. 

In one case. Leber toutid a large amount of leucin and lyrosln in the 8pl»_,_ 
liver, lun^. ao'l pancrpaa. Atteatioa tias been called recently to the larg^'^ 
amount of iron in the spleen. * 

The liver is generally normal in size. In rare cases, it is slightly en- ] 
larged. It is often pale, at other times the central veins are distended, f 
Hemorrhages are observed not infrerjnently. The gall-bladder is often i 
filled with dark bile. Pepper observed eccnymoees in the mucous mem- 
brane of the gall-bladder. I 

The hepatic ci>lht are often in a condition of fatty degeneration. In one m 
MuelliT anil WinKe observed the development of adenoid tissue with a. 
mulation of round cells. 

A Urge uuiount of iron has been found in the liver. 

The gastro-intestinal mucous membrane often presents cedematoiu 
Bwelliog and extravasations of blood. Enlargement of the inteatioaJ 
lymph follicles and fatty degeneration of the glandular ^ithelium hanl 
also been observed. 



^^ei 



The mesenteric glands are often awollen, hvperieniic in places, and' I 
speckled with blood. In one case, all the glands were awollen and red, 
and the lymphatics were dilated and contained bloody lymph. 

The pancreas may be very large and congested, with homorrhagea ] 
into the interstitial tissue. The glandular epithelium is m a condition , 
of fatty degeneration. 

The kidneys are generally very pale, and the epithelium of the 
tubules is not. infrequently fatty. In a few cases, there is slight increase 
of the interstitial tissue with accumulation of round cells. Tiiickening 
of the Malpighian capsules, and fatty degeneration of the blood-vesai'ls 
hzve also been noticeu. Hemorrhages have been observed upou the mu- , 
cona membrane of the urinary passages and eexnal organs. ^ 

Extravasations occur frequently in the meninges, particnlarly on the 
ler Buifaoe of the dura mater. 



26 DI8EA8BS OF THE BLOOD. 

The brain almost always contains numerons capiUary hemorrhages^ 

Senerally in the white matter. Certain vessels are sometimes in a oon* 
ition of fatty degeneration. In one case, Schumann foand spindle* 
shancd and ampuliary dilatations of the vessels. The brain and spinal 
cord are very pale. 

Changes 'in the sympathetic system (proliferation of the interstitial 
connective tissue, atropny of the nerve fibres and ganglion cells) have 
been described in a number of cases, but Lubimoff has shown that we- 
must bo very careful in our interpretation of such appearances. 
In my own cases the peripheral nerves were intact. 
•The retina contains hemorrhages and yellow patches; the optic- 
papilla is sometimes oedematous and swollen. 

In recent cases, the hemorrhageB consist solely of red blood-globiiks. In older 
caaee, granular disintegration b^ns in the centre of the extraTaaiition, and eiu 
tends peripheraUy; in such cases the ophthalmoscx>pe shows a liffht yellow centre. 
In rare ca^es white patches are produced by the presence of wuto blood-|^oboles 
in the centre of the extravasations. In one case, Krukenbiug noCioed varicose 
nerve fibres. 

The hemorrhaKM are generaUy situated free. In a few cases, tiie blood is sita* 
ated in the adventitious lymph space. 

The retinal vessoli not infrequently contain spindle^hi^wd and ampnllaiy di- 
latations. 



In many cases the medulla of the bones is unchanged. In otlier • 
it contains* hemorrhages, or the fat tissue disappears and is replaced by 
red lymphoid medulla. 



In addition to a large number of iphericfd red blood-^obates, the nedoDa 
tains numerous nucleated red Uood-globales (so-called tiansitianal fomi^ 1% 
often contains a large number of cdk which inclose blood-f^obniea. 

The majority of writers believe that progressiTd pernidottsaMwnia ia 
a disease ox the'ha^matopoietic organs which leads to insnlBcia&t fomift- 
tiou of blood. Perhaps the imperfectly formed red Uood-globiiles some- 
times undergo unusually rapid destruction. Whether the spheiical 
blooil-globules ai^ poorly developed or are approaching destracdon, le- 
mains doubtfut. 

All other anatomical and clinical symptoms depend upon die impor* 
erishmont of the blood. The fatty degeneration of the heart and gland- 
ular epithelium, and the abundant development of the panmcalus 
adiiv>$u$ are pn>bably owing to the fact that, on account of the impover- 
ishment of the oxycen-cftrriers in the blood, the albuminoids of the 
tissues not alone are decomposed freely into urea-formingand 2at-foniiin|f 
sulv^t^nivs. but that the laxter remain in situ and are not ft™i»— xi into 
oarK^nie aoid and water. 

The hemorrhap(^s are sometimes the direct result of the iaqpofeiisli* 
ment of the bUxvi. raiher than of fany degeneimtion and rs^lwe of the 
vasc'uUr wa]i& The nutrition of the vessels seems to he da tm be d in 
saoh a way that ihe red-^lobuies mdily pass liiTv^ugh by diapcdesisL 

The ohanpeis in ihe medulla of the bones aie a]so sc^ocndarr and an»- 
mic in C'.haraoten and K. Xeumanu has shown that thiqr dkmlop after 
other anx>tmio and caohtviio oondhions. 

IV. I>i \(;\c^i<^.^The diajmosis is by i^o moans easr^ paitindailT at 
the i>ns(ei of ihe disea^. Amor.c oihfr tnlnxTs. latent cancer aMT len^ to 
error. The disoase is roadilv disiiuir^iished fn 



I T 



DIflB&SEB OF THS BEOOD. 97 

latter occtm altnoat pxclusirely in womon at the period of puberty, is 
apyreiiiil, and disappears rapidlj' under the nae of iron. The occurrence 
of fever may lead to the aiagimsis of typhoid fever, endocarditia, or 
meningitia, out the further course of the disease will clear up the diae- 
nosia. Finally, atrophy of the peptic glands may present the aymptoma 
of progressive pernicious ansemia, but the former oiseaise is rare, uud its 
inaeuendent existence is oven questionable. 

V. Pbogsosis. — The majority of patients are inevitably doomed. 
According to some writera, interniiasionB may last for months and years, 
but filially a fatal relapse supervenes. 

VI. Tkeatbent. — If the disease is recognized early, we should order 
a change of air and nourishing food, especially a milk diet. The patients 
must avoid all bodily and mental exertion. 

Caution must be exercised in the administration of iron, since it is 
not tolerated by many patients. Aa in chlorosis, we prefer Bland's pills; 
if these are not tolerated, the ethereal tinctures of iron may be employed. 
Some authors recommend phosphorus, and particularly arsenic, 

When the auffimia becomes excessive, it is said that transfusion of 
blood (perhaps sodium chloride is preferable) Bometlmes produces good, 
and even permanent effects. 



6. Purpura Simplex. 



I. Symptoms. — In this disease, hemorrhages occur into the skin. 
They are generally round, aa large as a PJ'*'^ head, on the average ; at 
first discrete, later confluent in places. They are especially abundant 
upon the legs and back of the hands. The hemorrhages occur as simple 
patches (purpura maculosa) or as papular elevations (purpura papulosa). 
Here and there are noticed wheals which do not itch, and generally be- 
come hemorrhagic. At first the patches are blood-red, then brownish- 
red, then green, and finally yellow. 

The exanthem may have been noticed accidentally, or it may have 
been preceded by slight fever, gastric disturbances and a feeling of mal- 
aise. New crops often appear, particularly if the patients walk a good 
deal. The average duration is ten to fourteen days. 

II. Etiolooy, — In many cases no cause can be discovered. It some- 
times occurs in anaemic, phthisical, or scrofulous individuals, after pro- 
longed diseases or shortly before the appearance of the menses. 

III. Pboonosis, The^tmext, — Tne prognosis is always favorable. 
^^^^Tlie treatment consiats merely of rest and nourishing diet, perhaps iroa J 
^^^m aniEmic individuals. * 

^^M 7. Purpura Rheumatica {Peliosis Rheumatica). 

^^B; I. Stmptous and DIAGNOSIS. — This disease consists of purpura of 
^^^he skin, and painful swelling of tbe joints. 

It is often, though not constantly, preceded by prodromata. The 
patients feel weak and depressed, and have slight fever. In a few days, 
they complain of rheumatic muscular pains, and of pains in some of 
the joints. The ankle and knee joints are affected most frequently, 
sometimes certain of the other jointa, particularly the elbows. Not in- 
frequently there is alight swelling of the joints. 

Soon after, or coincidently with the paina in the joints, patches of 
kUrpura appear on tbe skiu. They occur moat abundantly and early on 



^^irf 



38 DISEASES OF THE BLOOD. 

the legs^ later the tnmk and upper limbs may be a£Fected. The exten- 
sor surfaces are the favorite site^ in some cases in the yicinity of the dis- 
eased joints. According to their age^ the patches are dark^ almost black- 
red, brownish-red, green, or yellow. They do not grow pale on pressare, 
and a few are elevated into papules. The legs are often oedematous^ and 
oedema of the eyelids is also ooserved not infrequently. Urticaria may 
be present in certain parts, and either disappears or is replaced by hem- 
orrnages. 

The pains in the joints generally subside with the onset of the pur- 
pura. The patches are gradually absorbed in five to ten days. In rare 
cases, the purpura is the first, the joint changes a later symptom. 

The disease may terminate in one to two weeks, but relapses often 
occur/ so that it sometimes drags along for months and years. Fever 
may or majr not be present. Kaltenbacli noticed apyrexia in the morn- 
ing, elevation of temperature in the early part of the afternoon, and 
gradual defervescence at ni^ht. Bohn described fever of a tertian type. 
Anaemic symptoms develop if the disease is protracted. Enlargement of 
the spleen has been repeatedly observed. 

Hemorrhages into the mucous membranes are generally absent, but 
hsematuria, hemorrhage of the gums, followed by gangrene, and bloody 
discharges from the genitalia have been described. 

II. Etiology. — The disease is most frequent in men from the a^e 
of fifteen to thirty years. It is rare in childhood , and has never been ob- 
served in infancy. I observed it very often in Berlin, more frequently 
in autumn and winter, and sometimes almost in the form of an epi- 
demic. In women^ the symptoms sometimes begin shortly before the 
menstrual period. It is claimed that a predisposition to the disease is 
created by anaemia, articular rheumatism, malaria, phthisis, and heart 
disease. I recently treated a case in which the disease followed a gonor- 
rhoea. 

III. Anatomical Changes have been described by Leuthold and 
Traube in a patient who died from a complicating tubercular pyopneu- 
mothorax. The joints contained an abundance of clear synovia; the 
synovial membrane was injected and contained old hemorrhages. Hem- 
orrhages were also found in the extensors of the knee joint. 

IV. Prognosis and Treatment. — The prognosis is almost alwajrs 
favorable, except in those cases in which hemorrhages occur into the mu- 
cous membranes. 

The treatment is similar to that of morbus maculosis Werlhofii. 

6. Purpura HcBmorrhagica, 

{Morbus Maculosus Werlhofii.) 

I. Etiology.— The disease manifests itself by spontaneous hemor- 
rhages, not alone into the external integument, but also into the mucous 
membranes and internal organs. 

Females are attacked more frequently than males. The disease is 
most common from the age of fifteen to twenty years, and is extremely 
rare in infancy. Cases have been reported at the age of five months, 
and at birth. Delicate, poorly nourished individuals are predisposed to 
the disease, though robust persons are not entirely exempt. This dis- 
ease is relatively frequent in northern countries and at the sea shore, and 
is more common in winter than in summer. 



^T] 



^^P DIBBASSa 07 THE BI.OOI>. 3sH 

HF In many cases, no oauee can be ascertained; in others, it is attributed^ 
To cold, expoaiire, dami- dwellings, and insufficient, nourishment, so that 

the disease is sometimes endemic in barracks, fouodling asylums, and 

board i ng- schools. 

Thu symptoms of the disease sometimes appear during convalescence 

from severe infectious diseases, particularly typhoid and intermittent^ 

fever, and also during pregnancy or child-bed. M 

Dohrn reports a, com in wtaicli a, pregnant woman, suffering from purpurarl 
beniDrrhaKit-'S'. gave birth to a child who presented evidences of lEe aatne disease. 
This \r&* evidently owing to the influence of the eame causes upon the blood and 
hlood.vesnels of inotber and ftetus. 

A few cases of toxic pnrpttm have been reported, for example, after J 

I inhalation of sewer saa, after the ingestion of pork, and in a maafl 
10 was buried in a well for ninety-six hours. ■ 

II, Syhptoms. — The disease begins suddenly, or it is preceded byf 
prodromata. The latter consist of anorexia, eenera) malaise, vomitingffl 
vertigo, and slight fever. They last for afew nonrs or several days. V 

Tne first visible nhanges are the cutaneous hemorrhages. These ap-fl 
pear first on the legs, later on the trunk and upper limbs. lu man; 1 
cases, the face escapes. The extensor surfaces are affected more severely 1 
than the flexor eurfaces. j 

The majority of the extravasations are as large as the point of o- 
needle or a pin's head ; a few vary from the size of a pea to that of a 
bean. In rare cases, we find ecchymomata or \ibices ; the latter as the 
result of pressure of the bedding or clothing. The extravasations are 
sometimes so closely aggregated that the skin appears to be diffusely 
hemorrhagic. With increasing age, the color of the estravaeationa- J 
changes to browniab-red, blue, green, and yellow. M 

Amone the rare complications la elevation of the epidermis into vesicleo, 
evideiitlT from the acoumulaliou of blood between the epidermis and rete Mal- 
pigliii. tirticaria is of^aiiion^ly observed. Suppuratioa or ganj^rene ot the hera- 
OTThagio parts ia a rare event, STill rarer is the escape of blood in fine drops 
upc'ii (he surface of the epidermin. Hemorrhages uiin some timee be produced 
Tuluotixnly by presaure upon the skin. I 

Hemorrhages upon the mucous membranes appear at the same time,, m 
or soon afterwards. They are most freouent upon the nasal mucoua * 
membrane, and may cause more or less violent epistaxis. Hemorrhages 
into the lips, cheeks, and gums are not infrequent ; and those into the 
gnm8 may give rise to very violent hemorrhage, although the paria aro 
not swollen or loosened. In a few cases, vesicles form upon the buccal i 
mucous membrane. HEematcmcsis or enterorrhagia indicates hemor- ■ 
rhage from the gastro-intestinal mucous membrane. These symptoma,'! 
are sometimes very violent, and may even terminate in perforation -peri- J 
tonitis. This is explained by the fact that an infarction of the intesti- 
nal mucous membrane may cause necrosis of the part, and finally rup- 
ture into the peritoneal cavity. Marked hsematnria, metrorrhagia, and 
hxraoptyeia have been observed. Hemorrhages beneath the conjunc- 
tiva, into the retina, choroid, and even the sclera have been repeatedly 
described. In older retinal hemorrhages, the centre boeoraea light yel- 
low aa absorption occurs, and the focus may disappear entirely in a few 
'- There may be considerable retinal hemorrhage without visual 






80 DISEASES OF THE BLOOD. 

distarbance. Epileptiform attacks and paralysis are sometimes ob^ 
serred as the result of meningeal and cerebral hemorrhages. 

After extensive hemorrhages^ the blood may grow lighter in color. 
Under sach circumstances^ the white blood-globules maybe increased in 
number^ the red globules diminished (in one case^ 900^000 in one cub. 
mm.). In two cases, Penzoldt observed microcytes. Several authors 
mention absent or diminished coagulability of the blood. 

In some cases, the general condition is very little affected. In others, 
there is fever ; the patients are pale and miserable, complain of weak- 
ness, and, if the ansBmia increases, suffer from albuminuria, palpitation, 
dizziness, and syncope. Death may result from recurrent or uncontrol- 
lable hemorrhages. The joints are sometimes slightly swollen and pain- 
ful. 

The average duration of the disease is two to six weeks. In some 
cases, death occurs in a few hours or days after the appearance of the 
first hemorrhages ; in others, the disease lasts for several months. 

Belapses have been observed in a number of instances. In Bohlfs' 
case, twelve relapses occurred in twelve years. 

The sequelsB include paralysis as the result of cerebral hemorrha^, 
and in one case, diabetes mellitus (perhaps from hemorrhage into the 
medulla oblongata). Fajgge states that he has seen six cases in which 
sarcoma developed in various organs. 

III. Anatomical Changes. — The majority of deaths are the re- 
sult of anaemia, so that the internal organs are very pale. The cuta- 
neous hemorrhages remain visible after death. The intermuscular con- 
nective tissue, fasciae, tendons, and periosteum are generally intact, but 
extravasations are found not infrequently in the serous membranes and 
internal organs. The suprarenal capsules have been found entirely filled 
with blood, and the intestinal mucous membrane sometimes contains 
bloody infiltrations of considerable size. Transudations into the serous 
cavities are not infrequently hemorrhagic. Extravasations have been 
found in the medulla of the bones, the endocardium, intima of the ves- 
sels, and the neurilemma. The spleen is often enlarged, and sometimes 
contains infarctions. Hindenlang described pigment infiltration of the 
lymphatic glands. 

Wilson found amyloid degeneration of the capillaries in the vicinity of the 
petechiaa. Variot attempted to show that tne hemorrhages are the result of dia- 
pedesis, not of rhexis, but this does not hold good of all cases. For example, 
Hayem reported a case in which the white blood-globules were increased in num. 
ber, and had given rise to hemorrhages, by forming thrombi in the finer arteries. 
Stroganow discovered infiltration of the intima of the aorta, vena cava, and he- 

Satic veins with red blood-globules which seem to have passed, by diapedesis, 
irectly from the lumen of the vessels into the tunica intima. In Hindenlang's 
case, the pigment in the glands formed clumps, was evidently produced by a 
transformation of blood pigment, and consisted of hydrated feme oxide. 

Nothing is known concerning the nature of the disease, but it seems to be a 
primary affection of the blood, with secondary injurious effects upon the wails 
of the vessels. 

IV. Diagnosis. — The diagnosis is easy. 

Purpura simplex is confined chiefiy to the external integument; at 
all events, it presents no free hemorrhages. 

In poliosis rheumatica^ the joint changes are prominent, and free 
hemorrhages do not occur. 

Scurvy shows the specific affection of the gums. 



OF THE BLOOD. 

' Hsmopbilia is an hereditary or a congenital, permanent disease. _ 
Acnte exanthemata of an hemorrhagic character are attended with 
high fever and specific cutaneous changes. 

V. Pbognosis. — Aa a rule, the disease runs a favorable conrse. 
Sudden onset, high fever, and profuse hemorrhages are grave symptoms. 
Death occurB with relative frequency in pregnant and puerperal women, 
because abortion and uncontrollable uterine hemorrhage may bo pix)* 1 
dnced. 

VI. Treatment, — The patients should be kept constantly i 
The diet should be nntritious, and stimulating articles, such as coffee, I 
tea, and alcoholics, should be interdicted. Thirst should be relieved by ' 
sniphnric-acid lemonade. The bowels should be evacuated daily, u J 
~~8 of weakness appear, we may order the following; 

3 Decoct, cort. chinfe 3 vi. 

Acid, sulphur, dil 3 i. 

Syr. simp 5 sh. 

M. D. S. One tableepoonfnl every two hours. 

vOtherwise, purely symptomatic troatment. 

9. Scorbutus. 
(Scurvi/.) 

I. Etioloqt. — Scurvy is clinically related to purpura hemorrhagica 
and purt>ura rheumatica. Hemorrhages occur upon the skin and mu- 
cous membranes in this disease, and are associated with a tendency to 
infiammations. 

Scurvy is an inanition process, which may result from various, s 
times diametrically opposed causes. 

The moat important cause is poor nouriahment. 

Id some cases, scurvy 13 ihe result of insufficient food, so that it is often ob- 
served in prisons, during famine, long siege?, lone trips at sea, etc. 

It is not infrequently th*» result of the ini^tion of spoiled articles of food, 
but tills cause is often asaiiciated with the former one. Good drinking-water is 
an important feature iji such cases. 

In a third group of cases, the quantity and quality of the articles of diet are 
sufficiently good, but their combiaatiou is defective. Moat important ia ab- 
etinenoe from fresh veeetables, particidarly potatoes. Thus epidemics of scurvy 
have been observed in Ireland and England aa the result of failure of the potato 
crop. On the other hand, there is no more certain and rapid means of relieving 
-a^V! 



..irvythan by giving plenty of fresh vegetables. In tike manner, abatin 
from fresh meat mayprodue scurvy. A very fruitful cause of the disease is the 
excessive ingestion of salted or corned beef. Some epidemics have been at- | 
tributed to an insufficiency of fat in the diet. 

Living in damp, poorly ventdated, and overcrowded dwellings, 
exposure to wet also act as causes of scnrvy. 

Epidemics due to these causes have been observed in prisons, bafl 
neks, orphan asylums, arctic explorations, etc. | 

It is evident, from the foregoing considerations, that the geographical 

Sosition and meteorological conditions influence the development of the 
i^aso. It is often observed in northern latitudes and in rainy, coid 
diatricts. Epidemics are more frequent in winter and apring than in 
ler and autitmn. 



^^^^UQIQ( 




^^^ IIM 



OF THB BLOOO. 

Bodily nnd mental strain must also be inclnded among the causes of 
Bcarrj. It has been observed re[ieat«dJy among sailors and besieiged, 
when they were required to perform increased work (perhaps also, be- 
cause the food then proved insufficient). Sometimes, however, the 
bard-working individuals escaped^ while the drones were attacked by 
the disease. It ia also said tnat, under such circumstances, courage 
and a hopeful disposition antagonized the spread of scurvy, while the 
hopeless ones and cowards fell victims to tfie malady, flomcsicknesa 
(nostalgia) has also been re^rded as an important causal agent. 

Scurvy is more freqneut in men than in women, because the former 
are more exposed to its exciting causes. 

For the same reason, the disease generally occurs in middle life. 

A predisposition to scurvy Je sometimes conj^enital or acquired. 
Under like circumstances, feeble individuals are affected more quickly 
and severely than robust ones. Drunkards are affected more readily 
than others, and scurvy sometimes occurs in individuals who take little 
else beyond alcoholics. It iaalso more apt to occur inpatients who have 
suffered from malaria, dysentery, typhoid fever, or syphilis. 

■Scurvy geueralty occurs in epidemics. The losses of life from thi^ 
cause were formerly enormous, so that in some sieges a larger number 
fell victims to scurvy than to the weapons of the enemy. 

But even at the present time, the disease is endemic in certain 
regions, for example, in Russia and Boumania. 

II. Symptoss.— Scurvy rarely develops suddenly, and such cases 
generally run an acute and often a pernicious course. As a rule, it is 
prL>ceded by prodromata which sometimes last only a few days, but ofteu 
one to two weeks or even longer. 

The patients gradually lose their healthy color, the skin becomes dry, 
fissured, and scaly. The face becomes sallow, the lips livid, the eves dull 
and sunken, and dark-browu patches of pigment are sometimes o^>served 
in the face. 

The patients are generally very depressed and even desperate. They 
lose appetite, more rarely manifest boulimia or a desire for sour, piquant 
articles of food, and become weaker and weaker. DyspncBa and palpita- 
tion become noticeable on slight exertion, and complaint is made not 
infrequently of headache, a feeling of pressure in the head, and attacks 
of syncope. 

As a rule, inflammatory changes in the gums constitute the first 
manifest symptoms, but they sometimes remain absent or are preceded 
by other scorbutic symptoms. The affection of the gums generally be- 
ginii at the anterior surface of the incisors, and then extends intemallv' 
and laterally. The changes are not observed in places where the teetD 
are absent, out they crawl along the stumps of teeth. 

The veins at the free edge of the gums are first distended, the guma 
become swollen and their tissue loose, and the color becomes bluish ; 
slight contact produces pain and more or less severe hemorrhage. The 
parts situated between adjacent teeth are particularly swollen. The 
gums become loose and may proliferate to such an extent as to come in 
contact above the teeth. The teeth may be loosened and fall out, either 
in an intact or carious condition. The swelling of the gums may be so 
intense that the vessels are compressed, the tisane becomes necrotio and 
is converted into a brownish or blackish pulp. 

The inflammation of the gums is so much less intense the gnater 
the distance from the free edge of the teeth, and it generally ceases eo- 



DISEASES OF THE BLOOD. 33 

tirely at the base. The mucous membrane of the lips and cheeks almost 
always remains intact. Pharyngitis has been observed in a few cases, 
and Pinder observed excrescences and ulcers on the posterior surface of 
the pharynx. 

The iDflammation of the gums is attributed to mechanical causes. Scurvy 
produces a tendency to inflammation in the most varied tissues, and the constant 
mechanical irritation of the gums during mastication sets up the inflammation 
in this part. 

The patients generally complain of pain during eating, but apart 
from this they are often free from suffering. There is often a pesti- 
lential f oetor ex ore. In some patients the secretion of saliva is increased,^ 
so that a sanguinolent fetid fluid flows almost constantly from the 
mouth. 

If recovery occurs, a complete restitution of the j^ms may take 
place. In some cases, however, a firm, cicatrix-like tissue forms and 
persists for life. 

Hemorrhages into the skin, subcutaneous tissue and muscles appear 
coincidently with or soon after the changes in the gums, rarely at an 
earlier period. 

The cutaneous hemorrhages generally appear as petechias which vary 
from the size of a flea-bite to that of a nail. They appear earliest and 
most abundantly on the legs, especially the extensor surfaces; the trunk 
or limbs are often affected at a later period, but the face generally 
escapes. Traumatic influences (pressure, blows, prolonged walking) not 
infrequently give rise to hemorrhages. They are often very numerous 
in the vicinity of old cicatrices. The limb is sometimes thicKly covered 
with them. 

The first changes often appear around a hair follicle, so that the 
blood-vessels surrounding the latter are evidently the starting-point of 
the hemorrhage. The hair not infreauently becomes dry and nbrillated, 
and falls out. The accumulation of blood is sometimes so considerable 
that the skin is raised in flat or pointed papules (lichen et acne scorbu- 
ticus). The blood collects occasionally between the epidermis and rete 
Malpighii, raising the former into vesicles (herpes et pemphigus scorbuti- 
cus). In pemphigus, the vesicle may burst, leaving an ulcerated base, 
covered by a bloody crust. After removal of the latter, a readily bleed- 
ing surface is exposed; it is covered with abundant granulations, has 
little tendency to heal, and sometimes furnishes a foul-looking, foetid 
secretion. Free extravasations upon the skin have been observed in a 
few cases. 

Hemorrhages into the subcutaneous connective tissue may be very ex- 
tensive, and sometimes surround the entire circumference of a limb. 
They develop acutely or slowly, and, in the former event, are generally 
attended with pain and elevation of temperature. As a rule, the over- 
lying skin can be moved very little or not at all, feels doughy, is often 
painful on pressure, and its temperature is increased. Such nemorrhages 
are seen with special frequency around the tendo Achillis and ham- 
strings, and are of tea the result of traumatic or mechanical causes. 
They may disappear without leaving any residua, or they are followed 
by sclerotic thickenings of the skin. Or adhesions form to underlying 
parts and impede the mobility of the limbs. This may terminate in the 
production ojf pes varo-equinus or other deformity, or of false ankylosis 
of the knee joint. The underlying muscles may also undergo atrophy 

3 



M*ftAS» or lEK 



I 



94 

^ tlii^ reiiiU of pr^Mar*. InSaatnusyvL sad scppondon BometimeB eel 
in. tht^ Hkiii U i^fflfffMUad, ftorf s €^i!KKi(iiiJa:iE'<iC'^}cTOd. MmeciiiieE fonl-Emell' 

fi\|ii*wiM^ (vfiUr>^>^t Uhthf^rrtJi^s^ HtaxiC'rridiecs xten to or beneath the 
nttilH Mi»i/ ti$if<» f ^i^ it// ifeg^fwnrjjttaqn, K>3ivedm€« lo kos of the mule (ony- 

\|iia/.h» itHiuhifi^ki^tsk ^jfc^c^T moEi fr&qpeiiilT into the calreB, exteneon 
iif \\\t* tMi^l»4, »Aai/y.lLtf «&d aLbdominaZ m^iscks^ Thev are so much mon 
III I II hit ti.'. i^/w* f4k|/».':Jv ti*trT derdop. S-rpaiaiion mnd perforatioi 
hi'ii(k(^* ^*»^ *^^'» ''»*> tiAisue, or aeleroiic thic&enings are left over witl 
utxu\int'\ui^ i^*^\ ^h^rmiw of the limhfi, or atxophT and muBenlar weak 

||<w^t'/M'Ka»jj^^* tft^m t\i^ mncons membimnes (epistaiis, hsmatemesis, 
\^u\*i'fh\*iii^ i^: i*^iuuiurhk, morerarelj metforrhapa and hsmoptysis) an 
l^ttcjf )(.«< tt^tc^iUJUht, but thej occadonallj prove falal. 

i^i^iifft4i «v*dlji^ of the joints derelope^ m some cases. The fluid ii 
Ml'. y/}ifU H^i^y ^^ {iurely seroae or hemorrhagic. The process is some 
'\nt*ii (*jihwt:di hy t^uppuratioD, erosion^ deformity of the ends of th 

)fc/^'//W/^^ aud inflammations may also oocnr in the eeroos cavi 
^^i:;:. jl^ i^^Aaiiir/iations are generally* hemorrhagic in character, am 
I^'j4 U^HUkhily iuvolve the pleara or pericardium, more rarely the peri 
^}ri,i^H^. Husy often derelop with extreme rapidity, and prodoci 
f*y(*/.i^h4 Mi^^i/iia or phu^ the patient in danger of sn^ocation froo 
'hit^ff^^'^**^^ ^*i tli<$ lungK or of paralysis of the heart. Some author 
)^'^si^ i/h^rviA rapid absorption of exuded fluid. Meningeal hemor 
fhi*^Uf:» uljMy fMii'Mr and are characterized by pain, parassthesia, spasms 
c'v/J/ucluicfcf, paralyseij, andiipoplectiform attacks. 



f 



p>uij^)i.^niMUM\ and epiphyseal hemorrhages are rare events in scmry. Th 
o^'incr ciiibd V iu volve tim anterior surface of the tibia, bat may also occur on othe 
)orjt'H /bcupMitt, lower jaw, fmni palate). The accumulated blood forms a painfu 
uw(.*JJj)i|/. Cut K^iuTiUJy undergr>H«f absorption. The epiphyseal hemorrhages ar( 
lejati vdv hitM freiiaani ou the mstal cartilages, where they cause separation o 
^je riha h>^iu like iWMj-tiiages, so that the free ends of the ribs sink inwards. 

fc)«.url;uiic rljanges are obnerved not infrequently in the eye. Con 
jinioijvaJ lxcmoj'j'ljiig<4M and inflammations may set in, likewise hem oi 
^•Jju^^Cfi' ial-v tJu' uijUirior ctiambor or hemorrhagic chorioiditis. Th 
KL'iiJjui /vi'iij 4>f k('rutitiii(f/erierally bilateral) with subsequent panoph 
liuljjjlljf; wliii'ii is iii'VH iift4*r dineaso of the trigeminus (vide Vol. III. 
jKi^t iSS), iiiui ii\i^) Ix't'ii obs<irv(*(l. Ilemeralopia occurs with relatiy 
fioijiujioy, u£> u j;j'4/dn/iiM), during the development of the manifcG 



I 



Ac <bc muiiil'tiBt tiyiiiptomn of Hourry gradually develop, the geners 
« ujiJiiioit ui'owti woiiu.'. Tbct iip|M*arance of the patient becomes cachec 
lit-, aud Mio jmiJJiiculiiM lulipoMUH atid muscles waste away. In som 
iUiti:6, Jiiivvovui'i Win gtinctral tnitiitioti remains intact for a very Ion 
iluH'. I'Vvur ijjuy hu ubttiMit or it Im nlight and irregular. Consiaerabl 
(.li^vuiiiiji ii/ Uiiipuiutin'M lit gtummlly the result oi abscess formatior 
Tlu Jimit j/iuauiH» iiMttitnlM (ijlatiitiou uud systolic murmurs, and tl 
gjilLLii j;^ 0oj)icii jiiutf uiiImi'ijihI, Thorn In oocAAionally diarrhoea which ma 
iLsouiiic ik i\\,bcn{ciUi i}ba»'(i<>l(ir. In ii numhor of cases a connection hs 
liLLii uhcLOt'l la«(wu(JM HtMirvv himI iiMin flynontory. The urine varies i 
umguni, ia tfu^u^lly M«'ldi ami Hm upvuitlo gravity diminished. It ofte 



DISEASES OF THE BLOOD. 85 

contains albumin^ but this does not justify the diagnosis of nephritis^ 
which is a rare complication. 

The amount of urea is generally diminished; Simon observed increased ezcre. 
tion of uric acid. In a number of cases the amount of potash salts was increased. 
Orocco mentions peptonuria. 

Examinations of the blood do not furnish uniform results. The following 
changes have been observed at times : diminution or abolition of coagnilability, 
increased alkalinity, diminution of the potassium and iron and increase of 
sodium chloride, increase or diminution of the amount of albumin. 

The most frequent complication is fibrinous pneumonia, which prob- 
ably takes its origin in many cases from hemorrhagic infarctions^ and 
may terminate in gangrene. ^Scorbutics are sometimes attacked by other 
infectious diseases (variola^ typhoid and relapsing fevers, septic endocar- 
ditis). 

The disease generally runs a chronic or subacute, more rarely acute 
course. The subacute cases terminate in four to eight weeks, the 
chronic cases in as many months. 

A fatal termination is not rare. It may be the result of the increas- 
ing weakness, or of excessive exudation into the pleural and pericardial 
cavities, of pneumonia or profuse hemorrhages, or finally it may follow 
symptoms of a septic condition. 

In favorable cases, convalescence sometimes lasts a long time. A 
marked tendency to relapses is left over. 

Iir. Anatomical Changes. — Bigor mortis is generally poorly 
marked, and livores mortis are very numerous. There is also a tendency 
to rapid cadaveric changes. The cutaneous hemorrhages are recogniz- 
able after death. The subcutaneous and intermuscular hemorrhages not 
infreauently contain clots, and manifest changes in the connective tis- 
sue wnich have terminated in gelatinous or firm connective-tissue pro- 
liferations and thickenings. Beneath subperiosteal hemorrhages, the 
superficial layers of bone are reddened and sometimes necrotic. Softening 
of pre-existing callus or absence of the formation of callus in recent 
fractures is said to have been observed in some cases. Uskow described 
lymphoid changes in the medulla of the bones. The joints often contain 
serous or sanguinolent effusions, hemorrhages into the cartilages and 
synovial membrane, erosion of the cartilages, and sometimes an accumu- 
lation of pus. 

The serous cavities often contain pure fluid blood, or clots mixed 
with inflammatory products. More or less extensive hemorrhages are 
often found in the subserous connective tissue. 

The blood may be cherry red and thin; its quantity may be verv 
small, so that the viscera are anaemic and, not infrequently fatty, though 
at the same time they often contain extravasations. 

The heart is flabby, brittle, pale brown in color, and fatty in places. 
Subepicardial hemorrhages are frequent, subendocardial hemorrhages 
are rarer. Endocarditic changes are found occasionally. Marantic 
thrombi are sometimes present in the heart, particularly in the right 
auricle. 

Subepithelial hemorrhages have developed not infrequently in the 
bronchial mucous membrane. In the lungs, we often find oedema 
(sometimes hemorrhagic), or pneumonic or gangrenous changes, or hem- 
orrhagic infarctions following extravasations or emboli (the latter sec- 
ondary to cardiac thrombi). 



86 DISEASES OF THE BLOOO. 

The spleen is often enlarged and very soft, and not infrequently con- 
tains hemorrhagic infarctions. 

The gastro-mtestinal mucous membrane frequently presents bloody 
suffusions, also follicular ulcerations and necrotic (diphtheritic) changes. 

Hemorrhages and fatty degeneration have been observed in the iirer. 

The kidneys are generally intuct. Bloody suffusions are frequent on 
the mucous membrane of the urinary passages and genital organs. 

Leven fouad fatty degeneratioa of the muscles, earliest in those which are 
most used, viz., the heart, muscle;* of the back, thighs, arms, etc. The liver and 
kidneys were affected next in order of frequency. In the capillaries and small 
arteries of the gums and intestinal mucous membrane, the endothelium has 
been found swollen, so that cells lying opposite one another came in contact and 
produced occlusion. On the central aspect of such places, the endothelium cello 
were separated from one another, and the red blood-globules had passed through 
the interstices into tlie surrounding tissues. 

No corpuscular or ciiemical changes have been found in the blood or other 
organs, so that nothing is known concerning the nature of the disease. 

Many assume that scurvy is an infectious disease, which is ac the same time 
miasmatic and contagious. We only know that certain cases develop under bad 
hygienic conditions, i. e., under circumstances in which other infectious diseases 
also develop. Contagion from man to man has not been proven. 

Some authors attribute scurvy to an excess of sodium chloride in the blood, 
but no valid proofs have been offered in support of this theory. 

This is also true of the potassium theory of scurvy. Garrod shows that fresh 
meat and vegetables are distinguished by the larger amount of carbonate of pot- 
ash and vegetable salts of potash from those articles of diet whose prolonged in- 
gestion gives rise to scurvy (in the blood the vegetable salts of potash are con- 
verted into the carbonate). Now. if there is insufficient carbonate of potash in the 
food, the blood and tissues grow poor in potash salts, and scurvy is the result. 
This may also happen in certain cases despite the presence of sufficient potash 
salts in the food, for example, after diarrhoea, or after perverse nutrition of the 
tissues as the result of bodily or mental strain. 

IV. Diagnosis. — The symptoms are so characteristic that the diag- 
nosis is easy. Special weight stiould be attached to the affection of the 
gnms. 

V. Prognosis. — The prognosis is not always good, because it is 
often impossible to bring the patients rapidly under other hygienic and 
dietetic surroundings. 

VI. Treatment. — Prophylaxis has been attended with brilliant re- 
sults. Ships and beleaguered towns must be supplied plentifully with 

food water, fresh meat and vegetables, particularly potatoes and saner- 
rant. Fresh fruits are also useful, especially oranges and lemons. 
Overcrowding of dwellings should be avoided, etc. 

After scurvy has made its appearance, we should first endeavor to 
meet the causal indications. If tne patient is placed in a well- ventilated 
room, and supplied with fresh meat, vegetables, beer or wine, the 
symptoms often disappear rapidly without medication. • Especially use- 
ful IS the fresh juice ( 5 ij.- § vi.) daily of certain cruciferae, such as 
cress, radish, sorrel, sauerkraut, various kinds of cabbage, dandelion, 
etc. Some recommend beer yeast in doses of 3 v.-x. daily. 

The drugs to bo recommended are, the vegetable salts of potash 
(potassium citrate, bitartrate, acetate, binoxalate). 

If signs of anaemia are prominent, we may order iron, quinine, and 
bitters. Giommi reports a successful result after transfusion. 

Prominent symptoms often require treatment. When the gums are 
affected, the mouth should be gargled, after each meal, with chlorate of 



DISEASES OF THE BLOOD. 37 

potash (3i. : Iv.) or acetate of alumina (gr. xv.: §iii.) TJicers on 
the gums and exuberant proliferations are touched with tne solid stick. 
Drastics must be avoided in scurvy, since they are apt to produce 
dangerous intestinal hemorrhage. 

Hmmophilia, 

{HcBmatopMlia. ffwmorrhophilia, ) 

Etiology. — " Bleeders '' are individuals in whom severe hemor- 
rhages, which often terminate fatally, develop spontaneously or after 
very slight causes. 

In the majority of cases, the disease is hereditary, and can sometimes 
be traced for many generations. The predisposition is generally in- 
herited by males, and is very rare in females. 

The heredity is either direct or indirect. In the former, hsBmophilia occurs 
in every geueration; in the latter, some generations may escape. 

Women are the most potent factors in heredity, although, as a rule, they 
remain free from the disease. If a bleeder marries a woman who comes of a 
healthy family, the children, as a rule, remain free from haemophilia. But if a 
healthy man marries a woman who, although herself healthy, comes of a family 
of bleeaers, the children are almost always bleeders. 

Some of the male descendants escape the disease, and it is not probable that 
such individuals will beget hsBmophilic children, if married to a healthy 
woman. According to Wachsmuth, families of bleeders are very prolific, their 
average number of children being nine, those of healthy families only five. 

Allied to hereditary haemophilia is the congenital form. This form 
includes those cases in which children are bleeders, although the 
parents came of healthy families. Very little is known concerning the 
cases of congenital haemophilia. Among those mentioned are: marriage 
between blood relations, phthisis, scrofula, rheumatism or gout in the 
parents, and fright during pregnancy. 

Some writers assume the spontaneous development of haemophilia in 
later life. This is asserted with regard to those cases in which the 
symptoms were not manifested during childhood, but developed at a 
later period. It might be claimed, however, that accidental exciting 
causes were absent during childhood. 

The chief contingent of the patients is furnished by Germany, next follow 
JSngland, France, and North America. Among 210 families of bleeders, 94 lived 
in Germany, 53 in Great Britain, and 23 in North America. Among 780 cases. 
717 were mades, 68 females. A predisposition to hsBmophilia has been attributed 
to the Anglo-GMrmanic family and the Caucasian race, but Heymann has recently 
reported a case in a Mohammedan family of Java. 

II. Symptoms. — The symptoms are sometimes observed accidentally, 
as when the patient has a violent hemorrhage, either spontaneously or after 
slight causes. Such facts may possess a medico-legal interest. For ex- 
ample, Wunderlich reports a casein which a boy, mildly punished by 
his teacher, was found covered with numerous extravasations. Legal steps 
were about to be taken to secure the punishment of the teacher, when it 
was discovered that the boy was a bleeder. 

A similar discovery is sometimes made accidentally by surgeons when 
making an operation upon a patient. 

In women, hsBmopnilia is sometimes masked behind profuse, long* 



38 DI8SASB8 OF THE BLOOD. 

continned menstraation. Eehrer has also shown that fatal hemorrhage 
after delivery may set in in such cases, and has recommended that prema^ 
ture labor be induced. 

The occurrence of rheumatoid pains, neuralgia, especially of the 
teeth, swelling and pain in the joints in the children of bleeders, indi- 
cate that the former are also bleeders. This becomes almost a certainty 
if profuse epistazis is f reauent. 

In some cases, it is saia that the muscular pains are followed by con- 
tractures and atrophy of the muscles. 

The children sometimes fall a victim to the disease immediately after 
birth, as the result of uncontrollable hemorrhage after tyin^ the umbili- 
cal cord. But, on the one hand, this does not occur very orten, and, on 
the other hand, does not always depend on haBmophilia. 

The first symptoms of the disease appear most frequently at the neriod 
of first dentition, in rare cases not until the period oi puberty is fully de- 
veloped. In one case the first manifestations appeared at the age of 
twenty-five years. Many bleeders die before the tenth year, and they 
rarel}r attain old age. The hsBmophilic disposition sometimes diminishes 
with increasing years, but rarely disappears before the twenty- fifth year. 

The spontaneous hemorrhages are sometimes preceded by prodro- 
mata, or, properly speaking, prodromal molimina, which consist of pal- 
pitation, rush of blood to the head, dizziness, ringing in the ears, etc. 
Certain individuals feel relieved after the cessation of the hemorrhage. 

The spontaneous hemorrhages occur most frequently as epistaxis, 
next in order of frequency beneath the skin, more rarely from the kid- 
neys, air passages, intestines, or genitals. Articular hemorrhages are not 
infrequent. The joints are distended, fluctuating, and extremely pain- 
ful, and the affection may terminate in erosion or the ends of the bones, 
ankylosis, and suppuration. Suppuration, gangrene, and perforation of 
the skin have also been observed as the result of the subcutaneous extra- 
vasations, which sometimes attain astonishingly large dimensions. The 
mass discharged often has a chocolate color, and is mixed with gangrenous, 
shreds. It must be remembered that the blood in subcutaneous hsdma- 
tomas remains fluid for a very long time, and that incautious opening 
may give rise to fatal hemorrhage. This has also been observed after 
spontaneous rupture. 

In a few cases, spontaneous hemorrhages have been observed upon the 
peritoneum, meninges, and into the brain. 

Traumatic hemorrhages are often produced by accidents. Gases- 
have been reported in which the pricking of the gums by a tooth-pick 
or biting the tongue produced a fatal hemorrhage. Rupture of the hy- 
men has also been known to terminate fatally. Uncontrollable hemor- 
rhage has been observed with special frequency after the extraction of 
teeth. Fatal hemorrhage has been observed hitherto in ten cases of cir- 
cumcision. Vaccination is relatively harmless, but leech bites and cup- 
f)ing are dangerous. Small wounds are sometimes more dangerous than 
arger ones, and Ford yce succeeded in checking the hemorrhage in 
one case by enlarging the wound with the knife. The same wound will 
produce varying grades of hemorrhage in the same individual at differ- 
ent times. The hemorrhage is almost always capillary. The blood flows 
from the wound as from a wet sponge, and no bleeding vessel can be dis- 
covered. 

At first the blood has a normal color, but after the bleeding has 
lasted for days, it assumes a serous and watery character. 



DIBEUXa OF THB BLOOD. 39 

Microscopical and chemical examination furnishea negative reanlta. 
The number of red blood -globules ia sometimes increased. Uerard states 
that the orgauio constituents of coagula are diminished, tlie salts in-J 
creased. I 

The hemorrhages are sometimes eo profuse that death ensues in a feir^ 
hours. In other cases, they last for days and weeks. The enormous ' 
amounts of blood lost, and the rapidity with which the patients arc re- 
stored, are often astonishing. Syncope following uuiemia of the brain 
sometimes checks the hemorrhage, inasmuch as it depresses the blood 
pressure. 

Albuminuria is noticed occasionally at the height of the hemorrhage. 
There are no other constant urinary changes. If the anseraia is ex- 
cessive, cedema may develop, together with anasmic changes in the heart 
(dilatation, systolic murmurs). Febrile conditions are sometimes ob* J 
served. I 

it hEis been claimed that bleeders are characterized by slighi'l 
phyBi()ue, blond hair, blue eyes, superficial vessels, and a tendency to ' 
blushing, hut there are many esceptions. Eunze observed premature 

fraynesB of the hairs, Legg and Sedgwick found multiple uffivi in 
leeders. 

III. Anatohical Changes. — So constant changes have been found 
in hfemonhilia. Virchow noticed smallness n( the heart, narrowness of 
the vessels, and thinness of their walls. The left ventricle was occa- 
sionally hypertrophic, or fatty degeneration was noticed in the intima 
of the vessels. Recent enlargement of the spfeen has also been J 
described. I 

HlcroACopical changes in the cinaneoua vesaela have been described in a lew 1 
cases, but they were probably mere coinciUencee. Birch-Hinchfeld noticed 
snlarueiuent of the endotiielium cells in the capillariea and transitional vessels, 
■irellingof their nuclei, and grunular deposits in tlieir protoplEUjm : silver prepara- 
tjonsshowed unusual irregularity of the endothelium. Cidddescribed iucreaseof 
the endothelium, Jroppical snetliiig of the muscular coat, and proliferation of ita 
ducIpI. in the Bner vessels of the subcutaneous connective tissue and in tba 
mutclee. Legg was unable to find these cliaiigea. 

Noiliing is known with certainty cont'erning the nature of the disease. 
Immeriunnn attaches clii''f imporlaiice to the narrowness and thin walla of the 
VMM>la, and to hicreaxe in the amount of btoiu], which occasionally seeks au out- 
let. In addition to the thinness of the walla of the vessels. Cohnheim oaauiues 
impoverish raent of the blood in red blood -globules (unproven) and a secondary 
tendency to hemorrhaKea. The following hypothesis seems to ine to l>e the most 
ptuueihte: diminution at the number of white blood-glob ides (A ssniann), hence slow 
production and dimiTiiitlied resutance of coagula (Lossen). injurious effect of the 
changed blood on the vessels, with increased tendency to diapedesis and TbesiSr 
Why the white globules are diminished in number is unexplaiaed. 

IV. DiAONOSis. — The recogLition of the disease is not difficult if 
manifest symptoms are present. It is distinguished from scurvy by the 
fact that It is unattended with infiammatiou and proliferation of the 
guma, and is not a temporary condition. The latter circumstance also 
BiBtiuguishes it from morbus maculosns Werlhofii and purpura. Tha 
differentiation between haemophilic and bacteritic hemorrhage in the 
new-born is based upon the presence or absence of bacteria in the blood. 

V. Prognosis. — The prognosis is always grave, so much more the 
greater the opportunity for sustaining injuries offered by the occupation 
of the patient. 

VJ. Tbe&thent. — Prophylaxis mast tirst be directed against the 



40 

DI8EA8B8 OF THE SPLEEN. 

T^; oMiereditary haemophilia, by prohibiting marriage in families 
m which the disease is hereditary. « -^ 

since > *^^°?> *' carried into eflfect, wonld not extirpate the disease, 
Inaam ®?'"®*''°^^8 develops primarly (congenitally)from unknown caases. 
f rmri ?K ^ ?^P^™^^ teaches that a number of children in a family suffer 
ar,A disease, it would be wise to recommend that the parents 

^^^ ^^ prevent an increase in their family. 
The i!r^^ should be protected, as much as possible, against injuries. 
, ®y should be exempt from conscription as soldiers. Their diet 

ouid not include stimulating substances, such as alcoholics, tea, or 
conee. If a hemorrhage occurs, it must be treated according to surgical 
pnnciples, by rest, elevation of the bleeding part, prolonged com- 
pression, the actual cautery, and sutures. Not much can be expected 
irom internal haemostatics. 

, Surgical operations must be avoided in bleeders. Vaccination alone 
IS devoid of danger. Circumcision should not be performed in bleeders. 
The internal remedies recommended in haemophilia include iron, 
ergotin, acetate of lead, and laxatives (in congestive conditions). 

If anaemia becomes excessive as the result of hemorrhage, trans- 
fusion with sodium chloride solution may be resorted to. 

Rheumatoid and neuralgic complaints, and non-hemorrhagic swelling 
of the joints must be treat^ symptomatically. 



PART II. 

DISEASES OF THE SPLEEN. 

Acute Enlargement of the Spleen. 

{Acute Splenic Tumor.) 

I. Ettolooy. — Acute splenic tumor is a rapid enlargement of the 
organ which only lasts a short time. It is merely a symptom of certain 
pnmary affecti(>ns. 

We distinguish four varieties, viz., traumatic and embolic acute 
enlargement, the spleen of acute stasis and of acute infection. 

Traumatic enlargement of the spleen is not very frequent. It is the 
result of a blow, fall upon the spleen, etc. Anatomicaliv, it consists of 
increased amount of blood, often of extravasations of blood, swelling, 
and proliferative processes in the cells of the splenic {)ulp. 

Embolic acute enlargement is the result of occlusion of the splenic 
arteries by emboli. It is almost always a sequel of endocarditis of the 
left side of the heart. 

Acute stasis spleen rarely occurs in general venous stasis following 
diseases of the respiratory or circulatory apparatus, since the intra- 
hepatic branches of the portal vein prevent the occurrence of stasis in 
the trunk of the portal vein itself. As a rule, acute stasis of the spleen 
is the result of circulatory obstruction in the portal vein itself, whether 
the result of hepatic diseases, pylephlebitis, or compression of the portal 
vein by abdominal tumors, retracting peritonitic cicatrices, etc. 

Temporary physiological stasis of the spleen occurs a few hours after meals, 
because the abunoant absorption of the digested masses from the intestines im- 
pedes the flow of blood from the splenic vein. 



ISBABB8 or THE SPLEEN. 



O 



the 

^^ Bevp 
epl 

8VI 

ale 
^m ale 
^bth< 
^t7I 



The moHt fret^nent and important form of splenic enlargement ia | 
_,t due to infection. It occurs in infectious diseases. It is rarely ab- ' 
int in intermittent and typhoid (ever, and ie also obaerred in typhoa 
and relapsing fever, cholera, yellow fever, dysentery, acute gastro- 
enteritis, ulcerative endocarditis, acute articular rheumatism, pneu- 
monia, acute miliary tuberculosis, pleurisy, pericarditis, peritonitis, 
cerebro-spinal meningitis, diphtheria, angina, corvza, variola, scarlatina, 
Toeasles, erj-sipelas, pysemia, septica-mia, puerperal fever, scurvy, splenic 
fever, glanders, and recent syphilis. Congenital acute enlargement of 
the spleen is sometimes found in the new-born, if the mother suftored 
^froTn intermittent fever or syphilis during pregnancy. 

In many of these diseases, enlargement of tlie spleen is not a constant I 
iptom, or at least it cannot always be demonstrated clinically. Til* ' 
severity of the infectious disease does not corresjiond to the degree o( 
splenic enlargement. The latter not infreqiienMy precedes the other 
svmptoms of the infectious process. In like manner, the enlargement 
also lasts longer than the other symptoms, because it is the result, not 
alone of circulatory changes, hut o! hyperplastic processes in the cellsof 

According to Friedreich, there is danger of a relapse inri 
'phoid fever so loug as the spleen is enlarged. 



_ .8 well known that fine particles of pigment which are introduced into the 
circulation of an animal are d*^posited in great part in the aplt^a snd even enter 
the cells of that organ. Aa we are juBtiHed in rff^ardinK bacteria as the cauae •>( 
inFection. it is probttble that tUeue likewise find a Tavorable place of depodtinthe 
spleen. The cells of the spleen will then react with special facility to the irrila- 
tation producpd by the bacteriH. because these cells form an intermediate oondl- | 
tion, inasmuch as they are awaiting trauaforination Into higher cells {red hlooo- 1 
globulet). 



(vie 



. Anatomical Changes. — The spleen may attain six times ita I 
iormal dimensions. I 

_ In traumatic enlargement of the spleen, evidences of injury arftl 
generally found in the neighborhood of the organ. I 

Embolic enlargement is characterized by the wedge-shaped infarction' I 
(vide page 46). I 

In gtaaie spleen, there is striking distention with blood, together 
,ffith changes in the district of the portal vein. 

In infection spleen, aa a rule, the capsule is transparent and tense; 

id is only wrinkled when the process is undergoing involution. The 

'enic pulp is soft and diffluent, but this is partly the result of post- 

•rtem change, siuco It is found even though the splenic tumorwasfeli « 

^b> be quite hard during life. The spleen is often so ^oft that fine di»^ 1 

tinctiona in its structure cannot be recognized. Occasionally, it con-'' 

taiue wedge-shaped foci, whose origin is not clearly recognized. 



weUiag 1 



In theapleen of iofectioui) diseases, the microscope showncongestion, si 
of the splenic cells, increase of the nuclei, fatty degeneration: under certs 
oumatances, increase of the hlood^curpuacle-containing cells, infiltration of tli* | 
walla of the vessels with round cells, aad extravasaCioos of blood. 



k 



In Hixty-oigbt cases of sudden death and suicide, Birch-nirscbfeMj 



49 tmEAtm ow the splmms. 

UmnA Ik*! lh# lif MTlM weight of the ^>leen was fire omicee, or 0.26)( of 

1(1; Ht^l^oiid.— in the majoiitj of Gases, splenic enlanzement is 
t^U r«HH>g«»i»^ by ilirecting special attention to the organ. Sabjectiye 
iif^|4<>Mi« may b« absent, but complaint is sometimes made of tension, 
li f##HiiM Mf (>«Wuii^. or stitches in the splenic region. The pains occa- 
^4fifi^l\y tmU^ip P^Pt\ into the left arm and leg. These symptoms may 
{M'^«»fH<> Ui \pt\ tui^ral or even in right lateral decubitus, oecanse the 
KMtf i>i*)«>4sii Umirtt UfHin its ligaments. 

\Hd^ |)M)iirtfi>invtit of the spleen is rarely so marked as to be recog- 
ff>4<|lii^ Mil iiii*)»«HHii)U. The splenic region would then be prominent, 
(lft4 (•♦»i^)>ti^M4 if the abdominal walls are thin and flaccid, a tongue- 

Ih«it«l^| ('HiMiiii^uoe. which moves with respiration, is seen in the left 

tSit>MMt(h furnishes the most important results. The spleen can 

!,iHiit MVisV tns M^ unless it is enlarged. If the tumor extends towards 
\h \U\^i^ t^tbti. indentations can sometimes be felt in its anterior edge. 
Hi(«^MMM MiMii)timeB gives rise to pain. 

HHf IMtf |«Mll*stirm. the patient should assume the right diagonal position, i, e.^ 
L^ dV<i UM*H \\w right shoulder in a position midway between right latend and 
fff^Hft j 4^>«4Ml'n«' The physician stands to the left of the patient, near his head, 
iH^d f Nk M|m **f th«« »econd, third, and fourth fingers are gently placed in the space 
fifif^ f^ff MM^ Utwtmi cortal cartilages and the free end of the eleventh rib. During 
^i^f^<'M» ¥*itii*ifiiU>ry movements the organ will be felt, at each Inspiration, pro- 
UiP^hi^ I^M^^ili the left hypochondrium. If the pressure of the fingers is too 
£ffff f / Ml^ it\t\tmu is often pushed upwards and backwards, and soft tumors thus 
^m^iwn fK^<^»gfiHi(in. 

^{^ tHtU**iti itmy be mistaken for digitations of the diaphragm, or the tendinous 
Hhi^^h t*f iN^i* Mt rectus abdominis. In pleurisy, pneumothorax, emphysema, 
f,^f^nU^u ttf the spine, and pericarditiB, the spleen is sometimes pushed down- 
Wi^^^* ^m4 \m(iiunen palpable, although it may not be enlarged. 

|:9^^|<[iM}n <irilargoment may also be recognized by percussion, although 
f.ifM '^If^ritt many sources of error. The most frequent source of error is 
(i\it^^hlUtH of the stomach and colon with firm masses. On the other 
mhtii JM irMdoorism splenic dulness may be absent, despite enlargement 
f/nl^f^ orgfin. Wo must always be on our guard if splenic dulness is 
i^hi^iti^^t ^'i<^ ^1^0 or^an cannot be felt. It is suspicious if the 
\Lf;f(iij44*t4\ rliilrioMS varies from the ordinary shape of the spleen, if it 
f^mh^^fi if*iu\ day to day or after evacuation of the bowels. 

\h muSihWii onlargomont of the spleen, it is conceivable that a peri- 
\^\i)\\n trU'Wnu murmur may l»o heard and even felt if the infarction has 
^\)m n«w io inrtammation of the capsule. Griesinger described inter- 
j^\\i^ui afMl c^miinuous roaring vascular murmurs in splenic enlarge- 
mmi M th« r«Milt of intermittent fever during the febrile period. Mos- 
1^^- liMUftt that tli(«w) murmurs occur almost constantly during the period 
wf /-hill, j^row fitublnr in the hot stage, and disappear in the apyrexial 
|u/u'^ j//4. <i ri(iMinK<^t^ aiiribuicd tiio murmurs to the large abdominal veins, 
lifi^itiUr Ui (!ontra<ttlonM of tlio Nplonic artery. Mosler also described a 
t^^itchUi lOMrrniir In a vnmj of rolapsing fever. 

^yUti tim%ilut\ of acuta Mplcnio enlargement depends upon the course 
f^f i-hi^ ^trimury (JlMiaMci. tn rare cases, tno soft spleen ruptures and gives 
f^ ti> imnUmiiln and raj)id death. 

In inmt^ iiiiMtin tlui anlartfnmcnt persists and becomes chronic. 

)V. ihAnnmin ASU PuouNOHtH. — T lie diagnosis is not always easy; 
ftu^iijtit: ium^rn otiMH romalu unrecognized. 



I 



Di8EAasa or thb sflsss. 

The prognoeia depends on the primary disease. Rupture of thesplae . 
is so rare that this possibility liardly affects the prognosis, 

V. Theatmbnt, — The treatment ia almost always included in that 
of the primary disease. A subcntanoouB injection of morphine may be 
necessary if the pains are very severe. If tnere ia dan^r that the con- 
-•ition will become chronic, the remedies mentioned in the following 

,ion should be employed. 



2. Chronic Enlargement of the Spleen. 
{Chronic Splenic Tumor.) 



i 



I. Etioloot. — This term is applied to those cases in which enlarge- 
ment of the spleen esists for a long time. It sometimes deTelops out of 
an acute enlargement, sometimes it is chronic from the start. In the 
former event, it is the result of the etiological factors mentioned in the 
previous section. Some of these causes favor the development of 
chronic spleaic tumor more than others. In acute infectious diseases, 
for example, acute splenic enlargement is the rule, while causes of stasis, 
chronic infectious diseases, syphilis, and embolism rather favor the de- 
velopment of chronic splenic enlargement. 

In malarial regions, chronic splenic tumors may develop, although 
there have been no manifest symptoms of intermittent fever. In 
certain tropical regions, the spleen rarely possesses normal dimensions. 

Among the causes of chronic enlargement of the spleen are: leu- 
ktemia, pseudoleukemia, waiy degeneration, neoplasms, tubercle, 
;umma, and parasites. Chronic spleaic enlargement has also beeu 
lund in rickets and scroftiEa. 
The affection rarely occurs in children and old people. But it is 
letimes congenital, and then is often regarded as an indication (k 
itary syphilis. 

II. Anatomical Chanoes. — The spleen sometimes attains ton to 
iDty times its normal dimensions, and it may weigh five to ten kilo- 

IQB. 

The organ sometimes oconpiea the greater part of the abdominal 
cavity, compresses and displaces adjacent organs, and extends into the 

Selvia, The capsule ia often thickened, and nere and there may contain 
bro-cartilaginous deposits. The anterior edfje often presents very deep 
indentations, and those may be more numerous than in the normal 
spleen. The capsule is often joined to adjacent parts by peritonitic ad- 
hesions. If neoplasms or parasites are present in the spleen, they often 
project above its surface as spherical prominences. Old infarctions are 
recognized upon the surface of the spleen by slight depressions and a 
oheesy yellow color. 

The transverse section of the spleen varies in appearance according 
to the character of the lesion. In some cases, there is pure hyperplasia 
of the splenic tissue, oa in leuksimia. In passive congestion of the 
spleen, the increase of the connective tissue predominates. In other 
oases, there is a combination of both lesions. In intermittent fever, the 
Bplecn is characterized by the abundance of black pigment. In neo- 
plasms and parasites, there is enlargement of the organ, although the 
splenic tisane proper is not infrequently diminished in amount. 

III. SYMPT0M8 AND DIAGNOSIS. — Tlie remarks made concerning 
symptoms and diagnosis of acate splenic enlargement also hold good 




^ 



I 



h: 



with regard to the chronic form. Snbjectire EjmptonLS msy be entirely 
abaeat. On palpation, tho spleen generally feels liriit. As tbe enlarge- 
meot ie sometimes very great, symptoms of compreaaion appear on tbe 
part of the lunge and hesirt (dyspntea) or the abdominal organs. Ac- 
cording to some anthors, chrome alcere of the leg may be tbe result of 
chronic splenic tumor (pressure on tbe inferior vena cava). 

According to Piorry, pressure on the spleen sometimes produces chill 
and tremor. Naunyn observed congli as the result of percussion or com- 
pression of the organ. This symptom disappears after several trials, but 
reappears after a certain length of time. Swining states that be has 
observed increased heat in tbe splenic region. Gerhardt recently de- 
scril)ed, in a case of aortic insufficiency, a pulsating splenic tumor, and 
at the same time heard a double sound over the organ. In two cases of 
acute febrile enlargement of the spleen in patients who suffered from 
aortic insufficiency, he observed pulsations. 

The patients generally have a pale, sallow, sometimes greenish or 
blackish complexion. They suffer from palpitation or dyspnaa, aniemic 
Bounds are audible in the arteries, and murmurs in the veins, hemor- 
rhages occnr into the skin and macons membranes. They suffer from 
<edema, and finally die of cachexia. Some of these symptoms, it most 
be remembered, may be the result of the primary disease. 

The disease sometimes lasts for j^ears. 

rV. Phobnosis. — The prognosis depends on the primary disease. 
Under specially unfavorable circumstances, the splenic enlargement itself 
may be the cause of death from the effects of compression. 

V. Treatment. — This depends upon the primary disease. If the 
eplenic enlargement is the result of a neoplasm, we can merely maintain 
tne strength of the patient as much as poE^sible by nourishing food and 
tonics. In gummata of the spleen, astonishing results are often obtained 
by the administration of potassium iodide. Ecbinococci of the spleen 
must be treated surgically. Under more favorable circumstances, inter- 
nal and external remedies may be employed. 

Tlie chief internal remedy is quinine, which may be given by the 
mouth or, better still, injected subcutaneously (with glycerin and water 
M) in the splenic region. If quinine is not toleratM. we may order 
arsenic (}J Liq. potass, arsenit., Aq. amygdal. amar., aa j BS. M. D. S., 
five to ten drops t. i. d. after meals). 

If there is pronounced iinasraia, we should order iron or iodide of 
iron, combined with quinine. 

Individuals who lire in a marshy and malarial region ebonld change 
their residence. 

The various alkaloids ot Peruviaa bark, piperine. salicta. erj^tin, potassium 
bromide, pilocarpine, etc., have also been recoiumeuded to dimimsfa the size ot 
tbe spleen, 

The efficacy ot internal remedies may be aided by external meaaurea. 
According to our own experience, the best plan is the application of ice- 
bags to the spleen. 

The following plans have also been recommended: cold douches to 
the spleen, faradization, application of iodine, issues or blisters, massage, 
injections into the spleen of Fowler's solution or carbolic acid. Sponta- 
neous disappearance of the enlargement has been observed after preg- 
nancy. 



DISEASES OF THE SPLEEN. 48 

Extirpation of the spleen (splenotomy) is indicated when death by 
soffocation threatens, as the result of compression. 

3. Inflammation of the Splenic Capsule. 

Perisplenitis. 

I. Etiology. — Perisplenitis is rarely primary (traumatic). As a 
rule^ it is the result of peritonitis or inflammatory processes within the 
spleen, which have extended to the periphery (generally embolic infarc- 
tions, but also all acute and chronic splenic enlargements). 

n. Anatomical Changes. — In acute cases, the capsule is covered 
with fibrinous deposits, which cause the spleen to adhere to surrounding 
parts, and sometimes form sacs which are filled with pus. In chronic 
cases, we find fibrous thickenings which have a tendinous appearance, or 
are thick and almost cartilaginous in hardness. They sometimes con- 
strict the spleen to such an extent as to produce atrophy of the organ. 
There are often fibrous adhesions to surrounding parts. 

ill. Symptoms. — The symptoms consist of pain in the region of 
the spleen, sometimes of a friction murmur. The surface of the organ 
is sometimes felt to be irregular. The disease is often unrecognized, 
particularly in acute perisplenitis. Firm thickening may be suspected if 
the spleen does not enlarge in infectious diseases or portal stasis, and 
other causes (hemorrhages) have not prevented the enlargement. 
Fibrous adhesions may be diagnosed if respiratory displacement remains 
absent, although the spleen can be felt and is not unusually large, or if 
splenic dulness remains, despite the occurrence of perforation-peritonitis. 

IV. Tbbatmrnt. — Application of ice-bags, otherwise purely sympto- 
matic. If there is severe pain, morphine subcutaneously^ warm poul- 
tices, cups, sinapisms, blisters^ or application of iodine. 

4. Hemorrhagic Infarction and Inflammation of the Spleen. 

Splenitis. 

{Abscess of the Spleen. Splenitis Apostomatosa.) 

I. Etiology. — Splenitis is rarely primary. This is observed as the 
result of injury (although this gives nse more frequently to rupture of 
the spleen), ana, according to some writers, of great bodily strain. 
Siiberstein reported a case in which abscess of the spleen is said to have 
resulted from violent sneezing. In many cases tne cause cannot be 
ascertained. 

As a rule, splenitis is secondary. It is generally the result of embol- 
ism of the splenic artery, which begins with the symptoms of infarction, 
and generally ends in inflammation. The emboli generally are second- 
ary to valvular diseases of the left side of the heart, more rarely to 
aneurisms, arterio-sclerotic patches in the aorta, and still more rarely to 
pulmonary disease. 

Changes in the spleen, which are similar to wed^e-shaped infarc- 
tions, but in which no embolus can be found, occur m infectious dis- 
eases (pyaemia, septicaemia, typhoid and relapsing fever^ cholera), in 
protracted, exhausting diseases, and in Bright's disease. 

Splenitis is sometimes propagated from adjacent parts. Bound ulcer 



46 



DttrEAflES OP" THE SFLSZS'. 



of the stomach, toxic gaetritie, peritonitis, and perinephritis may extend 
to the spleen, and give rise to fiecondary inflammation of that organ. 
Pnlmonary gangrene may also extend to the diaphragm and spleen. 

II. Anatomical Changes. — Among eightv-foar cases of embolism 
following valvnlar disease of the henrt, the splenic artery was affected 
thirty-nine times, the renal artery fifty-seven times. The relatively large 
Inmen of the splenic artery, and the slow circulation within it, favor the 
reception of emboli. 

One or more emboli may be present, and occasionally they are so 
numerous that very little ot the splenic tissue remains intact. 

A wedge-shaped infarction of the spleen is recognizable bv its pecu- 
liar shape. The broad base of the wedge is directed towards the sur- 
face of the spleen, the narrow apes towards the hilus (corresponding to 
the distribution of the obstructed arterv). In the majority of cases, the 
infarction extends to the surface. The capsule may then be inflamed, 
and be covered with peritonitic deposits. 

Becent infarctions are blackish-red, granular, and have an hepatized 
appearance. They gradually undergo decoloration, which begins at the 
apex and centre, and then extends to the periphery. The color changes 
to brownish-red, grayish-red, and finally yellow. At the same time the 
part becomes dry, cmmbly, and brittle. 

Under favorable circumstances, the infarction may be almost entirely 
absorbed, leaving merely a depressed, often pigniented cicatrix. la 
other cases, it undergoes cheesy degeneration and partial calcification. 
The infarction has a light yellow color, and the relatively well-retained 
Malpighian bodies appears as pearl-gray dots. Retraction occurs, and 
the spleen not iufrei^uently becomes irregularly lobulated. Finally, the 
infarction may termmate m an abscess. 

The size of the abscess varies from that of a pea to that of a hen'a 
egg. It sometimes exceeds the dimensions of the infarction and attacks 
intact splenic tissue. Cases have been reported in which the spleen 
formed a pns sac surrounded by the capsule, and in which hardly a trace 
of splenic tissue was left. (Thirty pounds of pus have been discharged 
from such an abscess. ) The spleen sometimes contains numerous sb- 
Bcesses. The pus forms a green, creamy, or light reddish-brown fluid. 
containing pus-eorpusclea, granulo-fatty cells, fat granules, and htematoi- 
din crystals. The wall of the abscess is irregular and villous, or smooth 
and surrounded by a fibrous capsule. 

The abscess may perforate into the peritoneal cavity, stomach, trans- 
verse colon, pelvis of the kidneys, large blood-vessels, pleura, pericardium, 
Inngs, or externally through the abdominal wails. In very rare cases, the 
pua becomes cheesy, sometimes calcified in places. 

in relapsing fever, splenic abscesses form which are restricted to the 
Malpighian corpuscles. Thia has also been observed in typhus fever. 

III. Symptoms axd Diagnosis. — The diagnosis can only be made 
under certain favorable conditions. The most important one is the demon- 
stration ot a valvular lesion or of other lesions which are known to give 
rise to embolism. If, under such circumstances, there is a sudden chill 
(attended in many cases with vomiting), if the patients complain of pain 
in the spleen, and the area of splenic dulness rapidly increases in size, 
the diagnosis of wedge-shaped infarction of the spleen may be made. 

The diagnosis of splenic abscess is impossible in the majority of cases. 
In some cases, the lesion is found accidentally at the autopsy, because 
marked symptoms were absent during life. In other cases, hectic aymp- 



DTBKA9ES OF THE SPLEEN. 

toms develop : chills, profuse sweats, remittent fever, auoresia. emacift* i 
tioD, diaiThcea, death from exhattstion (phthisis lienalis). 

The diagnosis can only be made if fluctuation can be detected in the 
spleen (which is usually enlarged) and if the affection has been preceded 
by the causes of Bplenic abscess. The sadden appearance of masses of 
pus, coincidently with diminution in the size of the spleen, also arousea ' 
the suspicion of spleuio abscess. This event indicates perforation into! 
adjacent organs, and the pus may be vomited, expectorated, discharged I 
in the urine or stool, or through the integument. In the latter event, 
the skin may bo undermined, sometimes even to the clavicle or axillary 
space, before perforation occtirs. Perforation into the peritoneal cavity 

fenerallj; proves rapidly fatal after evidences of perforation -peritonitis, 
ut previous peritonilic adhesions may give rise to encapsulation of the 
pns and prevent free perforation. In some cases, fatal pyaemia sets ia. j 
because pus and infection-cafriers enter the circulation tlirougli the | 
splenic vein. I 

IV. PuooNOSis AND Teeatmest, — The prognosis of wedge-shaped I 
infarctions is not always unfavorable: that of splenic abscess is grave, I 
and the only hope of a favorable issue lies in judicious surgical meo' J 
Burec, 
• Treatment is purely symptomatic. 



Tl 



5. Waxt/ Degeneration of the Spleen. 

I. Etiology. — The causes of waxy degeneration of the liver will also I 
e rise to a sirailar lesion in the spleen (vide Vol. II., page 213). i 
e spleen is generally the first organ affected, and if death occurs very I 

Buun, it may be the omy organ which has undergone waxy degeneration. | 
According to Cohnheim, it may develop in four months. In very rare I 
cases, the spleen escapes, while other organs are affected. 

HofTinann found that among eighty cases of waxy deKeneration the organsi 
were attacked as follows: " 

S~ ileen 74 timea (62.50. 
idneys 67 ■■ <84. (). 

Inteatlnee 53 '■ (05. J). 

liver 00 ■■ (68.5)r). 

II. Anatomical Chasges. — Slight grades of the lesion can onlv be ' 
recognized by the aid of the microscope and chemical reagents (vide VoL - J 
II., page iJ14). Advanced waxy de^n erst ion is recognizable macroscop- i 
ically, and includes two varieties, viz., the sago spleen and diffuse wax;^ 
spleen. I 

In the sago spleen, the Malpighian corpuscles are affected chiefly otM 
almost exclusively. On sections through the spleen they appear as pearl- \ 
gray nodules, which may exceed the size of a pin's head. In some of 
them, the centre contains a dull-gray dot. which corresponds to the blood- 
veasel of the follicle. The nodules are often surrounded by a red halo of 
dilated vessels. On the application of iodine, the degenerated follicles 
osaume a deep mahogany-brown color, which is especially distinct if the 
waxy follicles are situated within an infarction. 

In diffuse waxy spleen, the organ increases in size, and sometimes oc- 
jipies a large portion of the abdominal cavity. The borders of the spleen 



^^pi, 



48 DISEASES OF THE SPLEEN. 

are rounded and blanted, and its consistence is increased. It feels 
tense^ firm, brittle, as if frozen. 

On making a section through the organ, lar^e coherent pieces can be 
scraped off with the knife, and the organ is readily cut into thin sections 
which are translucent in transmitted light. The organ generally has a 
flesh-red color, and upon the application of iodine assumes a diffuse, 
dark-brown color. 

Transitional forms between sago spleen and diffuse waxy degenera- 
tion are sometimes observed. But we nave also seen sago spleen in old 
cases of waxy degeneration, so that the transition from sago spleen to 
the diffuse form does not appear to be a necessary event. 

The waxy degeneration begins in the capillaries, and then extends to the oon- 
nective- tissue framework of the spleen. According to Sechtem and fibertb, the 
splenic cells proper are not affected by the d^eneration, but undergo compres- 
sion atrophy, on account of swellingof the connective-tissue framework. Ky ber, 
Comil, and others claim that the spleen cells undergo waxy degeneration. Con« 
cerning the nature of the amyloid substance, we refer to Vol. U., page 215. 

III. Symptoms and Diagnosis. — The condition is not susceptible 
of diagnosis, unless^ after circumstances which usually give rise to waxy 
degeneration, a hard splenic tumor with round edges is felt, and at 
the same time there is firm enlargement of the liver and albuminuria; in 
some cases, diarrhoea points to waxy degeneration of the liver, kidneys, 
and intestines. Cachexia is often noticed, but it is doubtful whether 
this depends upon the waxy spleen or upon the primary disease. 

IV. Pboonosis and Treatment. — The prognosis is unfavorable, 
although a resolution of the process at the beginning of the disease does 
not ap{)ear to be impossible. The treatment is symptomatic. Special 
repute is enjoyed by preparations of iodine, iron, and iodide of iron. 

6. Tumors of the Spleen. 

Neoplasms of the spleen possess chiefly an anatomical interest. Some of 
them, such as fibroma, enchondroma, cysts, dermoid cysts, and caverii«»may 
are anatomical rarities; others, such as sarcoma and cancer, are more frt*quent. 
Cancer of the spleen is generally secondary to cancer of the liver, stomach, or 
retroperitoneal glands. Six cases of primary cancer have been reported. Me- 
dullary cancer is the variety generally observed, and pigment cancer is relatively 
frequent. Sometimes only a few nodult^s are found in the uniformly enlarged 
spleen, sometimes almost the entire organ is destroyed. It may increase very 
considerably in size, and occupy the larger part of the abdominal cavity. The 
disease occurs generally beyond the age of 40 years, but occadonally in very 
young individuals (one case at the age of 13 years). The diagnotds is onlv pos- 
sible if cancer is demonstrable in other organs, and the spleen is enlarged, and 
its surface nodular. The prognosis is unfavorable, and treatment is of no avail. 

7. Parasites of the Spleen. 

Pentastomum denticulatum, cysticercus cellulosw, and echinooocci have been 
found in the spleen. The two former possess only an anatomical interest. 

Echinococcus may occur in the spleen alone, but more frequently it is also 
present in other organs, generally the liver. We may find eitlier simple sal's, 
or the latter may contain daughter vesicles. The organ may increase very mark- 
edly in size, and compress adjacent organs (lungs, heart, stomach, intestifies, or 
bladder), as shown by dyspnoea, vomiting, constipation, and dysuria. Ezami- 
nation discloses a splenic tumor which moves with respiration, occasionally peri- 
tonitic friction sound and prominences. The latter correspond undoubtedly to 
echinococcuis vesicles if they present fluctuation, but the tumors are not infre- 



OIBEASES OF XHK BPLBES. 

quently hard ftnd firm. An ejcploratorv puncture may bo made, but thU d . 
not always afford positive resutU. Hince the fluid may contain albumin, and t 
sometimes deetittite ol echitiococcus hooba. The ^ti^ata often complain oc 
pain in the Bplenic region. Hectic Hymptomn set in if the yeaiclea undergo sup. 
pumtinn. The disease may last more than Hixteen years. Bcoovery uan be 
affected b;^ surgical measures alone. Otherwise death occurs from marasmus 
~ocalion. 






Rupture of the Spleen. 



._ BndLOQT. — When the or^u is liealthy, rupture of the spleen may occur as I 
result of injury in the sptunic region. In acute enlargement of tiie spleen, f 
rupture may tase place Kpontaneously because the capsule is unable to resiat ths 1 
increasing pressure, nr it is the result of trifling catises (lifting, vomiting, ouueb-- I 
ing, etc.). This happens most frequently after typhoid or intermittent fever, but J 
may also occur in typhus, cholera typhoid, and even in miliary tuberculosis. 1 

It. Syhptous AND ANATOMiCAi,CHAKaBS.~Tlie accident isgenerally attended I 
with the symptoms of severe internal hemorrhnge. The patients may experience 1 
u sensation as if something had burst iuteriialiy. They complain of tiain in tli«-f 
ninlomeD, confined at first to the spleeu ; tlie shin becomes cool and pale, the 1 
features sunken; then follow syncope, -vomiting, im perceptibility of the pulaei I 
increased splenic dulness, muscular twitchings, I 

As a rule, death ensues ; but a ease of recovery has been recently reported. I 
CicatrixatioD can be looked for only when the rent in the capsule IS iusigniQciint. I 
Death may occur at once, or life is prolonged one to two, rarely several days. At J 
the autopsy, the abdomen is fuunii Ailed with fluid and coHeufated blood ; peri- ] 
tunilic changes are generally absent. The capsule generally contains a singla I 
IrreKular rent. ' I 

CiihnheEm described a case in which varicose dilatations of the splenic v»- ' 
sets hod I'liplured. 

III. DiAONOaia, Pboonosis, Thkatment.— The diagnosis is based on the fact 
that, acute enlargement of the spleen beiiig present, there are sudden signs of 
internal hemorrhage, pains in the rfginn of the spleen, and increasing dulness, 
ProRnosis unfavorable. Treatment: ice hag, ergotin subcutaneously, oj-iam to 

Ive the pain, camphor and wine against threatening collapse, 
banges in the position of the spleen may be congenital or acquired, tempo- 
or permanent. iJoiigenilal dialociitiona include the situs viscerura inversus, 
bioh the spleen i» situated on the right side, the liver on the left. This con- 
I dltion may be cnnUued to the liver and spleen, or involve the other viscera. 
In pleurisy, pneurnothoras, npinat curvature, and deformity of the thorax, the 
flpleenianotiiirreqiieiitly dixplaceddowtiwards; in meteorism. abdominal tumors, 
and the liki>, it is often paslifd upwards. 

The Huleeii sometimes sinks so far that it is felt below the epigastrium, most 
frirquently in the left iliac fossa, but sometimes in the pelvis or right iliac fuaiia. 
It may be so movable aa to change its situation in different positions of the body, 
and may even he turned around its own long axis. In other oases, the mobility of 
ihespleen is impeded by adiiesions to adjacent organs. Tlie hitus generally looks 
Upwardn, while the anterior edge is situated along the anterior abdominal walls. 
The development of this condition is favored by along, Saccid gastro-splcnio 
ligament, by a blow in the splenic region, lifting heavy loads, and diseases 
at(«ndpd with cough, A fruitful eonroeof displacement is the increased weight 
of tumors of tli9 spleen, which dr^ upon the ligaments. Th6 gastro-splentc lig- 
ament, with the splenic arteries and veins and the pancreas, are drawn into a 
long cord, which fa often twitited upon its long axis. The vessels of the spleen 
mar undergo obliteration or the spieen may be freed from its ligaments, and then 
tuiilenjoea fatty degeneration and ntrophy. 

The objective symptoms consist of the demonstration of a tumor in the shape 
of the spleun. In one of my cases, the tumor could not alone be felt through tne 
thin aNIorninal walls, but the pulsating spk-nic artery could also be palpated 
is the bilus. Splenic dulness was abw<nt from its ustial position, and did not 
t until the tumor was replaced in the left hypochoudri — 



9. diani/en hi the Position of the Spleen, 
{ Wandering Spleen.) 



^mpMty 




50 DUEASMB or THB 

fbMM fMUmli ftn Mitlrdy free ftom sobjeeliTe . . 
&§ A ttmlinn M iraotion and pain ; adhenm %o tbe \Aaddmt 
4fMVi VMrimil And rvotal tenesmut. PNarare on Che nenrL __ 
•o r^mlMiilon iind panUyeii of the lower limfae. In Sepert'e 
Ml nlKrtilder wee produced whenever the qOeen wee com wi — tu . 

A neee hee lieen reported, in which preasore of the di el orm te d epleen vpoa the 
W^wm prfKliaced deetn from inteetinal ocdnrion. In anodier onn. ooik of the 
llmim hiKl beoome Incarcerated in an abnormal flanre within the elonnted 
UM%fi> upl^nlo Itfcament Gangrene and dihOatioB of the iloniach have alao been 
MiMifvMi. thfi fornier from ezceesive stretching and occhHion of the araries of 
th«» riifMliiii. the latter from preesore of the etietched p a n e un a upon the doode- 



" linfidagiHi may be employed to keep the qOeen in plaoe^ and •■ a 
t^\M¥iMmhf may be performed* 



SECTION IX. 



DISEASES OF NUTRITION. 



1. Obesity. Poliffarcia. 

I, EnOLoOT, — The term obesity is applied to an excesaiTe accnmu- 
latioii of fat in the subcutaneous cellulur tissue and Id those internal 
localities (mediastinum, epicardium, omeutiim, mesentery, appendices 
epiploicie, renal capsule, etc.) which are characterized, under healthf 
conditions, by the presence of a large amount of fat. 

Tlie disease not alone produces great annoyance, but also serioni 
danger to life. 

The causes are either indirect (prediepoBiug) or direct, but both setiJ 
of caases co-operate in the majority of cases. 1 

Heredity is the chief predisposing cause. In some cases, only a fBW'L 
members of a family are affected. In all probability, it is the result iit\ 
an inherited defective power of oxidation of the cells. 

Age is a potent etiological factor. The disease is often ob- 
served dnring infancy and beyond the age of forty years, while 
chiklhood and early adult life generally escape. According to some 
■writers, the tendency to obesity la particularly evident in men between 
the fortieth and fiftieth years, in women beyond the age of fifty. 

The female sex presents a greater predisposition to the disease than 
, the male sex. 

The more sedentary the habits of life the greater is the danger 
( obesity; hence it is frequent in those who retire from bnsineas, 
r who are deprived of the nse of the limbs on account of amputation 
* or of other causes which act in a similar manner. 

Racial differences are also manifested. Thna, obesity is frequent 
among Hungarians, Wallachians, Orientals, South Sea Islanders, 
and Hottentots. 

A damp, warm climate favors its development; hence the tendency of 
the Dutch to corpulence. 

These factors would probably prove insufficient in many cases, 
were it not for errors in diet. The latter may be excessive Id amount or 
improperly conatitnted. 

Apart from water and salts, onr food consists of albuminoids, 
fats, and carho- hydrates. The fat of the tissues is derived mainly from 

I the albuminoids, which are oxidized into nitrogenous and non-nitrogen- 
MU substances, the latter representing the fat-producers. Whether 
Be fat contained in the food is couverted directly into the fat of the 
Body has not been positively settled, hut, at all events, this mode of 
brmation is quantitatively inconsiderable, when compared with the 



^_ tll6_ 



52 DISEASES OF NTTTBITION. 

former method. Fat is not produced from carbo-hydrates unless these 
are ingested in very large quantities. 

The fat derived from the albuminoids of the food is at first destined 
for further oxidation into carbonic acid and water. Hence, if the 
ingestion of albuminoids and the corresponding production of fat 
is excessive, it becomes possible for the oxidizing capacity to be in- 
sufficient to decompose the fat, so that it is deposited in excessive 
amounts in the tissues. In practice, this mode of development of obesity 
is much less frequent than that arising from the irrational combination 
of albuminoids and carbohjd rates. 

If, in addition to albuminoids, an excessive amount of carbo-hydrates 
is ingested, the latter, being more readily oxidized than the fats 
formed from albuminoids, are first at the disposal of the oxidizing 

Sowers of the organism, so that the fats remain unoxidized and are 
eposited in the tissues. 

Hence, obesity is so apt to occur in individuals who are devoted to 
the pleasures of the table, and, in addition to lar^e quantities of albumin- 
oids, also partake of farinaceous articles, beer, wme, and other alcoholics. 

Tliese considerations render it evident that the amount of food 
ingested should be regulated by the destructive disassimilation going on 
within the body. If a man, who has been previously active, retires from 
business, and at the same time continues to take the same amount 
of food as before, he runs the risk of becoming obese, because the 
oxidative processes, which are diminished on account of rest, no longer 
suffice to oxidize the fats which are produced in the body. Diminished 
oxidation of fats is also, probably, one of the elements in hereditary 
obesity, since such individuals are often characterized by flabby bodies 
and phlegmatic temperament, and these are supposed to be associated 
with diminished oxidation. 

Among the immediate causes of obesity are losses of blood, because 
the diminution in the number of red blood-globules interferes with the 
power of oxidation. This is also true of anaemic conditions, and, hence, 
obesity is not uncommon in chlorosis, progressive pernicious anaemia, 
phthisis, scrofula, and even the first stages of cancer. For similar 
reasons, it may develop during convalescence from severe diseases. 

Attention has often been called to the relations between obesity and 
disturbances of the sexual organs and functions. Obesity has been ob- 
served repeatedly in individuals with imperfectly developed genitals. 
In men and women, castration ; in women, amenorrhoea and sterility are 
said to give rise to obesity. In many of these cases, however, the cause 
and effect are mistaken for one another. Women sometimes grow very 
fat after the first pregnancy, especially if they do not nurse the child. 

Cases of congenital obesity have been reported. Wulf described a case in 
which a stiU-bom infant measured 62.5 cm. m length, and weighed seventeen 
pounds. 

II. Akatomical Ohakgbs. — The panniculus adiposus is unusually 
developed, and in some places, especially in the abdominal walls, forms 
masses of fat as broad as the hand. The muscles often haveapale, 
brownish-yellow or sallow yellow color. In very advanced obesity, there 
is a considerable development of fat in the intermuscular connective 
tissue, which sometimes results in compression atrophy of the muscular 
fibres and partial fatty degeneration. The medulla of the bones is often 
unusually rich in fat. 



^^V BiBEiSEs OP NtmcmoN. sS| 

^^f7he mediastinal cellular tissue generally takes part in the abnormal 
^^^oeit of fat. This is dao true of the subepicardial tissue, and results 
occasionally in compression atrophy and fatty degeration of the muscular 
fibres of tlio heart. The left ventricle may undergo hypertrophy. 
Atheromatous changes upon the inttma of the great vessels are found 
not infrequently. The serum of the blood sometimes has a milky emul- 
bIvo character (lipfemia), the result of the presence of an unusual amouut I 
of fat in the form of granules. I 

The greater omentum is particularly fatty. In Boerhave's case, it 
weighed ten pounds. The appendices epiploicce are converted not infre- 
quently into large clumps of tat. The capsule of the spleen iilso con- 
tains a largo amount of adipose tissue, so that deep incisions must be 
made before the organ is reached. The epitlielium cells of the renal 
tubules sometimes contain accumulations of fat drops. The liver ia still 
more frequently in a condition of fatty degeneration. The dia]ihragm 
ia pushed upwards on account of the accumulation of the fat in the ab- 
dominal organs. 

TIL Stmptosis. — The symptoms develop very gradually, as a rule, 
but in rare cases thej^ assume a more acute course, the patients becom- 
ing visibly larger within a few weeks. The increase in the size of the 
body appears first and earliest in those parts which, in healthy individ- 
uals, contain a well-developed panniculus (cheeks, chin, nipple, nape, 
shoulders, extensor surface of the limbs, dorsal surface of hands and feet, 
abdominaJ walls, mons veneris, labia, and buttocks). 

The shape of the body approximates that of a globe. The cheeka 
are flabby, the palpebral fissure is made smaller by the pushing upwards 
of the lower lid, the chin appears drawn inwards, because one or more 
fat folds of the skin project beneath it (so-called double chin). The 
features appear expressionlesB, flaccid, almost stupid. An arcus senilis 
develops prematurely. 

The neck is short, the nape contains thick transverse folds, the chest ] 
and abdomen are particularly obese, and the abdominal walls often hang I 
down upon the thighs. The umbilicus is either unusually sunken, or I 
very prominent. Umbilical hernia is not uncommon. The genitals I 
often appear buried in the surrounding masses of fat, and varicocele ia 
not an infrequent complication. The buttocks often attain a monstrous 
size, and the hemorrhoidal veins around the anus are often dilated. 

The gait is generally waddling, and, on account of the change in the 
position of the centre of gravity, the head and upper part of the trunk 
are held backwards. 

The greatest weight hitherto attained is six hundred and nine 

fonnds, although it ts claimed that one individual weighed eleven 
uii'lrod ponnds (?). 
The following table shows the enormous weights sometimes attained 
by children. 

A boy, Est. H jBon Q3 pounds. 

Agifl.tBt, 4 years 83 

A girl, (Bt 4 years 137 

Aoiyj.mt, Gyeare 189 " 

A boy, wt. U yeani 900 '• 

A girl, «t. 11 yean 4S0 " 

The specific gravity of the body diminishes with increasing obesity, 
•0 that the individuals readily float in water. 
I According to the complexion, we distinguish plethoric and anamio 



54 DISEASES OF JXUTSmOS. 

obesity. Plethoric obese indiyiduals have a red, congested face, and 
complain of a rush of blood to the head, frequently of dizziness and 
ringing in the ears; ansemic obese individuals have a pale appearance. 

The skin is generally soft and delicate; it exhibits a tendency to 
eczema intertrigo, particularly in the lower fold of the breast, the 
umbilicus, and gluteal folds. Acne vulgaris and even acne rosacea are 
frequently observed. 

There is generally increased secretion of sebum and perspiration. 
The sebum accumulates not infrequently in the folds of the skin, where 
it decomposes and emits a nauseous odor. The well-known fatty sweat 
is a combination of perspiration and sebum. 

The temperament of the obese is generally phlej^atic. They avoid 
exercise as much as possible, on account of the discomforts connected 
with it. Many exhilbit an unusual degree of somnolence. There 
are frequent complaints of rheumatoid muscular pains, probably as the 
result of the opportunity for catching cold onered by the profuse 
sweats. 

The pulse is often very rapid, and not infrequently more than 100 
a minute. Dyspnoea is a common symptom on account of the enfeebled 
action of the heart, the impaired movements of the lungs (displacement 
of the diaphragm upwards), and the diminished amount of hsmoglobin 
in the blood. (Edema and varicose veins in the legs are observed 
not infrequently as the result of circulatory stasis. 

The percussion sound over the thorax is diminished in intensity 
on account of the thickness of the integument; the respiratory murmur 
is feeble, partly for the same reason, partly on account of the diminished 
respiratory movements. 

Marked dulness over the sterum indicates a large accumulation 
of adipose tissue in the mediastinal cellular tissue. Cardiac dulness is 
sometimes enlarged, and the apex beat displaced externally. The heart 
sounds are feeble, and systolic murmurs are sometimes heard, or, if the 
left ventricle is hypertrophied, the second aortic sound is intensified, and 
may be metallic m cases of arterio-sclerosis. Leichtenstem found a 
diminished amount of haemoglobin in the blood. Fatty liver may 
be suspected rather than demonstrated by physical exploration, on 
account of the thickness ^of the abdominal walls (vide Vol. I., page 54 
and Vol. II., page 211). 

Females often present menstrual anomalies, early cessation of the 
menses, sterility, catarrh of the genital mucous membrane, uterine dis- 
placement, and ovarian diseases. These result from circulatory dis- 
turbances, and displacement of the sexual org^ans by the fatty masses in 
the abdomen. Sexual desire is often diminished in men and women. 
In males. Kisch often found absence of spermatozoa in the semen, and 
this sometimes increased to azoospermia. Sterility in obese individuals 
may be the result of various causes; they may even be purely mechanical 
in character^ since an abundant development of fat around the genitals 
may interfere with coitus. 

The urine may often contain a sediment of uric acid and urates, more 
rarely oxalate of lime— the result of an excessive supply of albuminoids 
in the food and their imperfect oxidation. Sugar is sometimes 
found temporarily in the urine, and this phenomenon may be a 
prodrome of a subsequent diabetes mellitus. 

Gastric and intestinal catarrh is often seen in the obese. It is the re- 
sult in part of the excessive ingestion of food, in part of mechanical in- 



DISEASES OF H UTiUTlOK. SS% 

terference with the gaatro-inteatinal movements and of circnlatory n 
stasis. The latter accounts for the frequent devolopmeiit of hemor- 
rhoids. 

These indiriduals can perform very little muscular work, partly 
because the niuBcles are often rendered atrophic by the intermuscular 
proliferation of fat. There ia not infrequently a tendency to syncope, J 
and to nervous and hysterical disturbances, These become especially I 
marked in febrile diseases, which are particularly dangerous to ohese ' 
patients. Death often results from paralysis of the heart. In addition, 
the JDcreaaed bodily temperature is reduced with greater difficulty 
by baths than in lean individuals. The patients are also very sensitive 
to venesection. According to some writers, the use ot mercurials is also 
dangerous in obese individuals. 

Obesity furnishes a predisposition to other diseases, such as gout, j 
calculi in the urinary and biliary passages, and diabetes mellitus. Soma | 
maintain that it is often associated with cancer and multiple fiirun- 
culosi?. Rapidly fatal hemorrhage from the pancreas has been observed 
with relative frequency in obese individuals. 

Death may occur n-om various causes. It often depends on disturb- 
ances of the functions of the heart, and either occurs suddenly from 
heart failure or gradually after progressive symptoms of stasis. Cerebral 
hemorrhage is frequent, 'but is ratner the result of the artorio-sclerotic 
changes which are associated with obesity. 

IV. DiAONOSia AND Pkoonosis.— The diagnosis is evident at a 
glance. The prognosis is serious. The cr}nditton is attended with 
numerous dangers, and if the patient is unable to restrain himself and 
renounce certain of the pleasures of life, he will generally meet an early 
and distressing death. 

V. Treatment. — Certain forms of obesity may subside spontane- 
ously. For example, the obesity of infants, which generally disappears ' 
when they use their muscles and begin to walk, and when the diet is 
changed to one less rich in hydrocarbons. 

The obesity following losses of blood, anemia, and convaleBcenoe f rom 
severe diseases mny also disappear spontaneously. 

The methods of treatment adopted for the removal of fat from the 
bodv are manifold. 

Kbstein has shown that a relatively plentiful supply of fats diminishes 
obeeitVt and finally relieves it entirely. The fata not alone satisfy the 
need for food, but also diminish the desire for fluids, so that the plenti- 
ful ingestion of fat implies a diminished ingestion of food. It is neces- 
sary, liowever, to cany out the dietetic rules permanently, in order to 
prevent the recurrence of the obesity. 

Ebstein prescribes the following rules : Three meals may be taken 
daily: a. Breakfasi, consisting of a large cup of black tea without milk or 
sugar, 3 iii, of wheat bread or toasted rye bread, well buttered (at G to 
6:30 o'clocK in the summer; at 7:30 o'clock in the winter), b. Dinner, 
S to 2:30 o'clock: soup (often with the marrow of bone), liv.-vi. of broiled 
or stewed meat (fatty) with a fat gravy, a moderate amount of vegetables, 
especially leguminosa, also the varieties of cabbage, hut no potatoes or tur- 
nips; salad or stewed fruit without su^^ar; fresh fruit; two to three glasses 
of a li^ht white wine; shortly after dinner a large cup of black tea with- 
ont milk or sugar, c. Supper at 7:30 to 8 o'clock; in winter regularly, 
iM the summer oGcasionally, a cup of black tea without milk or sugar. 



56 DISEASES OF NUTRITION. 

ail ^Rgf a 'at roast, ham, sansage, smoked or fresh fish, I i. of wheat 
bread, well battered, now and then some cheese or fresh fruit. 

In other words, we may recommend fatt;|r articles, such as butter, fat meat, 
sauces, and ham, pati de foie grcu, etc. Hydrocarbons (potatoes, farinaceous 
articles, cakes, sugar, milk, beer, brandy, champagne) must be avoided as much 
as possible. 

In addition to exact recommendations concerning the amount and 
character of the dietary, the patients should be enjoined against dressing 
too warmly, they should live in moderately warm rooms, bathe in cold 
water, not sleep too lon^, and exercise a great deal. 

Ansemic obese individuals should take iron or a course of treatment 
at Kissingen, Homburg, or Marienbad. 

We can testify from our own experience that, under Ebstein's regimen, 
the patients rapidly diminish in weight, and feel better mentally and 
physically. But we sometimes come in contact with individuals who 
nave such an antipathy to fatty articles that the method of treatment 
described cannot be carried out. In some cases, I have found that the 
patient's stomach becomes very sensitive, so that the most cautions in- 
gestion of solid food produced vomiting and diarrhcea. 

Oertel's plan agrees with Ebstein's in that both recommend the small- 
est amount of food, but Oertel allows extremely little fat and relatively 
more hydrocarbons. Oertel also attaches great importance to diminu- 
tion of the supply of water, and endeavors to deprive the body of fluid 
by ordering Turkish baths, mountain climbing, or subcutaneous in^ 
jections of pilocarpine. Drinks and soups should be avoided as much 
as possible, at all events fluids should not be taken until one and a half 
hours after meals. Oertel furnishes the following dietary: Breakfast: a 
, small cup of coffee with milk and sugar, and 3 i.-ij. of wheat bread and 
butter. Dinner: | vij. of meat, 3 ij. green salad, ^ iij. fresh fruit, but 
no soup. Supper: two eggs, 3 v. meat, a little caviar, and 5 v. -vij. of 
light white wme. At a later period, after the obesity and circulatory 
disturbances have disappeared, the dinner maybe supplemented with 
fish and farinaceous articles aa 3 iij., and later even 3 vi. of white wine; 
cheese and bread may then be added to the supper. If circulatory dis- 
turbances are not present, the amount of fluids need not be restricted so 
markedly. 

The well-known Banting cure has been modified by Vogel as follows: 

Breakfast: coffee without milk and sugar, toast or zwieback without 
butter. Second breakfast: two soft-boiled eggs, lean raw ham or lean 
toieat, a cup of tea or a glass of acid wine. Dinner: a plate of weak soup, 
lean meat (cooked or broiled), a few potatoes, a little bread, green vege- 
tables. Stipper: bouillon or tea, cold meat, lean ham, soft-boiled eggs, 
salad, a little bread. 

According to the latter method, as much albumen as possible is sup- 
plied to the system, but the attempt is made, by the slight supply of fats 
and hydrocarbons, to force the body to use up its excessive amount of 
fat. Although the Banting method is effective, it cannot be continued 
for a long time, and not infrequently gives rise to gastro-intestinal ca- 
tarrh, palpitation, dizziness, syncopal attacks, insomnia, and other nerv- 
ous disturbances, even insanity. In several cases, Kisch noticed the 
development of phthisis. Voit showed recently that the dangers and 
inconveniences of the Banting system may be avoided by ¥rithd rawing 
the fats and hydrocarbons very gradually at the beginning of the cure. 



DISEABEa OF S UTlUTiUIT- 

. gradnalij matoring them a little, after our immediate object i 
Attained. 

Voit fumisheB the foUowing tables of the daily amounts ingested byl 
healthy individualB, and in the various cures for 0'—='-- ■ 

UiBCXEH. 

» Vigorous laborer, . . . 118 

Well-to-do physician, . . 107 

Ebstein, 103 

Oertel 155 

Banting 172 

The number of plans of treatment has not yet been exhausted, 
nier orders a strict milk diet (six to eight pints daily). We may also! 
mention grape cures, massage, and inhalations of oxygen, inhalations of 1 
compressed air, iodine wells, salivation, hunger, or sweat c 



85 
25 



500 



70 



^Kici 



2. Qoul. Arthritis Uratica. 



1. EtioLOOT. — Gout is a change in the nutritive processes in the bodrl 
_ hincliuesit toinflammations iu the various organs and tissues, and] 
of ten gives rise to the deposit of urates. The joints are affected most! 
frequently, but by no me»n8 constantly; the first joint of the great toe I 
is the one attacked earliest and most constantly. I 

In the majority of cases, there is an hereditary predisposition; the I 
disease appears in one generation after another, or one or more genera- I 
tioua may escape. 

AcL-ording to Hutchinson, the younger children of gouty paiente are more 
to suffer than the first bont; hi^reditary Iranamisaion is more probable when both i 
Iiarenta Buffer trom the disease, and the gout of the father ia more apt to be f 
tnuiaiiiitted than that of the mother. 

In the majority of cases, auxiliary factors are necessary to cause an I 
outbreak of the disease. 

'I'iie most important are dietetic oriors — heavy meals, eKceesive inges-- 
tion of albuminoids, wine, beer, and other aJcoholics. These conditions J 
may suffice to produce gout without the aid of an hereditary predisposi- 
tion. Hence, gout is mainly a disease of the wealthy classes. 

The danger of the development of gout increases if bodily rest is added I 
to luxurious habits. Whether mental strain favors the development of I 
the disease has not been positively settled. I 

The previous considerations explain the frequent coincidence of 1 
obesity and gout, tlie former to a certain extent forming a prodrome of 1 
tho latter, " f 

But although the disease results, in the majority of cases, from high j 
living, iu rare instances it follows deprivation and insufficient supply of 1 
food. ' 

Toxic gout is a special form of the disease. French writers have , 
shown tiiat gout, particularlv renal gout, is not infrequent in workers in 
lead, and there is nodoubt tnat the introduction of lead into the system 
changes the nutritive processes in such a manner as to produce a uric- 
acid diathesia. 



^^MMtixMlc 



&6 DISEASES OF HiriBnioBr. 

dinrnwiinil^rion (aric icid and lactic acid). Others maintain that the gastro-enfter- 
Hm Id such caaes 10 a manifestation of primary goat. Our own obeemttioiiB hari^ 
ied 118 U) ooincide in the latter opinion. 

Engluid is the classical territory, so to speak, of gout. Next f oIlo?r 
France and Holland, while it is less frequent in G^ermany, Spain, and 
Italy. According to Charcot, ^ont is infrequent in Bussia, Sweden, 
and Norway, although the population is strongly addicted to the use of 
alcohol. These variations are due to dietetic, rather than to dimatie 
<y>nditions. 

Age exercises great influence on the manifest deyelopment of ^ut. 
It occurs almost always from the age of thirty to forty years, it is ex- 
tremely rare in childhood, but cases have been observed at the ages of 
six, ten, and eleven years, respectively. 

The large majority of cases occur in males, because they are more ex- 
posed to the exciting causes. 

The symptoms generally occur in paroxysms, so that the causes of the 
diathesis must be distinguished from those of the individual attacks. 

The gouty paroxysm depends not infrequently on excesses in diet or 
in Baccho et Venere; or it is preceded by unusual mental excitement. 
Bheumatic causes seem to exert a certain influence; at least, attacks of 
^out are most frequent in the autumn and spring. It has been noticed 
m several cases that individuals who suffered from articular rheumatism, 
not alone are often attacked by gout, but that the latter is apt to attack 
those joints which had been the site of rheumatic inflammations. Inju* 
ries may at once provoke gouty changes. 

II. Symptoms. — As a rule, the symptoms do not occur unexDectedly. 
The patients generally give a history of hereditary gout, or they have 
long suffered from the symptoms of increasing obesity. Complaints are 
{^nerally made of increasing girth of body, dyspncBa, palpitation, vom- 
iting, pyrosis, flatulence, constipation, aizziness, ringing in the ears, 
etc. The patients have a red face, often suffer from acne rosacea, hem* 
orrhoids, varicocele, etc. 

The gouty attack, as a rule, is also preceded by prodomata, and rarely 
develops suddenly. There is an increase in the gastric symptoms, obsti- 
nate constipation, sometimes pain in or hemorrhage from existinj^ hemor- 
rhoids; the urine ^rows scanty and deposits a brick-red sediment of 
urates, more rarel;^ it is very profuse and pale. In some individuals, the 
sexual desire is increased. The patients complain of a feeling of 
oppression in the chest, palpitation, increased aizziness, and rush of 
blood to the head. They grow moody, hypochondriacal and irritable, and 
complain not infrequently of insomnia and excitement There is often 
a tirei]^ feeling in the limbs, drag^ng and i)ainful sensations in the mus- 
cles, espeoialfv of the calf, sometimes transitory pains in certain joints. 
In certain eases partesthesi®, paretic symptoms, tremors, and cramps in 
the calves make their appearance. 

l^ho paroxysm of gout is so much more violent the longer the dura- 
tion of the prodromata. 

The manifest symptoms of ^ut appear most frequently in the form 
of acute gouty inflammation 01 the joints^ although some gouty patients 
remain f^ for life from any affection of the joints. 

It is characteristic of articular gout that, in the majorit]^ of cases^ 
the metatarso-phalangeal joint is attacked. The second joint of the 
great toe or the ankle joint is affected more rarely. As a rule, the other 



I>ISBA8US OF HUTKinOH. 



£0 



jointB are not attacked nntil after repeated gouty parosyBDiB. The ones 
that arc moat frequently involved urc the fingers, and especially the 
thamb, but also tEe knee, hip, sliouldor, elbow, and the articalatiooA J 
of the clavicle, vertebrie, maxilla, and costal cartilages. ■ 

In the first attack, the great toe is generally alone aETectod, and even I 
in subsequent seizures the same joiut may be repeatedly attacked. Th» 
inflammation rarely occura at the same time in several joints, more fre- 1 
qaetitly oue joint becomes involved after the other. 

Gouty inflammation generally begins suddenly in the middle of the i 
night, usually from twelve to three o'clock. The patient who went to 
bed almost entirely free from snfferitie, is suddenly roused from sleep by 
excruciating pain in the great toe. Tho pain is described aa boring. 
compressing, burning, sometimes as a painful sensation of cold. The 
patients groan aloud, throw themselves about in bed, and cannot toleratA J 
the slightest contact. The skin is hot and dry, the bodily temperature J 
increased, and the pulse is hard and accelerated. The pains generally I 
moderateconaiderably towards morning. The fever also diminishes and ' 
diaphoresis generally appears, the sweat smelling intensely sour in some 
cases. At the same time the local changes in the joint have become more 
marked. It 13 uniformly swollen, the integumtmt covering it is very 
red, almost erysipelatous, is hot and cedematous ; the surroauding integ- 
nment not infrequently contains varicose vessels. The cedema some- 
times extends over the entire dorsum of the fool, and even to the ankle. 

During tho day, the patient experiences little pain if the limb is kept 
quiet, but in the following night tlie En.ffering returns. This continues 
on the average for five to ten days, then the pains subsides, and the 
attack ceases. The redness and swelling of the joint gradually dimin- 
ish, a prickling, itching sensation is felt, the epidermis, desquamates, and 
the ^omt remains a little stiff for a while, but noon regains its former 
mobility. Many patients feel in better health after the subsidence of the 
attack. The paroxysms are generally so much shorter the more violent 
the pains. 

We must also refer to those symptoma which indicate the accumula- 
tion of urates in the blood. Tiieir increase in the blood may be dem- 
onstrated immediately before and during the paroxysm. In healthy 
individuals, uric acid is absent from the blood, or is present only in 
traces ; in acute gout its amount may reach 0,25 or 1.75 per cent. i 

In some cases, the urates in the blood escape through the skin, a white 1 
deposit being left upon the integument after evaporation of the perspi- I 
ration. This is proven to consist of urates by the murexide test, its sol- | 
ubility in alkalies, and the deposit of uric acid crystals on the additioa I 
of acids. I 

If a blister is applied to the skin, the vesicle will be found to con- | 
tain a large amount of uric acid. 

Uric acid is readily <lemonetrated in tho blood, eamdations, or tronsudationHl^ I 
OarnHt'a thread test. For example, the blood is allowed to coai^late, and four k> 
right ccm.«t>rum placed in a watoh-glass, la which six to twelve dro]M ordiuuy 
>c«iiciu;id(30;t)are added. A cotton thread, which is not too smooth, is then dip- 
ped into the fluid, the whole covered with a glues ulideaud allowed lostandoneor 
tw-odavB at a temperature of IS to 20° C. Crystals of urio acid are then deposited 
npon the thread. 0.025 per cent is the minvnuim amount of uric acid which will 
dopoelt crystals (two to three). Tliey are readily recogiiizeil under the micro- 
scope (vide Fig. 0). The contents of blieters may be directly experimented 
upon in the manner junt described. Atkinwin states' tliat be has found aut-buit- 
' * ---acidiu the coating of the tongue. 



« 



Dnring the attack, tfao iirino i? geaerally Ecanty, saturated, scid, and 
often deposits a brick-red sediment. The specific gravity is tncrrased. 
OaiTod loond that the iimount of uric ai'id in the urine dtminisbee v»rj 
markedly shortly before the attack, and sometinjes merely a trace ia left. 
During the first part of the attack, it remains small, but gradual!; in- 
creases, and after tho termioatioa of the seisare ma; even exceed the 
normal amount. 



StolcviB slates that the smount of urea excreted during a paroxysm ia dimin- 
tohed ti) one-tliicd the noriual. This author also observed dimiuuUon of phos- 
phoric acid, especialljr of that portion which is combined with the oUoUiiie 



Acute goat may end with a single attack. This ia particularly trae 
of those individuals who ever after refrain from dietetic errors. De- 
spite Buoh eelf-reatraint, another attack may occur aS the result of a 
i^r. n blow, fracture or dislocation, or a 

cold. But the majority of patients 
soon discard their abstemious habits. 
Nevertheless, from two to five or 
moro yeara may elapse before another 
attack Rupervenea. In other caees, 
an attdck oecurB quit* regularly at 
the end of a year, or in the spring 
and autumn. As a general tning, 
they occur so much more frequently 
the more enfeebled the individual. 

The greater the number of the 
gouty attacks the more they lose 
their typical character. They be- 
come less acute, more protracted, 
ofUn leave permanent residua in the 
^ . .. ,, , ahitnc of gouty nodes or tophi; in 

Oann'l ■ UuBMl tent. Uric sdii cri-atals ,-'.i'''^ (T,*^. 

ri-i-i«ik.i on • cottoD ihn^j EuJart-c-i uue. the Hvmptoms of chronic gout 

'»"-'" _ develop. 

Chrouic gout is often, though not ulwavs, a sequel of acute attacks. 
In rare cases, it appears from the start m a chronic manner. Many 
joints are generally attacked, particularly tliosc of the feet and hands. 
As a rule, tnc joint changes present remissions and exacerbations. The 
pains in the joints are not so severe as in acute attacks, but the swell- 
ing IB often greater. The redness of the skin is much less, and often 
entirely absent. After the pains have disappeared, tho swelling 
subsides very slowly, and does not often disappear entirely. Hard 
nudes appear iu the vicinity of tho joint, and increase so much more in 
size the greater the number of relapses. These nodules are gradually 
converted into large nodes, which are visible beneath the skin, and feel 
aa hard as a stone. The overlying skin ia often pale in the middle, 
while tho jteriphery ia Yery red and contains dilated vessela. These 
nodes (tophi) consist chiefly of urates which are deposited upon the out- 
side of tne joint. They sometimes attain the size of a cherry, or are 
even much larger. The overl}'ing skin may inflame and ulcer- 
ate, and a chalky or mortar-iike mass is discharged, consisting of 
mates. Under the microscope, this is found to contain fine needles of 
the urates. These ulcers exhibit very little tendency to heal, and pft" 




present litxariant, easily bleeding granulatione. Their base aometimea 
contains chalk-like tophi, which may assume stalactite shapes. 

These tophi may produce sach deformity that Sydenham has com- 
pared the appearauce of the hand to that of a parsnip root (vide Fig. 
7). The joints are often movable with difficulty, and may become 
ankylosed. They often conyey a creaking and scratching sensation and 
sound. Subluxations aro produced, so that the terminal phalanges of 
the Sngers are deflected towards the ulnar side, and the other phalanges 
are bent towards the palm. The entire limb may be rendered nse)eBS, 
and the patient crippled for life. 

Chronic gout also attacks the burate, faaciie, tendons, cartilages, 
bones, and skin. 

The bursffl, particularly those of the elbow and patella, become 
Bwollen and painful, the SKin overlying them is reddened and swollen. 




cuttkge oF lAeeor. Alter 



After some time, the swelling and pain 




but firm deposits are 



M 



discovered which gradually grow larger, and finally form voluminous 
maaees, composed chiefly of urate of soda (vide Fig. 7), 

Among the tendons, the extensor tendons of the fingers are affected 
moat frequently, and present more or less hard and stony deposits. 

Gout of the cartilages is important in diagnosis. It is observed most 
frequently in the cartilage of the ear. This contains nodular hard 
apota which may attain the size of a pea, the centre white, the periphery 
aurrounded by dilated vessels (vide Fig. 8), When pricked with a 
needle they discharge, on pressure, a white, soft or hard mass, which 
consists of innumerable fine needles of urate of soda (vide Fig. 9)- 
These nodes are sometimes the only visible evidence of gout. They 
develop very rapidly (within ten days, in a caae reported by Garrod). 
The overlying sliin sometimes ulcerates, and they then fall out of the 
auricular cartilage. They are not infrequently the aite of painfal s — 



DISEASES OF ITDTSfrroTr. 63" 

loi)a shortly before the onset of an acnte gouty affection of the 

rarer cases, gouty deposits occur in the palpebral and nasal carti- 
lages. Virchow baa also described gonty deposits beaeatli the perichon- 
drium of the arytsanoid oartiluges, and states that these may determine 
the diaguosis in doubtful cases. 

Gont of the skin is rare, but tophi have been observed in the integu- 
ment of the face. Subperiosteal nodes are observed more frequently. 

In chronic gout, the blood is also overloadftd with urates, white there 
is a diminution of the urates in the urine. The phosphoric acid in the 
nrine is also diminished in quantity. 

Stokvis calls attention to notable differences in nutrition in gouty and liealtliy 
individuale. After the ingestion of inarganic acids (phosphoric or hydroclilorio 
Aolds), the amount of phosphoric acid in the arlne was increased both in gouty 
and health; individuals, but in the former tberi^ was an increase of the pbosphorio 
acid whioh was combined nitb the alkaline earths, in the latter of that combined 
with the alkalies. After the ineention of organic acids, the exoretion of phospho- 
ric acid was increased in the healthy alone. 

Patients who suffer from chronic gont sometimes attain an old age. 
But in other cases marasmus develops at an early period, asthenic or 
atonic goat develops, and the patients die from increasing exhaustion. 
Death also occurs not infrequently from interna! or visceral gout (anom- 
alous or latent gout). 

There is hardly an organ which may not be the site of gouty organic 
and functional changes. These may exist independently, or follow pre- 
vioua acute or chronic gout of the joints. In the former event, the diag- 
nosis is extremely difficult, since the symptoms do not differ from those 
of similar non-gouty conditions. A diagnosis may be made if Garrod'a 
thread test of tne blood furnishes positive results. The matter is much 
simpliSed if gouty deposits are found on the joints, cartilages, etc. Joint 
affections, and gouty affections of the internal organs, sometimes alter- 
nate rapidly with one another, hut the old doctrine of metastasis is not 
looked upon with epeoial favor at the present time. 

Benal gout is the most important form of visceral gout. It produces 
the symptoms of small contracted kidneys and similar anatomical 
chaoges ; it is recognizable by the large amount of pnle urine of low 
specific gravity, slight sediment, moderate amount of albumin, and hy- 
pertrophy of the loft ventricle. It may constitute the sole symptom and 
terminate fatally. 

Not every albuminnria during the courseof gout is indicative of gouty 
kidneys. It may appear as an evidence of cachexia, or as the result of 
gouty, waxy degeneration of the kidneys. 

Cerebral gouty symptoms include headache, hemicrania, syncopal 
attacks, and epilepsy. Paralysis may occur from eucephalorrhagia, the 
latter resulting from gouty atheromatous changes in the vessels. Psy- 
cboaee hare been attributed to gout in a number of cases. The symp- 
toms of meningitis and myelitis have been ascrihod at times to gout of 
the spinal cord; neuralgiform, paretic, and paralytic symptoms and par- 
sethesisa, to gouty changes in the peripheral nerves. 

The following ocular changes have been observed : conjunctivitis, 
with deposits of urates, deposits in the cornea, keratitis, iritis, and af- 
fections of the vitreona body. Gouty patients are also said to exhibit a 
' ' icy to the formation of cataract. Choroiditis and retinitis are rare. 



c 



64 DISEASES OF KUTSTTION. 

Impairment of hearing has been observed in some cases, and has been 
attributed to deposit of urates in the tympanic cavity and the mastoid 
cells. 

The following affections of the circulatory organs are often observed: 
palpitation, stenocardia, hypertrophy of the hearty myocarditis^ dilata- 
tion of the heart, sometimes symptoms of stasis, and valvular lesions. 
Pericarditis may also be associated with gout. The disease also predis- 
poses to arterio-sclerotic changes, and thus to aneurismal dilatations. 

V6rit6 has described gouty rhinitis, which was characterized by the 
formation of mucous concretions. Catarrh of the air passages, and in- 
flammations of the pleura and lungs may also depend on the gouty dia- 
thesis. The pneumonia sometimes terminates m gangrene. Huchard 
lays stress on the frequent occurrence of gouty hasmoptysis, particularly 
of the nocturnal variety. 

In some cases, functional disturbances ensue in the shape of gouty 
asthma. 

Gouty parotitis, angina, and oesophagismus have been observed. 
Dyspeptic and cardialgic attacks, vomiting, haamatemesis, and inconti- 
nence of the pylorus have also been described. Functional and ulcera- 
tive changes in the intestines occur occasionally. 

Gout, per se, is perhaps capable of giving rise to cirrhosis of the liver* 

Pyelitis, cystitis, or spasm of the bladder may set in, and even muco- 
purulent discharges from the urethra (gouty gonorrhosa). Inflamma- 
tions of the testicles and prostate, hydrocele, and indurations in the penis 
are attributed in some cases to gout. 

The skin presents a tendency to inflammations, so that eczema, the 
various forms of acne, and other inflammatory changes are not infre- 
quent. These are generally characterized by a tendency to relapses and 
bv marked obstinacy. This category also includes the predisposition to 
ptilebectasise. In not a few cases, injury to the skin is followed, in gouty 
individuals, by severe inflammations, accompanied by high fever^ ana 
even terminating in gangrene. 

Visceral gout often develops in a slow and insidious manner, but it is 
more dangerous than the articular variety. 

Gout is related not infrequently to various other diseases. It often 
occurs in the obese because both conditions are owing to similar causes. 
There is no doubt that gouty individuals often develop diabetes mellitus, 
and that diabetics may suffer from gouty symptoms. Gouty individuals 
also exhibit a tendency to the formation of calculi in the urinary pass- 
ages; more rarely in the biliary canals. 

In some cases, the patients experience only a single attack of gout in 
the joints; in others, they recur after intermissions of years, or the 
patients die after prolonged symptoms of chronic gout, or death is the 
result of visceral gout, and may occur very rapidly in apparent good 
health. 

III. Anatomic A.L Changes. — The specific changes in gout consist 
of deposits of urates in various organs. The inflammatory conditions 
which may be present hardly differ at all from those found in non-gouty 
diseases. 

Gouty joints often contain deposits of urates upon the surface of the 
articular cartilages. Thev form whitish, chalk -like masses, which begin 
as punctate spots, gradually increase in size and height; at first they are 
sometimes evident only on microscopical examination. The first and 
most extensive changes appear in the centre of the cartilage^ the peri- 



^ D1BBABE8 OP miTBrnow. 8^ 

^faeral parts often remaining intact for a long time, though in many ' 
oases their blood-veaaela are cougested. The more the earthy depoaits 
increase the more the surface of the cartilage is perforated ana the siib- 
atance destroyed and deftbrillated. The urates extend occaeionally into 
the adjacent osseous substance. 

In recent cases, the synovial membrane shows congestion and loosen- 
ing of its tissues; in older ones, thickenings, villous proliferations, and 
earthy deposits. 

Gouty concretions are especially apt to form on the outer surface of 
the capsule of the joint, where they appear as tophi. Garrod observed. . 
one iu the hand weighing two ounces. 

Gouty deposits are also found in the burste, tendons, fascite, and t>e- 
Death the periosteum. ] 

Virchow recently described uratlc deposits in the spongy portion of 1 
the phalanges. Garrod mentions a tendency of the bones to brittleness, as ] 
a result of the formation of cavities fllled with masses of fat. Gouty I 
deposits have also been observed in the medulla of the bones. 

The muscles are sometimes atrophied, especially when the limbs have , 
been inactive for some time. 

In the heart, we often find dilatation and hypertrophy, callosities, J 
and fatty degeneration. Chronic inflammation of the endocardium lafl 
not infrequent, and these foci of inflammation may contain urati^l 
deposits. Pericarditic changes may also be connected with gout. M 

Garrod found uric acid in exudations. m 

The aorta is often the seat of arterio-sclerotic changes, iu which 1 
Bramson found deposits of urates. Dilatation and aneurism of the aorta 
may also develop. ' 

Schroeder van der Kolk found urates in the walls of the veins. 

The air passages and lungs may eshibit Ifae signs of inflammation ; 
in the lungs, these terminate occasionally in abscess and gangrene. . 
The statements concerning gouty deposits in the lungs require confirm- 
•tion. 

Swelling, inflammation, and even ulcerative deetmctlon of the 
icons membrane have been observed in the gastro-intestinal tract. 

The liver is often enlarged and in a condition of fatty degeneration 
or cirrhosis ; in the latter event, the spleen may bo swollen. 

The renal changes appear at times aa simple, contracted kidnen 
(atrophy of the organ, nodular surface, adhesions of the latter to thft ' 
capsule, atroph}^ of the cortex, thickening of the walls of the arteries), 
or urates (occasionally carbonate of lime) are deposited in the form of 
infarctions in the tubules of the retracted kidneys, or there are intersti- 
tial gouty deposits, or a combination of interstitial and intratubular 
nratic deposits. The former are especially numerous iu the pyramids, 
rarer in the cortex. They sometimes form grayish-white streaks alon^f 
the straight tubes, or appear as dots at the apices of the pyramids. 

Gouty deposits and inflammatory changes are found occasionally m 
the pelvis of the kidneys, and in the bladder. In one case, Garrod found 
similar changes in the penis. 

In a few cases, deposits of urates have been noticed upon the cerebral 
meninges, the spinal dura mater, and iu the neurilemma. 

, n all organs. At 
es. After the Decr>>Bis ia 
« of a deposit or needlo- 



'ini 

IP"' 



(Ml wwiMW or vuTBmoEr. 

^)iiMiuL> I'tT^tn rf Ih#i0iil WNWitciCtoda. TheMoftan fill the necrotic focosso 
v^hmiJm^'U ^k khit iMMvr biKHMMM* Tisible <mly after the crystals are diasolved ; 
iH ^v^HM- \nm. ^tht «r«ii«|MMttl crystalline masses are found snnounded by a 
tH^Uii ^MH». ^i*«lt>. m %^ MMLlt*of reactive inflammation, the necrotic focos 
^nnmi* ^« «vMiMtuU 1^.« a SI.MM of round cells. 

*Hio ivMV.« ^kHH>«ftlfr ai¥ vvrapossd, in neat part, of the acid urate of soda. The 
H4^ik«iAgL wriftti^^ IIm wiiiltn of ohemioal examination by two obsenrers : 

Marcbaii<L Lehnuuin. 
(Tophi from thigh.) (Tophi from metacarpus.) 

ll^^^vMf^Hl^ . . 84.20 52.12 

y»HH^v^UiM^ 2 12 1.25 

0%tN^«4«|yof anmonia, 7.86 

i^»»M|»hAWol Uuie, .... 4.82 

Misl»H*u ^^Kmle» ... 14.12 2.84 

Vuiui^l lualiers. .... 82.68 28.49 

Whuh, , . . . • . ?•§?[ 3,98 



IvSNMm 2.27 



100.00 100.00 

\\mM «uw« (hat he has also detected hippuric acid in the deposits. 
Miii\>ii*4Uik HUil l4»hmann also analysed the osseous tissues, and found a dearth 
m( \4«iOv\ luuiitMTSi and excess of fat. 

Ifarchand. TAiitrt^wn 

Ulna. Femur, lit Case. SdCaae. SdCSasB. 

l'h*«*«iili4iM«*r lliiiD 48.18 42.12 85.16 85.88 87.22 

i^ot«<t»*^i«'«*^iulD B.50 8.24 8.41 9.82 a99 

Vlt>«.a«i«.a«Mtf magussia. . 0.99 1.01 1.81 1.05 1.18 

i:;;^*''^*M 45.96 46.82 ^\\ f^f, ^g;^ 

A,aMia..imiU. 1.87 2.27 2.98 2.08 1.82 

\M iiiu iit{i'0tu( thHt the excess of urates in the blood is the main cause of the 
l«(-. Ill' iliti ttf uoiit> H^iuptoms, but opinions differ as to the source of origin of the 
hi i • •« ri 'I'^MH U owmg to tht^ fact that we know so little concerning the site of 
i<ci he h'lti tit' ui'io HoM under normal conditions. 

'\*i M iM'tVUti* iif oouint^, tht> exoesis of uric acid in the blood will become still 

ii(< •)l>i li ilnt I'uniiutiou of urio acid is increased by an excessive supply of food, 

'It ll (nt>l«i llui liilluitiiiHt of load )HU»oning or deprivation and want, the processes 

,) MitV^**^'"** Hiii i«iii4(t«rtHl Uvts active, and a portion of the albuminoids are con- 

' ..i I I III! iuiti iu«Mi, but only into urio acid. 

|4>(ii«<l lH:liiivitit \\u\\ XU^ i^roxysmal character of gout is owing to the fact 
IimI ill* l»l>lnii.\ H u( tinuM pr\we unable to excrete the excess of uric acid, so that 
t . ImiihiImiv ur.ounuilati\m pnwokes a paroxysm. This theory is opposed by 
Ii< I If \ i)iut uMm^M of gxuit mav ixx'ur, although the kidneys are mtact. It 
. He i>.|m|ii, luui'li hu^'v plauHible to a;»ume an intermittent increase in the 
• ((((•ilV'ii m| luii' uoul, ruther than disturbed excretion. 
IM*- |htlli-Mi|' t'ouiluotion for the urio acid from the tissues to the Ijrmph and 
,.{',' A • iliii itUoUou kulttw. but Kn^al stasis is apt to ensue if the circulation is dis- 
jii)li> ^ \i\ liilluuinmUvtn, injurv. etc. For example, Charcot obeerved, in a case 
■ r l<> ih||iI* bt««. Hutt H^Mit dovoio(ie\i only in the joints upon the paralyzed side. 
'()«> Mi(Uiii*Hh li«H|UiMa KH^aUsatum of gvmt in the joints af^pearstobe owing to 
||i> f«t> i lliiil Uui uuiMouUr tiHsueand medulla of the bones take an active part 
(ii IIm |ii.i«Uir.niiu of \\\i<^ aoid which Ihey transmit in part through the Ivmph 
f |i.iiiiH*li ul \\\%\ \iti\\iU^%\ and al«K^ to the slowness of ibe circulation in the "bones 
Mi'l III! I liUuiuiiioiU \^»|Kvrtunity for stasis. 

I Im 1 1 ri|U(>u( ((U|ms\ati\vn of the ^reat tvvi^ owing perhaps to its extreme peri- 
1 1 • ii| "Kuitd^tu. is\\\\ to th«^ faot that il carries the weight of the body, and is 
I <| • liill) .>uli.|ui>U'\( S\^ uuvhauiv>al irritation. 

|\ lin(i(No:i(H. Aouto )^nlt l^f the jointdis generally recognized 
'- » , r •ilil\ luuu ilvo t>|v\\vU !i\tuatiou aiut $jHvifio course oi the disease, 
•! li'l s\\\\\ hoio\IUai\ auvl wuHtitutioual factors. 

\ >i \\\\v (IumUiv^usmi4 v^f ohrvmio ^nit of the joints is also easily 
ihi4>l>. 1 1 \{\s\ yi^\\\\\\^^\\\ U^s^w \^\\\s^\sX hyUfi^ aeiue attacks, and tophi 



attai 



i 



DIBKA8B8 07 SUTBITION. 

are fonnd in tlie joints, often in the bursse, tendons, cartilages of the ear | 
and nose, and sometimes of the larynx. It might possibly be mistakea I 
for artbritis deformans, bnt this could be excluded h\/ eiaminatioa of the ' 
blood and the chemical constitution of the contents of a vesicle (pro- i 
duced by application of emplast. canthandis). 

The recognition of visceral gout may be difBcalt so long as gouty de- 
posits are not observed. Carefpl attention must theu be paid to the 
previous history and constitution of the patient, and Garrod's thread 
test should be made. 

V. Proun'osis,— The prognosis is always serious. It ia doubtful 
whether the goaty constitution can be subdued permanently, although 
some patients who are careful in tbeir habits experience only a single 
attack. 

The paroxyms oF acute gout of the joints almost always terminate in 
.-Bdy recovery. Chronic gout often gives rise to deformity of the 
^ lints and renders the limbs useless. Visceral gout is always attended 
^ith danger, and ia sometimes followed quickly by a fatal termination. 

VI. Treathest. — The prophylactic measures are the same aa those j 
described nndei' the head of obesity. 

In an attack of acute gout of the joints, the limb should be kept ele- 
vated, in order to favor the outflow of blood, and should be wrapped in 
aalioylated wadding. Schroeder recently recomraeuded inunction of the 
affected joints with green soap. The patient is placed on fluid diet, 
and is allowed to drink lemonade. In several cases I think the attack 
been shortened by the administration of salicylic acid (^r. vij. 

rry hour) until tinnitus anrium was produced, but the efl*ect is never 

pronounced as in acute articular rheumatiam. 

After the pains have subsideded, the stiffness of the joint may often 

relieved rapidly by cautious massage and movement of the limb. 

. As a Kt'O'nnI thinK, the treatment should not be too energetic, since grave and 
~~iD fatkl Bjni|iU)ma of ioternal goat have betMi known to develo)) under eucb 
nimalBQces. For this reason we aliould avoid the application of ice, leeches, 
_d blisten to the joint, and the adnuniatraiton of emetics, drastics, large doaea 
I colchicum, etc.. to prevent a threatening attack. The warra-WAter cure of 
det de Vaux (200-3r>0 oom. of hot water taiien every quarter of an hour, for 
, tlve hours) should not be employed, eince this plan ia sonietimea followed bf 
idden death. 

Acute exacerbations in the course of chronic gout must be treated 

itheparoxyma of acute gout. Much cannot be expected from internal 

lediea. Tboae recommended are : tincture or wine of colchicum 

■xij. t. i. d.), aconite, lithinm carbonate (gr.ias. t. i. d.), 

dam iodide { 3 ij. ; 3 v., one tablespoonful t. i. d.), and salicylic 

ild. The functions of the skin should bo kept active by lukewarm 

batlis and frictions, and the occurrence of atiffneas of the joints Bhoald 

bo prevented by massage. 

ImporJ^ice is attached to the u 
waters. 

Obese patients should take a cure at Marionhad or Carlsbad ; 
if there is a tendency to the formation of uric-acid gravel, at Vichy, 
Neuunuhr, or Ems. Feeble, exhausted individuala maj" resort to the 
acrutothormal springs (Oastein, Wiidbad, Bagaz, Teplitz). while pro- ' 
nonnced gouty deposits, gouty ulcers, or cutaneous eruption are treated ( 
with flulphnr batha (Nenndorf, Eilsen, Meinborg, Aix. etc.). 

Symptoms of visceral gout generally require stimulating measures, 



e of lithia welis and artificial lithia 



68 DI8SABE8 OF NUTBinOK, 

and also treatment like that pursued when similar symptoms are the 
result of non-gouty causes. It is also recommended that the goat be 
diverted from the internal organs to the joints b^ the applioation to the 
latter of blisters, mustard poultices, or other derivatiyecu 

3. Diabetes MeUitus. 

I. Etiology. — Diabetes depends upon an anomaly of nutrition which 
is manifested by the permanent excretion of sugar in the urine. It is an 
independent disease which must be distinguished from transitory, symp- 
tomatic excretion of sugar (glyclcAuria or mellituria). The dis^tae ap- 
pears to be increasing in freouency, perhaps because the urine is now exam- 
ined more carefull;^ than heretofore, perhaps in part as the result of 
the mental and bodily excesses connected with modern civilization. 

Heredity is a prominent etiological factor. Diabetes is sometimes 
observed in successive generations, sometimes certain generations es- 
cape. It is also observed at times in families in which nervous diseases 
and psychopathies are hereditary. Hereditary obesity and gout also 
oreate a predisposition to the development of diabetes. 

In certain cases it is the direct effect of a nervous affection, partiou- 
larly of hemorrhage, softening, and tumors of the floor of the fourth 
ventricle. Claude Bernard showed that the lesion of a definite part of 
the floor of the fourth ventricle, iiear the origin of the pneumogastric, 
is followed by the excretion of sugar in the urine. Weichselbaum re- 
cently observed diabetes in a case of multiple cerebro-spinal sclerosis 
and, on autopsy, a patch of sclerosis was found in the floor of the fourth 
ventricle in tne part referred to. 

Functional nervous diseases, for example, chorea, epilepsy, and p^- 
chopathies, may also be associated with diabetes. Tnere is no doubt 
that it is sometimes the result of strong mental excitement. 

The disease is sometimes attributed to injuries, particularly those 
which give rise to general concussion of the nervous system, also to 
blows in the region of the stomach, liver, or kidneys. 

There can be no doubt that certain cases are produced by cold and 
exposure to wet, but the circumstances of the case should be carefully 
examined before it is attributed to such causes. 

Improper diet is sometimes a causative agent. Gantani attributes 
the frequent occurrence of the disease in Italy to the fondness of Italians 
for farinaceous and sweet food. Injurious effects have also been attri- 
buted to abundant ingestion of sugar and carbo-hydrates, or of fruit, 
new beer and wine. 

Some authors claim that diabetes is often associated with sexual ex- 
cesses. 

It develops occasionally after infectious diseases, with relative fre- 
quency after malaria, more rarely after typhoid fe^er, measles, scarlatina, 
or dysentery. Syphilis, either with or without lesions of fhe central 
nervous system, is an occasional cause of diabetes. It has been observed 
in a number of cases after cirrhosis and abscess of the liver, and portal 
thrombosis. A similar influence has been attributed to gastric and in- 
testinal affections, and to acute or chronic diseases of the pancreas. 

In not a few cases no cause can be discovered. 

The disease is more frequent in males, except in children, in whom 
the females predominate. 



DIBEABES OF NDTRmON, 



JXt devolopB most commonly between the agea of 3 
e earlier in females than in males. 



' to 50 years, a lit- 



A case has been repotted in a girl set, 7 months. Hollo reported one in a man 
on? yeara. 

It ifi generally asanmed tLat the disease is more common in the well- 
to-do classes. 

II. SvaPTOMB. — The specific symptoms of diabetes are preceded not 
infrequently by prodromat^, consisting of gastric distnrbances (changes 
in appetite, ermrtations, Tomiting, flatulence, irregnliirity of the bowels) 
with mental depression, hypochondriacal ideas, dizaineas, rush of blood 
to the head, etc. 

Id other cases, there are no prodomata, bnt insatiable hunger and 
thirst with progressive emaciation rouse a suspicion of the disease even in 
the patient himself. 

Some individuals develop obstinate neuralgias and rheumatoid mus- 
cular pains, which are associated with latent diabetes. Bilateral neural- 
gia is especially suspicious. 

Violent pruritna, obstinate eczema, chronic furunculoais and, in wo- 
men, pmritus vaginee should lead us to examine the urine for su^r. 

Diminution of sexual potency is sometimes associated with diabetes. 
Noctumal enuresis in childhood should arouse our suspicion. Com- 
plaints of a feeling of dryness in the mouth and throat must also attract 
attention, 

The existence of diabetes is sometimes indicated bv certain accidents, 
anch as a peculiar sour, apple-like, or chloroform-like odor from the 
mouth or urine, white patches on the clothing in places on which drops 
of urine have fallen (crystallized sngar), or masses of crystals in the 
night vessel. 

In some cases, the ophthalmologist is first consulted, on account of 
cataract, retinitis, neuroretinitis, ocular paralyses, disturbances of refrac- 
tion and accommodation, etc. 

In two instances I observed the occurrence of death during apparent 
good health. The patients suddenly lost consciousness, breathect sterto- 
rouBly, and died in coma. In both cases the bladder was found very 
m»rliedly distended, and the urine contained sugar. The patients were 
females, nt. 20 and 24 years respectively. 

Obesity, gout, and calculi are associated not infrequently with dia- 
betes and should lead to an examination of the urine. 

The quantity of urine is almost always increased, and may amount to 
3.000 to 10,000 ccm. or even more (normally 1,500 to 2,000 com.). 
Biermer described a case in which 16 litres, Hamaek one in which 18J. 
litres were passed daily. In many cases there is, at first, an excessive se- 
cretion of urine, but the latter does not contain sugar. In other words, 
the diabetes mcllitns is preceded by diabetes iusipidus. The reverse 
condition also obtains in some cases. The patients pass water fi-equently 
and are often disturbed at night. According to LccorchS. a larger 
amount of urine is passed at night in the early stages, during the day in 
the later stages. 

ses the amount of urine voided never exceeds the normal umount. 

e ie unusually pale and sometimes is hardly distinguishable 



Inw 



^^dbe I 



70 DI8BA8B8 OF NOTBTnOV. 

from water; it is so much lighter in color the larger the amount. The 
nrine is generally clear, froths readily and for a long time, and rarely 
contains a sediment. 

In some cases the excretion of fat in the urine has been described. In a recent 
case, the excretion of fat and sugar was intermittent, anddinppeared when the 
patient was placed on low diet. 

The urine generally possesses a peculiar sickening odor, occasionally 
it resembles tne smell of fruit or chloroform. In the latter eyent, the 
urine usually turns a dark cherry red on the addition of dilute chloride 
of iron and often contains acetone. The urine has a more or less sweet 
taste. 

On account of the insatiable thirst, children sometimes drink their own urine^ 

• 

Its reaction is almost always acid and remains so even after it is ex- 
posed to the air for a long time. This is owing to the fact that lactic 
acid is one of the producte of fermentation of sugar. The specific grav- 
ity Is increased in almost every case. It ranges from 1.030 to 1.050, or 
more (normally 1.015 to 1.020). It may be laid down as a rule of prac- 
tical importance that a large amount of urine of a normal or increased 
specific gravity is indicative of diabetes. 

In rare cases, diabetic urine has an exceptionally low specific gravity (1.006 to 
1.002). 

It has been claimed by some authorities that su^r is present in nor» 
mal urine. But, at the most, normal urine contains merely traces of 
sugar, which cannot be discovered by the ordinary methods of examina- 
tion. 

The average daily amount of sugar excreted is six to ten ounces, but 
it may reach one to two kilograms or more. The percentage of sugar 
may reach ten to fifteen per cent. 

The sugar may vary considerably in different portions of urine, so 
that, in making quantitative tests, it is well to take the entire quantity 
passed in twenty-four hours. It increases in amount the greater the 
quantity of sugar and starch ingested. If the patients are pbc^ on an 
exclusively nitrogenous diet, the sugar in the unne disappears entirely in 
many cases, in others it persists in smaller amounts. The former cases 
are tne milder, the latter the graver ones from a prognostic standpoint. 
The latter generally develop out of the former, so that we are justified 
in speaking of a mild first stage and a severe second stage of the disease. 
Euelz found that there are mixed forms, t. e., the same patient will 
sometimes present the symptoms of the first stage, at other times those 
of the second stage. While fasting, the excretion of sugar ceases in many 
cases, but not in all. As a rule, muscular effort diminishes the excretion 
of sugar, in rarer cases it increases it. During febrile diseases, the sugar 
sometimes diminishes and even disappears, while mental excitement not 
infrequently produces marked increase. 

During the first stage of diabetes mellitus, sugar is sometimes entirely 
absent from certain portions of the urine. Even at a later period, there 
are sometimes marked differences between the daily and nocturnal urine, 
and the latter may contain merely a trace of sugar. If the diagnosis is 



DUtusBB OF HuntinoN. IX I 

bstfnl. the patient should be ailovred to partake freely of saccharina 
m furioaceoiiii food, aad the arine examiued two to four hours Uter. 

As a ru le, the excretion of sugar dependent on the food oeasea at the end 

of flix honrs. 

Before the examination tor sugar is made, the phTsical qualities of the urine 
(quantity, color, reaction, apeciflo gravity, odor) should be known. If tlia urine 
(.■outainH albumin, it should be boiled in a test'tube and a few drops of dilute aceiio 
acid udded to remove the albumin. The tests for sugar are then applied to the 
filtered urine. 

Moreover, if the urine is not clear, it must first be filtered before the tests for 
sugar are employed. 

Tlis meet convenient practical teat is Moore's or Heller's test. One fifth of the 
test-tube is filled with urine, about one-third caustic potash is added, and the . 
upper layers nre heated over a apirit lamp. Tlie heated pai'ls a;rt>w yellow, then 
reddish, finally browniuh-red and mahogony colored, The lignt yellow color is 
produced often in normal urine; the mahogony color alone 13 decisive to a cer- 
tain extent. If a drop of nitric acid is nddea to the boiling urine, it bubbles over 
and emits the odor of burnt sugar or niolaBsea, 

II positive results are obtaiaed. Tronimer's test should be applied, after the 
manner modified by Scilkowski. A test-tube is filled one-fifth full withurine.and 
about a third part o( officinal liquor potasHEe is added. A len-per-cent solution 
of sulphate of copper is then adOed, drop by drop. With each drop is farmed a 
light blue, cloudy deposit of hydrated oxide of copper, which at ant dissolves 
completely on shaking, and gives a beautiful deep Dlue color. The drops of acid 
are added until the hydrated oxideof copper no longer dissolves completely. The 
upi>fr lavers are then heated to boiling, and if sugar is present they will turn 
yellriwiah-red from the production ot suboxide of copper. This color will spread 
tlirou;^ h the fluid even if the tube is removed from the flame. A deposit of the 
suboxide, afl4'r prolonged boiling or on cooling of the boiled urine, is not proof of 
the presence of nugar. 

u the tests are not decisive, the urine may be filtered through animal charcoal. 
then diluted with two to four times the amount of water, and Trommer's test 
employed. 

Other t«ste may also be tried. The following is that suggesied by Boettger; the 
urine in a test-tuM ia mixed with an equal volume of a solution of sodium carbo- 
nate (1:8) and a little basic nitrate of nismuth added. After prolonged boitingi 
metallic bismuth will be deposited, if sugar is present, as a gray, then a block 
precipitate. 

lu doubtful cases, the fermentation test may be employed. In the presence of 
jeaat, grape sugar undergoes alcoholic feiiuentation, and ia split into carbouio 
'^KUd fucohd, with glycerin and succinic acid oa by-products : 

2CO, 



2C,H.O. 



(Mthyi alcohol) [carbonic acid) 

iDtoa fermentation tube(vlde Fig. 10)urineispoureduntil the long vertical arm 
ot the tubeia filled with urine. Shaking the tube and the formation of frotlt must 
be avoided, since, after sulficient urine has been added, it should comedirectly in 
contact with the top of the lung arm. Apieoeof compressed yeast as largeas a pea is 
then added, and finally the long arm i-i Meparaled from the bulb by the introduc- 
tion of mercury. If Mie apparatus ia put in a place which ia not too warm (not 
oTer thirty degrees), bubbles ot carbonic acid begin to form within a few hours, 
and rise to the top of the straight tube. The teet is onl^ decisive when we are 
sure that the veast iafree fromaugar. and to determine this point a similar experi- 
ment should be made with pure water. 

A somewhat more complicated fermentation apparatus is shown in Fig. 11. 
Into B ar(> placed thirty to fifty ccm. urine, to which yeast is added, and time or 
baryta water U placed in B', The carbonic acid developed in B' passes through 



the lube (' to B', where it prodi 
increasing cloudiness. 

The quantitative analysis of sugar in 
solution or the fermentation teet, but we 
s on urinary analysis. 



carbonate of hn 
thou 






show 



by 



^i^Bes 



7S 

It ii now geotif*^7 beliered that gnpe ngsr a not tlw onlj form <A 

ittgsr io diabetic urine. 

In A few ctat* it containa inodt, vhich doM not sffect the plane of 
pr>)ari nation, and does not ferment or radace an alkaline solntion of 
mt'uttt fit cnyfter. Vohl rei>orted a gsk in wliich the gnpe sagar was 
tCrffinHiWj replaced by inodt, so that the disbetn was conrertod into 
parit inMiituriA. 

In 'me case. Bdchardt found dextrin in the diabetic nzine. 

Thn iiflmi mar bIm oontaiii fruit BngarOaralcMB). 
M.birliMMon t(i tnn Ittft, and redacee the nlti of a 

(hit Wwm Miwller has shown thattbe ' 
AM rartstta irf sugar, but nerertbeleM p 



tbe[daae oC 




mple oxTbotTric add. Heaoe, tfae 
„,r.r,„..„ ,„,„.„„_,„ . urofen anievu" " " ' ' ■■ - 

ft/t'l'lif/tHll ItHWUlttaitM. 

'(f'fl iiiili'iiiMunti hu been attached to the eo^adled iron-chloride 
nf h'lif. uml 1" til" <)«m''riNtnition of acetone io tfae diabetic nrine. If 
f'rn' 'tih/tHh' lafiilHtfl utitii it aasnmea the color of Rhine wioe, and then 
hiri'-t 'h'ii> Uf liiiifi UiH tiiNt-tube half filled with arine, a dark cherry- 
fi.-f I,/ it'iniiiuA^ luiinr (s>M;alled ferric chloride reaction) appears not 
tiilr'i'i"i'^i "I 'llulfU'i iiririft, in addition to the floccalent cloodinesB 
i,ri'tiin'i i't Hi" li'iji'isit of ifliMKjihatefl. It should be diBtingoiahed from 
}(,■ u-Hi-hiiii lAimmtai nil ifldiriK ferric chloride to the urine of diabetics 
iif,-' iri't- tut"'!! iinU"y\i" n^i'i- In the latter event, the color is a violet 
hi !•', Mi'l M mil- \iMi»tmmit, 



^Hreeei 



DISEASES OF HCTKITIOIT, 

Wi Diabetic urine which gives the ferric chloride reaction generally has 
^ peculiar bout, aromatic odor, aoraewhat like that of chloroform or 
apples, and acetouo (and alcohol) has been discovered in the urine in 
such cases. It was very natural that a connection was eonght between 
the ferric chloride reaction and the acetone in the urine. This was sup- 
posed to be proven by Gerhardt and Geuther'a case, according to which 
the ferric chloride reaction is produced by tethjldiacetic acid, and which. 
nnder the action of alkalies and after the absorption of water, is decom- 
posed into acetone, alcohol, and carbonic acid: 

C.H„0. + H,0 := C.H.O -t- c.n.o -I- CO, 

fflthyldi acetic water acetone lethyl carbonic 

acid alcohol acid 

According to this view, the ferric chloride reaction is owing to the 
leence of eelhyldiacotic acid in the urine, and the apj^Ie odor to one of 
products of decomposition, viz., acetone. Since diabetics who pre- 
sented the reaction inqnestion sometimes diffused the odor of acetone in 
the expired air, and Fetters discovered acetone in the expired air of dia- 
betics, there was a tendency to attribute to acetonasmia (overloading of ■ 
the blood with acetone) those conditions of coma and grave impairment 
of the central nervous system (diabetic coma) tn which the patients not 
infrequently die more or less suddenly. In recent times, however, this 
theory has met with a good deal of opposition. 

In the first place, Fleischer showed that the chloride of iron reaction 
aometimes appears in diabetic urines which do not emit the odor of 
acetone, and also in others which do not contain sethyldiacetic acid. 
Hence it appears that this reaction, perhaps even in the majority of 
oases, ia not connected with sthyldiacetic acid. Furthermore, Deich- 
mueller and Tollens found acetone but no alcohol in one specimen of 
diabetic urine, thus controverting the opinion that acetone is produced by 
thu decomposition of lethyldiacetic acid. It appears probable, therefore, 
that in many co^es the ferric chloride reaction is the result of an 
abnormal fermentation of the sugar, for which Markofulkofif and 
Fleischer assume a special acetone ferment. 

With regard to acetonsemla, it must also be remembered that human 
Epsoan tolerate large doses of acetone, and the vie wis gaining ground 
diabetic coma ia the result of various conditions. 






The ferric chloride reaction and acetoDe in the urine are not alone not con- 
Stanlitidiab«tea iiiellitus, but have also beea observed in infeotiotia diseases, febrils 
oomlitiona in genernl, and cachexia. 

The ferric chlorido ri-actinn HoineCimes appears in diabetes mellitua or becomes 
T«ry marked when the patients are placen on a strictly meat diet. Ebatein 

erveU it increase on the occurreniw of typhoid (ever. It gometlmes continues 

days, andgrarlnHllj' subsides. If tbe urine is allowed to stand fot some time, 
reaction gradually grows weaker. 

In addition to sugar, acetone, and alcohol, diabetic urine sometimes 
JDtains albumin. Slight albuminuria {often transitory) is not unusual. 
■may be the result of cachexia, calculi in the urinarv passages, cystitis, 
_Jerhapa of an implication of that part of the floor of tKe fourth ventricle 
wiioae irritation, according to Bernard, produces albuminuria. True 
nephritis is rare. Frerichs observed it sixteen times among three hun- 
dred and sixteen oases of diabetes. In one of my patients who returned 
1 Garlsbod with the urine free from sugar, severe parenchymatous 




i 



'^ DIIXA8K8 OF HUTSmOH. 

rt^MtU dufubped at the end of a month, and proyed fatal in three 

iUiA^iiJj^l^ **"??*{f ^ ®/ ""^ ^^ ***« ^f^^® ^ increased. Eramioations in healthy 
MMNu!\u^i* "MllvMuAlii. living under the same external conditions, and with the 
!Ki*« .. l^^^ i^K\'^^ ^^*^ ^^« ^»^^»' produce more urea, i. e.. decompose more 
Mi!!!!i! !i : » *"** "•**y amount excreted sometimes exceeds five ounces. The 
X.iH/J'*. i**f?*i*'*** ■**«**• »«* "«^ directly connected with one another, and 
VuZlJf\\ ""* iworeaiitt and diminish simultaneously, nevertheless there are 
htmmuuH ujioeptlons to UiIn rule. 

.Ui.Im *^*****11'«<' <>f uric acjid la diminished; occasionally, a sediment of urates is 
ILiir A ' '**'"* "^^ ^^'♦^ '"^ diabetics who suffer from renal s^ravel and cal- 
iImi ill 7j *ul**'^*^*^ referable thereto grow less with the increasing severity of 

y*** •/♦***^ii»li» uiwy be slightly increased or diminished in amount. If fever 
' IK?' //*'* wrttH, urUi ai>id, and kreatinin increase as in non-diabetics. 
^M(K| nUiUm llmt i\w amount of hippuric acid is increased. 
HHIIiiVMrdttit Mui Leube noticed increased excretion of ammonia. 
. jT'*^**^ M*^ amount of chlorides is unchanged, that of the phosphates and sul- 
ju|f«|i^4 |4 UturtitiiH«d. The relation between the phosphates and urates varies. 
fp^lMlMi' (ihntsrvmt ottsua in which all the symptoms of diabetes mellitus (increased 
|»Mi»*»V'MMm«i', Inoroased urine, furunculosis) were present, with the exception of 
i(M^^^' *** ^H** urliiH, while the phosphates were considerably increased; in other 
^Hf****i Mi^ preMfiiioe of sugar alternated with increased excretion of phosphates 
CiiMJ^MttMtiti «ll»ilwteii). In one case, Fuerbringer noticed the alternation of sugar 
i^O\^}*^*i\Ui liuid III the urine. 

I Mti MKiirat loll of lime and alkalies in the urine is increased in diabetes. 
lUumy Mailinieiit U generally absent, but urates and oxalate of lime have been 
^ibti«<rvM| III a fHw oases. Renal casts are sometimes present in nephritic com- 
iitiM^Mfiim. Lbptothrix has been observed in freshly passed urine, if the urine 
U M.^M^wmi to the air and undergoes fermentation, it contains cloudy opacities 
v^liidi aru ooiuposed of yeast cells. 

Iiitjatirtl)le hunger and unquenchable thirst are among the most fre- 
ijuuiit BymptoruH of diabetes. In three of Fetters' cases, five to eight 
lUrod ttiiiil weiv drunk daily, and Dupuytren reports that one of his pa- 
tioiitB uto in aningle day an amount of meat which almost eonalled one- 
Miird tliH weight of his own body. The thirst is especially increased 
iiiiiiitidiutoly aftor tho ingestion of food, and also after eating sugar and 
iiturt:hy fiMul. Tho greater the amount of food and drink ingested the 
gi'uatur thu uiuouut of sugar excreted in the urine. 

Tliu liiortiaiitMl hunirer and thirst are not alone the result of increased nutritive 
uJiuHtfun, hiKi nU(» 4)( iilAturbanoes of innervation. In some cases of diabetes, how- 
uvur, lumger and thimt are not increased. 

Ilocipito tho oxoeaaivo ingestion of foo<l» the body steadily emaciates * 
tlu) lohgor tho dialH'tos lasts. The uanuiculus adiposus disappears, the 
lUiiHi.loH hoi'omo tluhby and wet^k. The patients are sometimes confined 
to llio hotl for \vookj» and mouths* on aocouut of exhaustion. They are 
riomoliiuo-i roduivd uhuivtt to skin and bones, while the face not infre- 
luoiiily roumiu!* unutiualty nnh a]mi>st hivtio. 

Thu tiKiu U gouomUvdrv and brittU\ and often ov^vered with thin, 
yruyibh-whilo doidoj* of epidermic LvHtoI mllor and diminished sensi- 
uilit V (li»oul vasi^ultu* sii^^m?) ar^> vxx^asioually noticeable. There is very 
litllo (ouilohoy to dii^moi^v^isH. but hootio sweats may occur if the disease 
id ooiupliimhnl with ailvauvHH) pulmonary phthisis.' The sweat may or 
i^HY not ooutau^ sugar. 

rhuvo U i^U\^\\ a touvlouoY X\> obstinate infiammations of the akiu 



( 



DISEASES O? SUTRTnOS: 

PtfaniTiculoBiB, eczema). Many complaia of obstioate prnritns, vhiob ' 
mterferea with sleep iiiid ie BometimeB one of the first symptoms of a 
latent diabetes mellitus. Wounds of the stein are apt to lead to gangrene, 
and operation wounds heal with difficulty and even become gangrenous. 
Very marked defluvium capillitii is often observed, and occasionally 
shedding of the nails. Spontaneous gangrene sometimes seta in in parts of 
the limbs. AH these trophic changes are attributed to overloading of 
the blood with sugar and other exorementitions products. 



Eocli mentions, as a con3tantHyii^>toiu, enlargement of the peripheral Ijrapba- 
-llanda, as the i-esult or irritation by the sugar-containing lympn. This ia i ~" 
kmed by my own experience. 



^^K It is said that diabetics sometimes pass a larger amount of arine tbac 

^^^B accounted for by the fluid ingested, and this has been explained by the 

^HEipiratinn of fluid from the atmosphere through the skin and respiratory 

^^F^iicous membrane. Such aspiration does not take place. It is true 

that, in a few cases, the amount of urine temporarily exceeds that of the 

Huid ingested, but this is explained by the withdrawal of waterfront 

the tissues. 



■unl 



The bodily temperatnre is not infrequently nnnsually low, and the 
.se is generally rapid. Attacks of dyapnoaa sometimes occur, either 
the result of disease of the heart muscle, or as one of the symptoms 
diabetic coma. CEdema may be expected after cachexia has developed. 
Psychical changes develop very often. The patients grow fretful, 
rose, hypochondriacal, and sometimes apathetic. Delirium and mania- 
oal attacks are occasionally observed. 

Rheumatoid muscular pains are not infrequent, and neuralgias, par- 
ticularly of the sciatic, also occur. In rare cases, articular pains with 
slight swelling are noticed. 

Some writers call attention to the frequent occurrence of central 
facial paralysis. Rosenstein and Uaschka noticed frequent absence ot 
the patellar tendon reflex. 

Among the organs of special sense, the eye is often affected. The 
best-known change is the development of cataract which is almost 
always bilateral, though it may be more marked in one eye. Certaio 
ooalar muscles are occasionally paralyzed. There may be diminution 
in the power of accommodation, and disturbances of refraction from 
changes in the length of the axis of the globe (often rapidly increasing 
hypermetropia from shortening of the axis). In three cases, Qa- 
lezowski observed keratitis attended with severe pain, although the 
sensibility of the cornea was lost. The vitreous body sometimes pre- 
i>i'nta hemorrhages and opacities. The retina may contain hemorrhages 
and white patches of degeneration, as in diseases of the heart and 
kidneys. This may be followed by atrophy of the disk. Among the 
rarer complications are iritis and mydriasis; amblyopia without ophthal- 
moscopic changes and hemianopsia are more frequent. The tears 
sometimes, though not constantly, contain sugar. 






1 question are attributed to nutiitive diaturbanoes 



76 * DISEASES OF NUTRITION. 

due to the excessive amount of su^r in the blood, and often in the secretioiis and 
excretions. This may produce disturbuices of function either directly or indi- 
rectly, by giving rise to hemorrhages. The cataract has been explained as the 
result of marasmus and withdrawal of water from the lens by surrounding 
sugar-containing media, but it also occurs in well-nourished diabetics and 
usually begins in the central portions which are farthest removed from the 
surrounding media. 

Impairing of hearing, ringing in the ears, diminished power of smell 
or taste are observed much less frequently. Sugar has been found in the 
cerumen of the ear. • 

Pulmonary lesions develop verv often in diabetics. Phthisical pro- 
cesses are more frequent, abscess formation is a rarer event. Pulmon- 
ary gangrene develops occasionally, but the sj)utum generalljr has very 
little or no gangrenous odor. Many of the patients die of phtmsis. The 
sputum may contain sugar. 

The pulmonary changes are probably the result of irritation of the tissues bj 
the bloocl which id overloaded wicli sugar and other excrementitious substances. 
As a rule, the sputum does not differ from that of ordinary phthisis, except that 
it does not constantly contain tubercle bacilli. 

In a case in which the patient suffered from oxaluria, Fuerbringer observed 
oxaloptysis, and later aspergillus developed in the phthisical foci (pneumo* 
nomycosis aspergillus). 

The expired air sometimes has a sour, apple-like odor, resulting from 
the presence of acetone. At the same time tne urine generally emits the 
same odor, and furnishes the ferric chloride reaction. 

The circulatory organs are often unaffected for a lon^ time. Leyden 
has observed cardiac asthma, and Lecorch6 assumes a diabetic endocar- 
ditis. In two of my cases, the blood had an unusually bright red color. 
The serum may have a cloudy, milky color, from the presence of the 
finest drops of fat (lipjemia). its proportion of water may be increased 
or diminished. Bock and Hoffmann found that it contained 0.3 to 0.355^ 
sugar (normally 0.04 to 0.1^). Petters andBurseri found acetone in the 
blood. 

The majority of patients complain of dryness in the mouth, stickiness 
of the tongue, and a feeling of constriction in the gullet. The buccal 
mucous membrane is often dry and sticky to the feel. 

The patients also complain frequently of a dry, sour, sometimes 
sweetish taste. The reaction of the saliva is often acid (lactic acid 
fermentation of the sugar). This probably explains the rapid caries 
of the teeth and their loosening. Swelling and bleeding of the gums 
have been described. The saliva does not always contain sugar. In 
the later stages of the disease, sprue develops in the mouth, partly on 
account of increasing marasmus, partly because the sugar in the salira 
favors the development of fungi. 

The stomach rarely presents functional or other disturbances. 
According to some writers, the gastric juice contains sugar; others have 
not confirmed this statement. The liver is sometimes enlarged and 
tender on pressure. 

The bowels are usually constipated, the faeces are hard and dry, and 
may contain sugar. In one case I found fat in the stools (stearrnoea). 

Many patients complain of dysuria, and sometimes of painful 
sensations in the region of the kidneys. It is also said that a sensation 
is sometimes experienced as if cold drops were falling into the bladder* 



DKEASXS or RnTBFIUHr. 

Nbctarnal enearesie is frequent in childreii. Erosions and papillary 
'■eiereacences are observcfl in not a few cases near the nrethra, Male 
patients otten suffer from inOammatory phimosis. Masses of leptothris* 
occasionally accumalate in the prfflputial sac. 

DiHturbimcos of the sexual apparatus are very common symptomB. 
At the outset of the disease, I have repeatedly observed nnoatural ia- 
crease of sexual desire in men. But gradually desire is lost, the leeti- 
cles become small and flaccid, and complete impotence results. 



In Buzzard'a patient, thi^ ei 



□ contained a few n 



iticnless apermaUiEoa. 



Lesions of the external genitalia are frequent in females. In soma 
cases, we find redness and swelling of the labia, with the formation of 
white plaques which are composed of fungus threads, and are evidently 
the result of the contact with the saccharine urine. In others, furun- 
culosis of the labia sets in. Phlegmonons processes are especially 
dangerous on account of their tendency to spread, so that they some- 
times extend from the mons veneris to the sacrum and nates. These 
conditions are the result of nutritive disturbances. Many women suffer 
from annoying pruritus vaginse. According to my experience, this is 
almost always associated with the development of fungi. 

IbtucI observed Hpontaneoua necrosis ot the ovarjr. and, in another case, of the 
paacTBaa. Hofmeier Btat«e that atrophy of the ovaries is a not infrequent cause 
of sterility in diabetica. According to Duncan, pregnancy in diabetics is often 
interrupted by abortion and deatli of the foetus. 

Emaciation generally occurs; but at the beginning of the disease 
many patients are well- dou ri shed and even obese. 

'the average duration of the disease is one to three years. In some 
cases, death takes place in a few weeks (acute diabetes); in others, the 
affection has lasted nearly twenty years. As a general thing, it runs a 
more rapid and dangerous course in children. 

Cancer, articular rheumatism, and, according to some, valvular dis- 
eases of the heart are said to be rare in diabetics. 

Death occurs in many cases from the increasing marasmus, often aa 
sscqnelof pulmonary phthisis. The marasmus is accelerated occasionally 
by cutaneous gangrene following accidental wounds. Death may be 
the rtsult of cerebral hemorrhage which, according to some writers, is 
not infrequent in diabetics. In rarer cases, nephritis and anffimic symp- 
toms terminate the scone. This should not be mistaken for diabetic coma, 
which may assume various forms. In some cases, there is quite sudden 
tmconsciousness, feebleness of the pulse, increasing collapse, and death. 
Iq others, there is increasing weaunees, followed by hea<lache. restless- 
ness, delirium, maniacal attacks, a feeling of anxiety, difficulty ot 
breathing, increasing cyanosis, feebleness of the pulse, sinking of the 
bodily temperature, coma, and death. The expired air of such patients 
often diffuses an intense acetone odor. This condition may last one to 
five days before death ensues. Finally, cases are observed in which the 
patients complain of increasing headache, the gait becomes staggering, 
and then somnolence, increasing coma, and death ensue. In these cases, 
likewise, there is generally an odor of acetone in the expired air, and the 
nrine gives the ferric chloride reaction. Such conditions may develop 
in patients whose diabetes had been unrecognized. They have been ot 

'ed in several cases in which a strict meat diet was suddenly inauga- 



^^|»ed 



• ni8BA8li8 OF KTrXIII JX. 

.lU.i. They lire Husceptible of rec/^-rar 4iZi:c^ fatal relapses often 



Until rcHvntlv xh^- '^t-k-'rvrn^ ^rcw- Ktnbaceii co aceccnsmia. but this is 

riMKii'rtHl verv rfv>ii>Hf r. '-t. -»' ^*-' "«»fc maisui beings tolerate considerable 

1 MtM of rt».VK*T^- '^.-t>j^ -«. ; fti'***'*"* "^ "jH^iiuotHl bv Other TzzJknown excre- 

inenl'*n^*> TV"-*"^ • '- '•' '^•"•*' ' '**• >^'^neiy been held that diabetic coma 



; -^J .vi'l-" - ■ ->«.•«», ^■•- • -o*iia>.i auy •fcnbolism of the palmonanr and 



.. ^.. .•.i>^ ■• Ts«.i«. ik»» Hiuiie cades are the result of weakness of 



■ • > 



'i. 



.1. I • • • 



» • * 



iiIlM ■ 



•'.. ■.-;>. The lesion? found in autopsies on 
.,.- •«.». %i.-Miaenril and secondary. If tumors, 
. -< v:"&i< ire f*mri'i on the fl«x)r of the fourth 
^.>.'*vu ta* iirecc t.-aiises of the disease. 
v..4..*t'iKv :o rupiJ 'ie^.'ompijsition. Furuncles, 
. «. :\>.:if orteu "?een up«:»n :ne intesmmeiit. 
.. . -..v. !:K«jn.i. or :hcy have a deep br»3wn color. 
•».... !i any :r:4iL5U'ia:i'.n3 or exudations which 

. ^rtis^'f liOLi-i pr»xes.*es may t-e noticeable in 
. . .t^i fc -itiliiUiT .:ei:r»rt: o: endiirteriiic changes in 

. *vi. a;.v>::*'o:" j.v.vzr:: in the heart: thev are 
» . ^ m:v:^c5 :.' :::■: naiei eye. 

•\.i..v:i:ly iila:c\i. ::? walls thickened, and the 

. V >••■*'*• v.\i!:a'..: .:Tjcrl":^.: i'.z:z[--j of the peptic 

V ..,^ .> .::v*'. ,' •: : :.1t :c:r :i aceione. The mes- 



. .;»*o v^xvi«^.*!:tfsiL :»4l .•■va=j??? <.=iil3r :j? ih'.-«e of Asiatic 



Hf ^ -j:>:1-Z:h: :o Mivx^wee these 



I .. .. V- -. ■ .v".>.v . -. .::*i::."i .: :i:7r!?:i::a* oon- 
■. .V ,^.>.-. . *i.:j: ?<:o>.-Iirv :;?:::i de*enera- 

.. •., ,iv:. -' '■* •■•,- :::.". ;x!:::,:i fzlargement, 
...... •■ , -^ •.. ?<i/.:. ■.•_.:c:-s::::j.1 hcnior- 



..u.v. K-.i.A.'i ^■>-A'<^:! -riAiiy *«."u?« i:^rr i-r-a:!:: ids sub- 

» \v .\» N *. "k at- .■»•».■ i-^ :c -..i^ s:i'zi. Iz. n:y own 

vx ?« ^^ -X'^ ■•.»•... I. • ^r-5t :r;v-: .vc.-r cr. the 

; . . .. ....... xO-xf >i'»\ .•*.- . V •'•.■ie-sc-.* •:;i:z:5 :o hare 

.:«...,• .. ..u .*...>. Vjv v.:iv.u^j: c£" ia- -^ tie liver is 



< > 



■ ■ ■ ■ 

» • -.Ax, . V ■?. ..■ -> ■'.■..:: ."Ti';-: ci l-r uri- 



« . \ . •. 









^V DISEASES OF* miTBrnoiT. 7M 

^H(ted mto transparent vesicles with well stained nuclei); Bbsteia also nottoeCl 

^^Mches orepitheiinl necroda in the cortex. Frerichs observed glycogenic degetl^ 

«r(ition of tho rensl epithelium, and coruiders it identical with hyaline degenerwfl 

tioD. These lesions are perhaps associated with diabetic coma. I 

The lesions observed in the central nervouB system are meningeal I 
thickenings, adhesions, and hemorrhagee. Thickenings of the ependj-nia 
of the ventricles are also mentioned. Dilatation of the bloofl-vesaels, 
atrophy or pigmentation of the ganglion cells, proliferation of the inter- 
Btitial connective tissue have also been described, but these lesiona are ■ 
accidental, or unimportant. m 

The sympathetic may be iataot or its ganglia, particularly in thtfl 
-solar plexus, may exhibit proliferation of the interstitial connective ti»>9 
sue, pigment degeneration and atrophy of the ganglion cells, and dilata-l 
tion of the vessels. ■ 

Inaseriesof cases, there is no doubt that diabetes mellituB is the result of dit. I 
turhances of cerebral innervation, the starting-point being found in tlie floor oCV 
the fourth ventricle. It may also be regarded as certain that the liver ia concerned ■ 
in tbe formation of suear, and that the sympathetic forms tbe connecting linkfl 
between the medulla oblongata and the liver. Hence, diseases of the central ner-^ 
vous system which are associated with vaso-motordisturbancesin the hepatic cir- ' 
culalion may result in diabetes niellitua. But why the blood becomes overloaded 
with sugar ia uot settled with certainty. 

The function of the liver cells may be impaired to such an extent that they are 
unable to convert completely into glycogen the sugar which is conveyed to ihem 
frnm the food through the portal vein; heacs the excess of sugar paraea into the 
hepatic vein and thus into the genera) circulatiou. Or there may possibly be 
complete conversion of the sugar derived from the fowl into glycogen, but the 
hepatic cells supply the blooa with an uuusual amount of glycogen and thus of 
sugar. Or perhaps both processes are combined. 

Similar conditions are to be expected if the nervous system ia affected, not ia J 
-the medulla oblon^ta, but in the eympathetlo. M 

Nor is it lmpo3i»ble (hat some cases of diabetes melMtus develop in a reflOK.1 
manner, for example, in peripheral neuralgias. 1 

In addition, tliere ia also a gastro -hepatic form of diabetes mellitus. Clinical 
experience teadies that the excessive ingestion of sugar and starchy food may 
give rise to diabetes, either because the liver cannot convert itij entire supply of 
sugar into glycogen, or because the hepatic cells, which are overcharged with 
elycogen, furnish an excess of sugar to the hepatic veins. The symptoms of dia- 
. betes are preceded not infrequently by those of gastro-inteatinal catarrh, so that 
the disease has been attributed to abnormal processes of decomposition and ab- 
sorption in the gnstro-iritestinal tract and the portal circulation. Diabetes melli- 
tus soraetimea follows diseases of the portal vein or liver itself. 

In some oases the source of the sugar lias been sought iu the muscles. There 
-is DO doubt that the muscles form glycogen and sugar, and that in rare cases 
muscular excretion increases the amount of sugar in the urine in diabetics. 

IV. DiAONOHia. — A suspicion of diabetes mellitua is often aroused 
by prominent symptoms. As the sulphate of copper in Troinraer's test 
JB also reduced by uric acid, kreatinin, or pyrocatechin, various teats, 
especially the fermentation test, should be made. 

In intermittent diabetes, only certain portions of urine contain sugar, 
80 that, if the symptoms of diabetes are present, bnt sugar is absent from 1 
the nrino, it is well to allow the patient to take a liearty meal of swee' 
farinaceous articles, and to examine the urine two to four hours later. 

In mild cases, the sugar disappears on purely auimal diet ; in severe 
CMOS, it merely diminishes. 




Hoffmann report a case in which an hysterical woman introduced j 



DISHIASES OF NCTBinOM. 

sagai into the urine and then injected it into the bladder, in order to deceive her 
physicians. 

V. Pkookosis, — The prognosis ie ftlwaja grave, and many authors 
believe that permanent recovery never takea place. 

As a general thing, the prognosis is worse in children than in adulte, 
since in the former the disease runs a more rapid and pernicious course. 

Advanced emaciation and phthisical changes in the lungs render the 
prognosis very grave. 

Finally, a more serious prognosis attaches to cases in whose etiology 
heredityplays a part. 

VI. Teeatment. — Individuals in whose families obesity, gout, or 
diabetes is hereditary, should avoid sugar and starchy food, and main- 
tain a diet similar to that prescribed in cases of obesity. 

After diabetes has developed, strict dietetic rules should be made 
from the beginning, since they are more important than theadmiuistra- 
tiou of drugs. We should endeavor to give the patient ae much animal 
food, especially meat, as possible. A certain amount of variety in the 
diet IB secured by allowing the patient to take all kinds of fats, although 
this increaaee, to a very slight extent, the excretion of sugar. Vegeta- 
bles may also be allowed, but, as a matter of course, only those which 
contain the smallest amount of sugar and hydrocarbons. As drinks wo 
may recommend carbonated or alkaline waters (Sclters, Apollinarig, 
Vichy, Giesshuebel, etc.), or lemonade made with lactic acid (Aq. destil., 
5 vij. ; Acid, lactic, gr. vij.;Natriibicarbonio.,gr. vij., after each meal). 
Beer, alcohol, sweet wines, and champagne should be avoided ; red wines 
are more serviceable. Ordinary bread should be replaced by gluten 
bread. Diabetic coma has been known to occur when the patient was sud- 
denly placed on strictly animal diet, so that it is well to begin gradually. 

The following ia a table of the articles of diet allowed and inter- 
dicted: 



. .._ _^ _ ^.. , :, apinach, 

green tips o( aaparagua, kotirabi, lieans, white cabltago). Lettuce, endive, horae- 
radiBb. water cresses, almonds, nuts, gluten bread, alkaline waters, red wine, 
white wine, lemonade (with lemons or lactic acid) without sugar, tea, coffee. 

Articles of food interdicted : sugar, honey, flour, ordinary bread, farinoceom 
articles, rice, sago, arrow root, potatoes, maccaroni, oatmeal or barley, milk, 
whey, chocolate, beer, sweet wines, champagne, alcohol, liquors, sweet or pre- 
served (ruite, turaips, onions, radishes, celery, rhubarb, cucumbers, chestnuts. 

If the sugar has disappeared for a considerable period, or is present 
in trifling amounts, one or the other interdicted articles may be allowed 
for a time. But this may only be done if it does not give rise to an 
increase in the amount of sugar excreted. 

Great importance should be attached to the care of the skin, and the 
patients should take lukewarm baths several times a day. They should 
take exercise in the open air, even gymnastics, riding, or mountam tours, 
if excess ia avoided. A trip to the mountains in the summer, and to an 
uniformly warm climate in the winter ia very serviceable, and in some 
cases is followed by considerable diminution or even disappearance of 
the sugar in the nrine. 



PIBEABES OF NTTTBITION. 81 

The most important medicinal agents are opium, arsenic, salicylio 
acid, and carbolic acid, but they are useless without anti-diabetic diet. 

It is a peculiar fact that diabetics tolerate large doses of opium for a 
long time without suffering from symptoms of poisoning. Even thirty 
grains a day have been administered. Morphine has a similar favorable 
effect, but no certain results are obtaiued from other narcotics (narceine, 
narcotine, potassium bromide, strychnine, belladonna, chloral, cannabis 
indica). 

The reports concerning the action of arsenic are less favorable than 
those concerning that of opium. 

Carbolic acid and salicylic acid have been recommended by Ebstein and 
Mueller, the former drug in solution with peppermint water (gr. xv. [\\ 
: i V. ; 3 i. every two hours), the latter in the form of powder (gr. vij. every 
hour or two until tinnitus aurium is produced). We must experiment 
with these remedies, since different patients react differently. 

A host of other remedies have been employed, but it will suffice to mention 
the following: a. Alkalies (especially carbonate and bicarbonate of soda) have 
very little or no effect, b. Preparations of ammonia (carbonate, chlorate, acetate). 
Adamkiewiez recently recommended the acetate very highly. In two of my 
patients who were treated with carbonate of ammonia, the sugar in the urine dis* 
appeared very rapidly, but the pulmonary changes advanced to a speedy fatal 
termination, c. Iodine, iron, qumine. d. Creasote, thymol, benzoic acid, iodo- 
form, e. Glycerin. /. Pilocarpine, g, Qall and biliary salts, h. Beer yeast, 
diastase, i. Diuretics, drastics, astringents, ergotin. k. (Galvanization of the 
cervical sympathetic and medulla oblongata. 

A course of treatment at Carlsbad often causes rapid disappearance of 
the sugar in the urine, but this is probably owing, in great party to the 
strict diet. The sugar generally returns after the strictness of the diet is 
relaxed. 

Donkin recommended a strict milk diet, and Duhring claims to have 
cured (!) a number of cases by the following plan : Three to four meals 
daily, consisting of | iii. to iv. p. d. of rice, hominy, barley groats, or buck- 
wheat grits, 3 viij. of smoked or broiled meat, stewed dried apples, 
plums, or cherries, coffee and milk with wheat bread, and red wine and 
water after meals. 

The various complications of the disease require symptomatic treat- 
ment. In diabetic coma, stimulants should be given. Surgical opera- 
tions must be avoided as much as possible. 

Appended 

Mellituria (glycosuria) is the term applied to the temporary excretion of sugar 
in the urine. It is merely a symptom of various conditions nnd rarely requires 
special treatment. It has been ooserved under the following circumstances : 

a. Excessive ingestion of sugar and farinaceous food. 

b. Functional and organic diseases of the nervous system, viz., cerebral hemor- 
rhage, epilepsy, acute delirium, melancholia, general paralysis of the insane, 
sciatica and other neuralgias, violeiit mental excitement, cerebral concussion, 
and meningitis. 

c. Disturbances in the pulmonary interchange of gases (?). 

d. Cirrhosis of the liver and portal occlusion, especially after the ingestion of 
sugar and farinaceous foods, probably because the sugar which has been absorbed 
passes directly into the general circulation without being converted into glyco- 
gen. 

e. Convalescence from infectious diseases (cholera, variola, pneumonia, mala- 
ria, erysipelas, phlegmonous inflammations, etc.). 

/. After poisoning with carbonic oxide and illuminating gas, glycosuria if 
6 



I 



DISEASES OF jniTBITION. 

>8 OuseTTed tor several hour?. Whether the reducing substance found in 
lilt; urine utter opium nnd ciiloi-al poisoning is really sugar requirea further inves- 
tigation. The redui-ing eub^Cunce found in the urine after nitrobenzol poisoning 
is ijot sugar. AraenLc poiEoning and pruBaic-acid poisoning produce true glyco- 
suria with increased thirst and increased amount of urine. 

g. Sugar is found in thu urine of puerperal women, eapeciallv if Ifaev do not 
nuri^, and in that of infants. HoHmeister and Kaltenboob showed that milk 
BUgar is found in BUi:li cases [lactoBuria), 

h. According to Liveing, glycosuria is not very rare in chronic ecKema. 

i. Diabetes Insipidus. 

I. Etiology. — Diabetes insipidus is an independent disease whose 
chief Bvmptoms are increased excretion of urine (polyuria) and increased 
thirst (pDlydipsia), the latter being secondary to the former. 

The disease is rarer than diabetes mellitus, and affects men two or 
three times as often as women. 

Miildle life (fifteen to forty-five yearsj la attacked most frequently. 
Kuelz recently collected thirty-five coses in children; two of these cases 
began in the first year of life. 

The disease is sometimes hereditary, being observed in several chil- 
dred of one family, or in several generations. Diabetes mellitus and 
diabetes insipidus may also occur in different members of the same fam- 
ily. The disease appears occasionally in families which are also affected 
by insanity and nervous diseases. 

It is produced not infrequently by diseases of the nervous system, 
such as concussion of the nervous system, penetrating wounds of the 
skull, inflammations of the meninges, hemorrhage, inflammation, soft- 
ening, and tumors of the central norvotis system, hydrocephalus, chronio 
diseases of the spinal cord, and neuroses (hysteria, Basedow's disease, 
chorea, epilepsy). Diabetes insipidus may be looked for with so much 
more certainty the more tiie floor of the fourth vefltriole has beeo 
affected, 

Bernard showed that injury to the floor of the fourth ventricle, above the rite 
whose irritation causes diabxtes, will give rise to increased excretion of urine. 
Acoordiitc to later experimunters, irritition of adjacent parta produces the same 
effect. Polyuria is produced in rabbits by irritation of the vermis of the cerebel- 
lum, in dogH by section of the splanchnic nerves; also after section of the spinal 
DOrd below the twelfth vertebra. 

Diabetes insipidus is sometimes attributed to mental and bodily 
strain, triKht, insolation, cold, exposure to wet, and taking cold drinlfs 
when the Dody is heated, but such statementsare not always well founded. 

It sometimes follows infectious diseases (intermittent fever, diph- 
theria, scarlatina). When observed in syphilis, it is generally the result 
of softening or gumma of the central nervous system. 

II. SVMPTOMa. — The symptomsaometimesdevelopwithinafew hours 
after the action of the etiological factor. In other cases, they develop 
80 gradually that it is difficult to determine the onset of the disease. 

The most constant symptom is the increased excretion of urine, and 
two to five times the normal amount may he passed. Trousseau reports 
a case in which forty-three litres were passed daily. The patients are 
compelled to micturate frequently at night. The smaller the capacity of 
the bladder the more frequently is the urine voided, and the smaller the 
jquantity discharged at one time. The urine is light-yellow, sometimes 



J 



DISEASES 07 NCTKniON. B8 

almost OS clear as water, has an acid reaction, but readily becomes neu- 
tral or alkaline after etaniling, and has a low specific gravity {1005-1008, 
occasionally even 1001 or 1000.5). 

As a rule, the solid constituents in the entire daily amount of urine 
are increased. 

The amount of area is generally increaaed: Senator has fonnd as 
much as two and one-half ounces per diem. In a doubtful case, re- ' 
ported by HofFoiann, the uric acid was replaced by hippiiric acid. Ao- 
cording to Senator, the excretion of kreatmin ia unchanged. The plioa- . 
phates, chlorides, and sulphates are generally increased. These changes 
are explained, in great measure, by the copious supply of water to the 
tissues, as the result of the increased thirst. To this is probably owing 
the fact that inosit has been found in the urine in a number of cases. 
Strauss showed that this also appeared in then riue of healthy individuals 
after copious draughts of water. Temporary glycosuria may occur; al- 
buminuria is rare. 

. An increased feeling of thirst is a constant symptom. The greater 
the thirst the greater the amount of urine excreted, though these two 
factors do not correspond entirely at all times. For a abort time, the 
amount of arloe may exceed the amount of fluid ingested, as the result 
of withdrawal of water from the tissues. If healthy and diabetic in- 
dividuals drink equal amounts of fluid, the amount of unno Is Increased 
more rapidly In tiie former, but persists In the latter for a longer time, 
inasmuch as the excretion of urino occurs more uniformly. 

The increased feeling of thirst prodnces a sensation of dryness 
and stickiness in the mouth and throat, and occasionally a feeling of , 
constriction in the pharynx. Children sometimea drink theirown urine 
or any otbor fluid which falls into their hands. 

That polydipsia islhereflnlt of polyuria ia evident from the fsct that tlie latter 
contiiiues after the patienta are depriveii of fluids. Id very rare cases, however, 
tliere appearn to developapriniary polydipsia with secondary diatietes. Notb- 
DBgi-l re<*?iitly reported the fullowinj; cnse: A mason, set. RS yeurs, fell on the 
Invk of lilt head; ud consciousness; half-hour later, intolerable thirst; two and a 
bal' to three liouni later, permanently increased excr<>ti(in cf urine. In primary 
potydiptiia. the amount of urine must diminish very rapidly and become sub- 
normal if tl 



nnch 
grow 



k 



if the ]>ati^ntB ore deprived of tlnids. 

The insensible perspiration Is usually diminished, but occasionally 
nnchanged. The skin is very dry and bnttlo. Some patients complain 
of partesthcslse and pruritus; furunculosis is rare, llyperhidrosis and 
**' vation have been observed in exceptional cases. 

The bodily tomperaturc may be abnormally low, and the patlenti 
grow cold very quickly, owing to the fact that a large amount of heat ia 
given ofl in order to warm the large amounts of fluid Ingested. 

If the dise;iso develops in early childhood, the bodily development ia 
often very much retarded. In other cases, general nutrition is very ' 
little impaired. The appetite ia more frequently diminished than in- 
creased. There Is sometimes a desire for peculiar articles of diet. Gas- 
tric pressure, flatulence, eructations, and intestinal disturbances are not 
uncommon. 

Nervous symptoms (pressure In the head, vertigo, depression, etc.) 
occasionally develop. Paralysis of cerebral nerves sometimes occurs, 
with relative frequency in the abducons. 

The following ocular changes have been observed: retinal hemor- 



^ 

^ 
^ 



84 DIBSAASS OF mTTttmoN. 

rhages, Benroretinitia with fatty degeneration as in Bright'a disease, 
atrophy of the optic nerve, hemianopsia, and amblyopia; cataract does 
not develop. 

The disease may last many years (fifty years in Willis' case). Ra- 
mJBsionB and exacerbations are not infrequent; the latter occur par- 
ticularly after emotional excitement. The symptoms sometimes dis- 
appear during intercurrent diseases, but return at a later period. Dia- 
betes insipidus occasionally appears at the beginning or end of diabetes 
- mellitus. Death is the result of intercurrent diseases, increasing maras- 
mus, or the advance of the primary disease. 

III. Anatomical diANOES-^There are no specific anatomical 
changes in this disease. Connective-tissue proliferation and degenera^ 
tion of the solar plexus have been found. The kidneys are sometimes 
enlarged and contain an imiiBuiil amount of blood; Neuffer noticed dila- 
tation of the urinary tubules and fatty degeneration of the epithelium. 

The nature of the disease is unknowD, but the sy mptoma are probablj the 
result of VHGO-motor disturbnitces in tlie renal (^irculation. iu the production of 
whicb tbe sympathetic renal fibres play the chief part. 

IV. Diagnosis. — The diagnosis is made from the increased excre- 
tion of nrine of low specific gravity, and the increased feeling of 
thirst. Tlie following conditions must be taken into consideration in 
differential diagnosis : 

a. In diabetes mellitus, the specific gravity of the nrine is increased, 
and sugar is present. 

b. Cirrhosis of the kidneys causes increased thirst and increase in 
the amount of urine with diminished specific gravity, but albuminuria 
and left ventricular hypertrophy are also present. 

c. Primary polydipsia with secondary polyuria is distinguished by 
the effect of the willidrawal of fluids upon the amount of urine. 

d. Transitory and symptomatic polyuria is only of short duration. 

Transitory polyuria is observed unJer the following conditions : after the on- 
eet of cerebral apoploxy, after menial strain in hysteria, and during coiivalcs- 
oence from nevere infectious dieeiLBes, especially typhoid fever. 1 iibaerved it 
twice after the ad ininisi ration of digitalis, once after salicylic acid. In some in- 
dividuals (especially femakK) it occurs after coitua. It is also observed fre- 
quently in diseases of the urinary passages. 

V. Peoqnosis. — Permanent recoverv from diabetes insipidus occnrs 
only in exceptional cases, but life is ohen maintained for a long time. 
The prognosis is so much more serious the more rapid the emaciation 
and the more grave the primary disease. 

VI. Trb.itment. — Causal indications must first be met. In a pa- 
tient set. e yoars, in whom the disease was associated with syphilia, 
Demme obtained successful results by means of the inunction treatment. 
If there is marked amemia, I have obtained great benefit from iron pre- 

farations, notably tlnct. ferri acetic, and tinct. fcrri chlorat. aither. 
3 i. three or four times a day). 
If there are no causal indications, we would recommend the adminis- 
tration of opiumand lead in combination (Plumb. acet.,gr. J ; Opii puri, 
E, sa. ; Sacch. alb,, gr, vij., one powder every three hours). As in dia- 
tes mellitus, very large doses of opium often are tolerated. The 
thirst may be quenched with acid drinks ; the patients should wear thin 
flannel to aroid catching cold. 



J 



^^P DIBEAABB OF ITCTBITION. 85 

^V The other remedies employed include the following : a. Vslerian, 
^fetassitim bromide, ergotiu, arsenic, belladoDna, digitalis, caetorenm, 
aeafiptidA. b. Jaborandi and pilocarptn. c. Oreaaote, carbolic acid, 
eodinm salicylate, d. Tannio, turpentine, copaiba, potassium iodide, 
calomel, nitric a^id. e. Constant galvanic current to the tipinal cord 
and renal region, also to the medulla oblongata, cervical cord, pneumor I 
gastric, and Bjmpathetic. | 

5. Rickets. Rachitis. 

I, EnoLOQi. — The nutritive changea which lie at the bottom of ra- 
chitis are manifested chiefly by abnormalitiea in the growth of the 
bones. Proliferation of the cartilaginous and periosteal portions, with 
imperfect and irregular calcification, produces deformities of the bones 
which arc such a prominent part of the clinical history that we might 
almost be temptea to consider the disease a purely local' affection of the 
bones. 

Rickets occurs most frequently between the ages of seven to thirty 
months, is rare beyond the third year, and hardly ever occurs beyond 
the age of live years. 

^r^ In H number of cases, the bone ohanees develop in utero (fiBtal rachitiB). Bat 
Vit is not cert»m that these changes are nisto logically identical with the rachilia 

Tlie term congenital rachitis is applied to those cases in which the disease 
appears \elj soon after birth. 

Some authors nesume the existence of rachitis tarda, in which the diseaae 
develops durioK the period of puberty, but this asaumptioa is still unproven. 

The disease is more common among the children of the poorer | 
classes. I 

It is an extremely frequent disease of childhood. According to Rit- 1 
ter T. EitterHhain, about thirty per cent of the children brought to the 
Prague Policlinic presented evidences of rachitis. 

It is generally the result of the combination of a number of causes. 
Hereditary agencies are often at fault. Rachitic children are often 
bom of parents who suffer from phthisis or tho late stages of syphilia 
or exhausting diseases in general. Children born when the parents 
have attained an advanced age are attacked not infrequently with rick- 
ets. Rapid succession of chiidreu, or nursing by a pregnant mother, 
or excessive lactation also favors its outbreak. Whether rachitis as 
such is hereditary has not been proven with certainty. It has alao 
been asserted that anssmia of the mother favors the development of 
the 'lisease. 

In many cases, tho disposition to rachitis seems to be acquired, for 
example, as the result of improper nourishment. The disease very often 
attacks children who are fed with cow's or goat's milk, condensed milk, 



infant foods, or a diet which is rich tn vegetables. It is more apt to de- 
velop if the patients, in addition, live in overcrowded, dark, damp 
rooms. The exciting cause is sometimea furnished by intercurrent 



I 



diseases. 

The disease is extremely frequent in England, Holland, France, and 
Oermntiy, while it is extremely ra."^ in the tropics. It is said not to de- 
Totop bfvond the height of 3,000 feet above the sea level. 

n. ^TMPTOUS.—In iiome cases, rachitis begins without special pro- 



86 DISEASES OF NITTBITIOK. 

dromata. Children who had learned to walk tire very easily, then cease 
to walk, and present deformities of the limbs. Or disturbances are ob- 
served in the outbreak of the teeth. The children attain the age of two 
years before a tooth appears, or the eruption of the teeth is irregular, or 
dentition ceases. Finally, deformities of the skull or spinal curvatures 
may be noticed. In other cases, the disease is preceded by pro- 
dromata, consisting of obstinate disturbances of gastro-intestinal diges- 
tion. The appetite is disturbed (generally anorexia, more rarely bouli- 
mia), the tongue is almost always coated, there is a sour smell from the 
mouth, eructations and vomiting are frequent, the abdomen is tympa- 
nitic, and there is obstinate and generally loul-smelling diarrhoaa.* Gen- 
eral nutrition is also impaired. The face grows pale, the muscles flabby, 
the panniculus adiposus emaciates, and sinuous veins appear beneath the 
skin. After these symptoms have lasted for a longer or shorter time, the 
characteristic changes in the bones make their appearance. 

The entire skeleton is generally affected, the changes beginning often 
in the skull, and then extending to the trunk and limbs. More 'rarely 
the process begins in the lower limbs and extends upwards, and the skull 
is then relatively unaffected. This is most apt to happen if the disease 
begins after the fifteenth to eighteenth month. The rachitic changes are 
often developed with striking similarity in corresponding parts of the 
body. 

Bachitis of the skull is characterized by the peculiar" shape of the 
head (vide Fig. 12). While the skull appears to nave increased consid- 
erably in size, the face appears very much smaller. 'J'he long diameter 
of the head is often increased (dolichocephaly). The occipital bone is 
flattened, the frontal and parietal eminences are unusually prominent as 
the result of subperiosteal proliferations. 

The frontal bone passes straight upwards, the parietal bones project 
outwards. On transverse section the skull is almost quadrilateral. But 
the increase in the size of the skull is only apparent, and in reality the 
skull is smaller than normal if compared with that of healthy children 
of the same age. 

Another important symptom is the patency of the fontanelles and 
often of the sutures, and elevations along the edges of the bones. The 
large fontanelle, which should be ossified by the middle of the second 
year, remains soft and compressible. It is sometimes increased in size, 
extending anteriorly to the middle of the frontal bone, posteriorly to 
that of the parietal bones, and laterally to the frontal eminences. Its 
four sides are bounded by convex, prominent edges of bone. From this 
fontanelle we may occasionally trace all the sutures, which also appear 
broadened; the adjacent edges of bones are elevated like a wall. 

In severe cases, craniotabes is usually noticeable. The occiput, par- 
ticularly near the lambdoidal suture, is as thin as parchment and crac- 
kles, or such places are situated only here and there, or in places the bony 
substance has disappeared entirely and the dura mater and pericranium 
are in close contact with one another. As many as thirty openings of 
this kind have been found in the occiput. Their development is proba- 
bly the result of the combination of various causes: pressure of the brain 
on the occiput with counterpressure of the pillow; constant lying in bed, 
and irregular absorption processes of the osseous substance with defective 
new-formation of bone. Excessive pressure upon such places may give 
rise to unconsciousness, general convulsions, or spasm of the glottis. 
Similar softened and atrophied portions of l)one are found occasionally 



DIBBABEB OF HTITBmOIt. 

in the parietal, sphenoid, and even the frontal bone. Slight grades of' \ 
this condition are said to be obaervcd at times in non-rachitio children.* 

The hoir of the scalp, espeeially over the occiput, is apt to fall out, on account I 
of the profuse swesttog and tbe constant recumbent position. The hairs beconiB' f 
'rinle and breab, fln&Uf they fall out, and the occiput then appears more or leaa I 




thiclKDlngB of the costal caittla«M udtgh | 



ThiairaserroneouHly lietd t<. — 

■hown thHt it is obHt-rved in children from the age of three months to the end of 
"'•■ixthyear. It occurs only vben a airnilar sound is heard in the internal 
— U, wlience it ie conveyed to the surface of the brain. According to Juraci;, 



88 DISEA8B8 OF lOTTBITION. 

the murmur is the result of stenosis of the carotid, owing to the temporary 
diminished growth of the carotid canaL 

The symptoms of rickets of the jaw assume a prominent part in the 
clinical history of rickets of the skull. 

The lower jaw approaches the shai)e of a hexagon, inasmuch as the 
anterior portion corresponding to the incisors becomes flattened, while 
the lateral portions behind the canines are bent at an angle posteriorly. 
At the same time the alveolar process of tbe jaw turns, its upper surface 
being directed more posteriorly and intemalljr, its base more externally. 
As a matter of course, this induces a defective position of the teeth. 
Fleischmann attributes these changes to the traction of the muscles 
inserted into the lower ^aw, the bone itself being abnormally flexible. 
He also attributes to similar conditions the changes in the shape of the 
superior maxilla. This bone is narrowed laterafly in the region of the 
malar process, so that its long axis increases in size, and it becomes beak- 
shaped. 

If rachitis develops before the seventh months dentition often 
remains absent, so that the children may attain the age of three years 
with toothless jaws. In other cases, the eruption of the teeth is delayed 
and irregular, or they may be situated in abnormal situations, for exam- 
ple, they perforate the anterior alveolar wall. They often grow prema- 
turely canous and loose. Nicati calls attention to the fact that terraces 
which are in places deprived of enamel, form upon the persisting incisor 
teeth. 

In normal dentition, the first teeth generally appear in the seventh month. 
Twenty teeth appear by the end of the second year, four incisors, two canines, 
and four molars in each jaw. 

At the end of the fourth year two permanent molars appear, so that the jaw 
contains twentv-four teeth. At the end of the seventh year, two new molars in 
the upper and lower jaws, making twenty-eight in all. Between the eighteenth 
and thirtieth years, the four wisdom teeth make their appearance. 

Durinj^ the seventh year and later, the milk teeth are replaced by the perma- 
nent teeth. The former fall out in about the same order in which they appeared. 

Amon^ the symptoms of rickets of the thorax, the chief attention is 
attracted by the button-shaped enlargements at the boundary between 
the ribs and costal cartilages. In lean individuals, they are distinctly 
visible as prominences ; in others, they are readily felt with tlie fingers. 
They form a curve running from above internally, below and externally 
(rachitic rosary). They are the result of proliferation of the cartilage 
cells, and are co-ordinate with the epiphyseal enlargements at the ends of 
the bones of the extremities. On account of the yielding character of 
the ribs, the entire thorax is deformed. At first it undergoes flattening, 
and finally is depressed in the lateral regions. This depression begins 
between tlie fifth and seventh ribs, and then extends upwards and down- 
wards. The transition from the posterior to the anterior portions of the 
ribs is sudden and angular. The lower edge of the ribs projects out- 
wardly, and is, to a certain extent, pushed upwards, so that the lon^ 
diameter of the thorax is shortened. Betractions are noticeable with 
each inspiration. The sternum often projects at an acute angle (chicken 
breast). On transverse section, the shape of the thorax resembles that 
of a pear (vide Fig. 13). 

The shape of the rachitic thorax is the result of various factors. In the first 



DISGASEB 07 NUTRITION. 

place, thesott ribs field to the inspiratory traction of tlie lungs inwards, eepeciaU; 
since the disease is often complicated by obstinate and extOuslTe bronchitis. Id 
addition, the ends of the ribs, on account of their changed i?rowth, grow anteri- 
orlj pBEt the enlarged costal cartilagen and thus favor a bending! awards (Hueter). 
Not should we underestimate the eSTffi of lifting the children up by means M 
the liauds pressed beneath the lateral surfaces of the thorax. 

^^^1^ The ribs sometimes present fractures or subperioateikl enlargements. Finallj, 
B prominence. poHaessio); a very acute angle, may develop between the manubrium 
and the body of the sternum, and the tatter may form a more or less deep (UTTOW. 




lUcalo wcUtnetna. 600 




I tow 



(uuitb aalural lUse, 



The ciayicles often present rachitic changee. Both epiphyseB are en- 
larged into fihapeiesB maseos, thp gentle curves are replaced by angular 
floxiouB, iiTid partial, even complete fractures may ensue, generally as the 
result of vigorous pressure with the arms. The scapuln may also pre- 
sent tiiickeuing of the free border, Bometimea partial fracture of the 
lower half. 



90 DISEASES OF KUTBITION. 

Thoracic deformities are greatly increased after rachitic spinal cnrva- 
tares superrene. Kyphosis is most frequent, lordosis or scoliosis is rarer. 
The curvature is generally most marked at the level of the first lumbar 
vertebra, but often involves the adjacent dorsal and lumbar vertebras. 
Kypliosis, lordosis, and scoliosis are often combined. 

The pelvis not infrequently presents the characteristics of the flat, 
rachitic pelvis, the sacrum being pushed into the pelvic cavity, as it were, 
by the weight of the body. The conjugate axis is very small, and in fe- 
male patients this may liecome a source of difficult labor. In addition, 
the acetabular region is occasionally pushed inwards, so that the trans- 
verse section of the pelvis becomes neart-shamd. These deformities are 
produced not alone by the weight of the boay« but also by the traction 
of the muscles inserted into the pelvis. 

The most noticeable change m the bones of the limbs is the enlarge- 
ment of the epiphyses, particularlv at the lower end of the ulna and ra- 
dius, tibia and fibula (vide Fig. 12). A deep groove often forms beneath 
them, and separates the epiphyseal enlargements from the wrist and 
ankle joints. In addition, there are curvatures of the bones which are 
generally exaggerations of the normal curves. In the legs, as a rule, 
the curvature is convex to the outside, more rarely towards the front, 
rear, or inside. The forearm is generally curved convex towards the 
extensor side. The humerus and femur are often curved, but to a 
less degree. The epiphyses are often pushed strongly to one side of 
t e shaft of the bone. These deformities are the result of the action 
of the weight of the body, together with muscular traction. Partial 
fractures sometimes occur upon the convex side of the curvatures; com- 
plete fractures occur more rarely. The former affect mainly the bones 
of the forearm and leg, the latter the humerus and femur. The 
patient's gait becomes awkward and waddling. 

Many of the children manifest precocious mental development, prob- 
ably owing to the fact that, on account of the restriction of bodily 
movements, they are more confined to mental exercise. They sometimes 
complain of pain in the limbs, and this appears either spontaneously or 
as the result of pressure on the diseased bones. There is often obstinate 
bronchitis whicn does not yield until the rachitis is cured, and often 
terminates in broncho-pneumonia. The heart may be displaced on 
account of the deformitv of the thorax and spine. Ijeucocytosis, nucle- 
ated or red globules, ana diminution of the number of red blood-globules 
have been described. Enlargement of the spleen is not uncommon. In 
a number of my cases the spleen projected more than six centimetres 
beyond the left ribs. Some physicians claim to have found enlargement 
of the liver. / The appetite is generally poor, but when sypiptoms of 
tabes mesenterica appear, there is usually msatiable boulimia. Disturb- 
ances of digestion are almost constant. Chemical examination of the 
faeces has shown an increased amount of lime, but not of phosphoric 
acid. There are no characteristic urinary changes; the amount and 
specific gravity of the urine present notable variations. 

The results of chemical examination of the urine are in part contradictory. 
According to recent investigations, the amount of lime in the urine is unchanged 
or diminished. 

The general development' of the body is retarded in this disease. The 
children often sweat profusely upon the head and neck, and experience 



^V DISEASES OF NU'I'KITION. M** 

^VHQaatioD of increased heat under the bed-clothes, so that they arc apt ' 

^^> lie uticoTcred at night. 

The dtBcase generally lasts several months. Acute rachitis (sudden | 
onset and rupid course of a few weeks) has been described, out the > 
eyiiiptomutology is so different from the typical clinical history of rickots 
toat Hireat care must bo exercised in the interpretation of such cases. | 

Complications are frequent. The disease is very often associated 
with scrofula, but wo do not beliere that rickets, per se, gives rise to 
enlargement of the peripheral lymphatic glands. The scrofula may be 
followed by phthisical changes iu the lun^ and miliary tuberculosis. 
Spasm of the glottis often occurs in rachitic children; cnronic hydro- 
cephalus and eclamptic attacks are also observed. Waxy degeneratioti 
sometimes develops. According to Rehn, rickets maybe associated with 
osteomalacia. Cortical cataract has also been observed in rachitic cliil- i 
dren. 

A large proportion of the cases are cured by proper treatment. Even 
considerable deformity of the limbs may disappear after a certain period, 
but the patients sometimes remain dwarSab. Supernumerary bones de- 
velop not infrequent! V in the cranial sutures, and the fontanelles and 
sutures appear very deep. The bones are sometimes very much con- 
densed (rachitic sclerosis or ebnmation), in later years they may become 
extremely brittle. The patients are placed in special danger by spasni 
of the glottis, b ronch i ti 9, oroncho- pneumonia, exhaustion from obstinate 
diarrhosa. or tubercular processes. 

III. Anatomical Chanoes. — The bones are affected almost exclu- 
aively, the internal organs remaining free from specific lesions. The 
following unimportant changes have been found: milk patches beneath 
the anterior epicardium (probably from friction against the enlarged 
costal cartilages), enlargement of the spleen (dependent mainly on hyper- 
plasia of the cellular efements), accumulation of fat in the liver. 

The rachitic bones present the following lesions: enlargement of the 
epiphyses, thickening and hyperplasia of the subperiosteal layers, nn- 
nsual congestion of these parts, flexibility and softness of the bones. ' 
The boues, especially those of the skull, may not infrequently be cat , 
vitb a knife. If a longitudinal section is examined, it is seen that the 
epiphyseal ehanges start from the cartilage situated between the epi- 
pnysis and diaphysis. This part, as is well known, provides for the 
longitudinal growth of the bone by the constant production of cartilage 
cells, which are added to the diaphysis and are coaverted into osseous 
tissue. 

The healthy epiphyseal cartilage is divided into the epiphyseal and 
diaphyseal zones. The former has a bluish-white color, and la one to 
two millimetres in height. It is subdivided into two parts. In the 
youngiT one, adjacent to the epiphysis, the process consists chiefly of 
proliferation of cartilage cells and gradual arrangement in longitudinal 
rows {liyporpluatic portion), while in the older one, nearest to the 
diaphysis. there is cniefiy an increase in the size of the cartilage cells 
{ hyiwrtrophio portion). The diaphyseal portion of the epiphyseal carti- 
lage is about 0.5 mm. in height, and has a yellowish color. It is also 
known as the zone of temporary calcareous infiltration, because the 
cartilage in it is gradually converted into osseous tissue. Both zones are 
sharply separated from one another by a straight lino. 

In rickets, both portions of the epiphyseal cartilage are greatly in- 

^creaaed In height. The proliferation zone may be several centimetres in 






thickneeB, and project laterally from the side of the bone. The shurp 
boundary between the two layers of the epiphyseal cartilage is lost, and 
both are abnormally roscular. In the zone of temporary calcareoue in- 
filtration, the voBsels aro increased iu size and number, and extend into 
the proliferatiou layer of the epiphyseal cartilage, which under normal 
conditions contains no vascular spaces. In the healthy cartilage, the cal- 
cification of the diaphyseal portion occurs in an uniform manner; in 
rickets, we find irregular patches infiltratid with lime which, in phices, 
extends into the proliferation layer. In this manner the diaphyseal por- 
tion assumes a porous, spongy character (apongoid tissue). 

The growth of bone in thickness depends upon the periostenm. 
On the surface of the periosteum adjacent to the bone proliferations 
form, and are gradually converted into osseous tissue. At the aame 
time an absorption of osseous tissue occui's on the side of the medullary 
cavity. In rickets, periosteal growth undergoes changes similar to the 
epiphyseal growth. There is considerable increase of the proliferation 
layer, which may attain a thickness of several millimetres. This layer 
is very rich in vessels. Calcification occurs irregularly in islets, so that 
a spongoid tissue is formed. Osteoid tissue often adheres to the in- 
ner sunace of the periosteum, when the latter is stripped from the bone. 
At the same time the medullary cavity continues the process of absorp- 
tion, even to an excessive degree, so that the bone becomes unasually 
llexible. The medulla is generally very red, and occasionally hae a 
lymphoid appearaiLce. 

The microscopical chttngBH are atill the subject of diapute. The proliferniion 
layer preaenia excessive proliferation of the cartilage cells. The cell groujis coa- 
tain an unuaually large Dumber of cloeelj aggregated celln, between which the 
basement substance has disappeared in great part. The latter loaea its homoge- 
neous character nnd aasumes u more llbrillated structure. 

In the Hine o( temporary calcareous iiiJUtralion, the development of tneiliillarT 
spaces, and of vascular Bpaces within them, is uunsually extensive; contrary to ih« 
rule, this often extends into the proliferation zone. Calcification and oesincatioo 
occur irregularly, and also extend into the proliferation zone. Somcuf the<:arti- 
lage cells are converted directly into bone corpuscles. Klebs found that others 
were converted into medulla celts, anil then into oonnective-tiasue corpuscle!!, ao 
that the vascular s|)aces in the nieflullary spaces were surrounded in many places 
by dense masses of connective tissue. Similar processes are observed in the peri- 

The specific gravity of the bont-s is diminished, In a child set. 8 years. Trous- 
seau found that the entire skeleton weighed one kilogram (normal weight, seven 
to eight kilograms). 

fnedleben found an iacreaaed amount of water, fat. and carbonic acid in the 
bones, dinunutiou of lime salts ; in general, increase of organic, diminution of 
inorgaDic constituents. 

CoDcerninfjr rachitic changes in honea. two factors must be distinguished, viz.; 
the proliferative processes and excessive vascularisation. and the irregular and 
imperfect calcification. 

It is evident that a deficienov of lime salts in the bones may arise when the 
food is poor in these salts, or their absorption from the intestines is interfered 
with, or if there are conditions of the blood or bones which prevent the precipita- 
tion of lime salts from the blood. 

A deficiency of lime salts in the food does not obtain in the majority of cases, 
because milk contams sufficient amounts for the development of bone. It faas 
been claimed that rachitic changes may be produced experimentally in aolmala 
by depriving them oF lime salts, but this has been denied. 

From the fact thnt obstinate diarrhoe.Lisa prodrome of rachitis in many cases, 
it was assumed thnt Isctic acid wns formed by the fermentation of ingested milk, 
that this, being absorbed by the blood and tissue juices, dinsolved the lime salta 
and prevented their precipitation iu the bones. Great importance was attached 



J 



^^V DISEASES 07 miTBITIOH. 9»« 

B^BId th(< fact that lactic acid was said to be demonstrable in the urine. But this 
■ hu recently been nought for in vain in the urine, and it has never been found in 
Ibe bonea. Nor does the urine contain an unuaiially large amount of lime salts, 
Senator lias recently called attention to the view that the carbouic acid in the ti»- 
sues perhaps acts aa a Rolvent of the lime salts. Seemann believes that the absorp- 
tion of lime salts from the intestines is diminished, and this is rendered plausible 
by the abundance of lime in the faeces. This writer calls attention to tlie larite 
aniriunt of the potassium combinations in milb (particularly of animals), and c<> » 
still greater degree in vegetable food, When the potassium salts are absorbed 
they oombine with all the chlorine at their disposal, so that very small amountsoC 
chlorine remain to aid the abaorption of lime salts. Hence, the latter pass in 
the fieces, in part unchanged. 

But this factor explains only the poverty of the bones in lime, not the inflam- , 
matory character of the proliferatian of cartilage cells and vessels. In our 1 
opinion, rachitis may be explained as follows : disturbances of nutrition in con- 
Be(]iience of perverse nutritive processes or other general causes; a predominantly 
local inSamniatory affection of the epiphyseal cartilage; imperfect and Irregular 
calctScatJon, on account of deflcienoy of lime in the tiitsues and the existing in- 
fiammatory conditions m the cartilage. This theory tallies with theexperirnenta 
of Wegner. who produced mflammations of the epiphyseal cartilages in animals 
by administration of phosphorus, and at the same time gave to them food deficient 
in lime salts. This experiment was followed by ractiitic changes in the 

IV. Diagnosis. — The diagnosia is easy. Delayed and irregu'ar den- , 
tition and profuse sweating of tho head and obstinate diarrhiBa point 
towards latent rickets. ' | 

Osteomalacia occurs almnet excluaiTely in adults. In cases of congenital 
syphilis, the epiphyseal cartilages may become separated, but the patients are 
only a few weebs old, and there are other evidences of syphilis on tiie skin and 
mucous membranes. The rachitic skull should not be mistaken for chronic hydro- 
cephalus. In the latter, spasms often ocour, and mental development is iia- 
perfect. , 

V. PR00N0SI9. — The prognosis ia not unfavorable as regards life, if 
the disease is not too far advanced, or associated with scrofula, tabes 
meeenterica, or other serious corajilicationa. Deformitiea of the bonea 
may subside spontaneously. Persistent deforniitiea of the thorax and 
spine raay give rise to shortness of breath and a tendency to inflamma- 
tions of tho air passages. 

VI. Treatment. — Propernonrishment and treatment of diarrhoea are 
extremely important as prophylactic measures. In our own experience, 
the following plan of treatment has been attended by the most rapid and 
successful results in this disease: 

The diet should bo regulated; infants should be nursed atthebreaat, 
if possible, or should receive cow's milk with the additioti of lime-water; 
older children ghonld receive less vegetable, more animal food. | 

Tho children should be kept a good deal in th» open air, and should ' 
sleep upon a hard mattress. They should not be urged to walk, and in , 
currying them care should bo taken not to produce artificial de- 
fortniticB, i 

A teospoonful of cod-liver oil ia given morning and evening. For 
four weeks, a sodium-chloride bath should be given every morning 
^^. (Sd** R ; sodium chloride, ; xxx,-l, ; twenty minutes' duration; then 
^Puw-tialf to one hour's rest in bed). 
^^B' The following prescription may bo ordered: 



^^ DUUflSB OF Jt T I UTHIB , 

a Vem kale,, 

0*J<ar pbcwphorio , &&3ii]. 

H^nnea, carbon., 

Hair, chlorat., 

Hiuuih. al b ft& 3 isfl. 

M. I>. H. Tbo point of a knife full t. i. d. after meals. 

liiarrbom offora no contra-indication to this plan of treatment. 

Preparations of iron and lime, bitters, tonics, phosphoros, and arsenic havs 
giMo hetta reconiinendttd in rickets. 

fl. Softening of the Bones, Osteomaldcia. 

I. Etiology. — Osteomalacia is a rare disease, hardly more than 
one hundred and seventy cases having been reported hitherto. It is most 
frequent between the ages of 20-50 years, but is not as rare in childhood 
as has been believed. Amon^ one hundred and thirty-one cases collected 
by Litzmann, men were attacked eleven times, women one hundred and 
twenty times. An extremely large number of the cases are associated 
with pregnancy and parturition. It occurs particularly in certain locali- 
ties, such as the Rhine districts. East Flanders, and in the vicinity of 
Milan. Oasati observed it, in Milan, in 0.8 per cent of all puerperal 
women. The majority of the patients came from the Olona valley, in 
which typhus fever and pellagra are prevalent. 

The non-puerperal form is sometimes attributed to colds, wetting, 
insufficient food, and dark, damp apartments. Behn described a com- 
bination of osteomalacia and rickets in children, but states that the 
former is not connected with congenital syphilis. 

II. Symptoms. — The first symptoms consist of rheumatoid pains in 
those parts of the skeleton which are first affected — in the puerperal 
form, generally in the pelvis; in the non-puerperal form, in tne spine. 
Thojmins are sometimes worse at night and cease after profuse sweating, 
or they are increased after prolonged sitting, on motion or pressure. 
Febrile movement is not infrequently present. Curvature of the bones 
soon ooeurs. The promontorv of the sacrum passes deeply into the 




lapo. The narrowing of the pelvis may 
but also with the evacuation of the bladder and rectum. Individuals 
HulToring from softening of the pelvis complain very quickly, while 
Hitting, of pain in the tubera ischii. The normal curves of the spine 
aro niorbiilly increased. The cervical curve is sometimes so great that 
i\\o (>hin and sternum come in contact. Considerable deformity appears 
iu t ho hnubur spine. The spine is shortened, and the patient sometimes 
slnMiikK to dwarfish dimensions. The ribs and sternum often present 
BuritMirt iloformitios, and these may bo associated with partial or complete 
frut'turoH. llonoo oomprosiiion and displacement of the lungs and heart, 
pulpilution. tlvspnu'a. and asthmatic attacks. The limbs mav also be 
tiubitut tt» iUirvaturiMind fracture, and the gait becomes wadaling and 
tiiiallv i^\po^Hiblo, Multiple fractures after slight injury are sometimes 
the tirdt e> iilonoo of osttH>n)aIacia. In fractures, the formation of callus 
may be al>dont or iuiH^nploto, or it may undergo absorption at a later 
ptiiiad. Htiftonin^ rt^rt^ly ocinir^ iu tUe'himesof the skull. The teeth. 
aro not attaoktnl, although they may UH»mo carious and drop ont. 



^H The muE 
^H iwinful COD 



i 



_ The muscles are softand flabby. Fibrillary twitctiings, spasms, i 
< fwinful coatraclures have been described. They occur spontaoeoi: 
or after slight cutaueons irritatiou. 

The sweat, saliva, and milk are said to be overloaded with lime J 
salts, and the latter are also said to be excreted through the brouchii^' 
and gastro-inteatinal mucous membrane (?). 

No specific changes are noticed in the urine. There is sometimes 
temporary increase of nric acid. The specific gravity is generally 
diminished. As a rule, the excretion of urea and phosphonc acid is 
diminished. There is no constant increase in the excretion of lime 
salts. Lactic acid has been found repeatedly in the urine (also in nor- 
mal urine). Albumin and hemialburaose (vide Vol. II., page 2i5) are 
found occasionally. 

The urine often contains a sediment of carbonate, pho3i>hate. and 
tOzalate of lime, and the bidneys may contain concretions of a similar -I 
rtbaracter. I 

' Ijeube found 0.345 gm. lime in the faeces in two days. 

The disease generally lasts many years. The most acute case lasted 
nioe months; the most protracted, thirteen years. Uemiseions and exa- 
cerbations are frequent, the latter generally during pregnancy. Death 
occurs from increasing marasmus, from respiratory and circulatory 
disturbances caused by the deformity of the thorax. Recovery is 
rare. 

, III. Anatomical Changes. — The principal changes affect the 
bonee. They are sometimes as flexible as if the lime salts bud been re- 
moved with acids, or they form membranous structures like the intes- 
tines, and are readily cut with a knife. 

The medullary cavity is increased in size. The osseous parts of the 
spongy substance may have disappeared, so that it forms a continuous 
mass of medulla. If the absorption of the bony framework has 
occurred only in places, cystic medullary spaces are produced. The 
medulla itself is at first congested and here and there contains extravasa- 
tions of blood. In later stages it contains a large amount of fat, arid 
becomes yellow, finally atrophic and gray. 

The Haversian canals are increased markedly in size and filled with 
reddish succnlent tissue. The bone thus appears porous and unusually 
juicy. While the medullary cavity and Haversian canals increase in 
size, the surrounding osseous substance atrophies, the latter process 
ocourrine from the medullary cavity towards the periost-eum. I'inally, 
only a tnin layer is left beneath the periosteum, and even this may 
disappear almost enfirely. The periosteum is thickened, its pro- 
liferation layer congested and conUtins extravasations. According as 
the remaining masses of bono are fiexlble or still contain firm portions, 
tba diseased hone presents a varying tendency to fracture. 

The micrasoope Bhonrs great changna in the osseous tissue in the immediiite 
Tidnityof the medutlarv cavity and HaverHian canaU. This part stains readily 
ViUi carmtue, has lost tuehme salts and ssHumed aRbrillaCed structure, and (N)n- 
taiUH a few spindle-shaped, unbranched remains of l)one..corpuscles. At n latf r 
period gradual mucoid liqueraction and absorption aeem to take place. At 
th« boundary between the healthy and diseased tissui^s are found the so-called 
Howsbip's lacunee, in which inyeloplaqiit^B have be«n found. 

The medulla of the bones and the contents of the Haversian canals present 
eontteetion of the veHsela (pa<isive hyperemia, according t<i Rindfleianij} and 
BUmeruna extraTasations. In the red marrow we find only tiie remains iif 
~ ' cells, in great part lymphoid cellsi at a later period nuineroua pigment cells 



M^ OI8i£A8E8 OF KUTBITiON. 

;tm»w ClMir App«aranc6. In the fcnij atrophic medulla tiie baaement snbetance 
jHM^'<*v.i/i«Uf«, find the cells which are poor in fat and scantj have an almost 
4^.Ai«rl^/f'iaJ cliaracter. 

A//y/f'iifiK u> O. Weber, the bones sometimes contain lactic acid. Their 
tya^.itk: gravity is diminished, the;^ are rich in fat, and unosoallj poor in inor- 
l^ic; /y/f«stitiiisnUi, <*H[Mtcially the lime salts. In one case; Huppert foond phos- 
$f$^^^. i4 irtm. Not alone simple atrophy and fatty changes, bat also degen- 
aoUi^m lnLVtf \mfn found in the muscles. 

Hsuty ^ilaifii tlittt tiie disease is the result of the formation of lactic acid 
is* UtM rntainiiurv Hpace8, this giving rise to decalcification of the osseous 
mtmliifif'M, UindfliriHcli attributes a solvent influence to carbonic acid, which is 
y^ti^im pf'i'luccd exreHstvely in the medullary spaces as a result of stasis 
t4 M/x/d. Hut f^ngundorff and Mommsen showed that osteomalacic changes 
do II//C onsist Hini|>ly of decalcification. For example, they found, in the base- 
WJtiA sulistanc^e of 'the bones an imperfect formation of lamellar systems* 
iofigitudinul striution and fibri Hated formations, and in such places there 
wi^re often large masses of Sharpey's fibres. Cohnheim does not look upon the 
liineless places as having been previously healthy, but regards them as an 
a|>p<isition nf dineased tissue. The frequent occurrence of the disease during 
pregnancy has been attributed to the fact that the maternal organism supplies 
the ftjutus with a large amount of lime, and thus retains an insufficient amount 
lor its own conHumption. 

The obscurities of the problem have not been cleared up by experimentation. 

IV. Diagnosis, Prognosis, Treatment.— The disease is distin- 
guished from rachitis by the fact that the bones, instead of remaining 
ioft, grow soft. 

The prognosis is unfayorable, and recovery is exceptional. In women 
there is danger of relapse during pregnancy or of death from difficult 
labor (narrow pelvis). 

The treatment is similar to that of rickets. Busch particularly rec- 
ommends phosphorus. ^ 

7. Arthritis Deformans. Deforming Inflammation of the Joints. 

I. Etiology.— Arthritis deformans is a disease of advanced age^ and 
is rare before the thirtieth year. It is more frequent in women^ par- 
ticularly among the poor. 

The disease is sometimes attributed to heredity, cold, exposure to 
wet, living in damp rooms, insufficient nourishment, bodily and mental 
strain. It is observed in women after parturition, too frequent confine- 
ments, and excessive lactation. Eohls observed it as the result of fright^ 
and it has also been found associated with diseases of the spinal cord, 
especially locomotor ataxia. Deforming changes in the joints have also 
been found in hysteria. 

The disease may be the result of injury, such as dislocation, fracture 
near the joint, contusion, etc. Those joints which are used a great deal 
are attacked with special frequency, for example, the joints of the fin- 
gers in seamstresses, watchmakers, etc. 

Oaskoin maintains that arthritis deformans develops after psoriasis, lichen, 
variola, and particularly after area Celsi. 

H. 8tm!»toms.— The disease always develops gradually and slowly. 
/i niiiy attack only one or a number of joints. In the former event, 
th" liiji in frequently involved, particularly in old men (malum cox» 
iM«nll'«). Polyarticular arthritis includes two varieties, according as it 
u^^^^kt^ i\w trunk and large joints of the limbs, or the phalang^ and 



t jnetacarpo -phalangeal joints of the feet and hands. 
■ «triki[igly Bymmetrical. 



The disease may be 
prodrome of 



Obstinate hemicrania has been noticed in women as i 
I "the disease. 

The symptoms generally begin with paine in the joints. These may 
r extend over the entire lirab, and are either confined to a definite nerve 
I tract or are of a vague character. Remissions and exacerbations are fre- 
I 'qoent, the latter occurring particularly in windy, damp, and cold 1 
r weather. Some patients complain of parissthesiEe, a feeling of coldness, ' 
formication, etc. The joints gradually become stiff, are easily tired, ■ 
and firm, bony prominences appear, which gradually increase in size. 
The overlying skin is generally thin, but otherwise unchanged; more 
rarely it is slightly reddened and inflamed. The longer the condition 
lasts and the more the ends of the bones are swollen the less movable 
the joints become. A hard crackling is often felt on moving the joints. 
The muscles inserted near the joint often undergo rapid atrophy and 
contracture, thus increasing the deformity. 




I of t 



In the hands, it is generally found that the second, third, and fourth * 
fingers are flexed in the metacarpo-phalangeal joints towards the ulnar, 
more rarely towards the radial side, so that the fingers lie across one an- 
other like the shingles on a roof (vide Fig. 15). The little finger and 
thumb are generally unaffected. 

In the feet, the great toe is usually affected with the greatest severity. 

The spine presents deformities, impaired mobility, and symptoms of 
compression of the spinal cord and nerves, from narrowing of the natural 
openings and canals. 

If the disease is very eitensive, the patients are rendered completely 
helpless, although life may be maintained for twenty or thirty years. • I 
The internal organs are generally intact. Hueter has noticed disease of 
the endocardium, and early arterio-aclerosis is sometimes noticeable. 
Death is generally the result of intercurrent diseases. 

III. Anatomical Ohanqes. — The capsule of the affected joints 
first undergoes thickening, and villous proliferation develops upon its 
inner surface, especially where it folds upon the cartilage. Long, 
thread-like prolongations extend occasionally mto the joint cavity. Some 
of the villi may undergo oesification, and they may become eepanted 



98 DISEASES OF KUTBITION. 

and float free in the joint. Parts of the capsale itself may be ossified, 
and sometimes the entire synovial membrane forms a sort of bony 
capsule. 

The ends of the bones are thickened laterally, and proliferate, in a 
measure, like fungi. Their surface is generally smooth, shining like 
iyory, and destitute in great part of cartflage. There may be consider- 
able destruction of the osseous substance itself; for example, the neck of 
the femur occasionally undergoes more or less complete atrophy. As a 
matter of course, the ioint surfaces are thus changed and mobility im- 
paired, and occasionally new joint surfaces are formed. 

The tendons inserted into the joint are often thickened, occasionally 
ossified in places; more rarely they are defibrillated and atrophied. The 
associated muscles present atrophy, fatty degeneration^ and fibrous cal* 
losities. 

• 

Weichflelbaum regards the lesions as the result of advanced, sometimes pre- 
mature senile changes; others lay stress on its primary inflammatory character. 
It would appear to us as if there are different anatomical and etiological varie- 
ties of arthritis deformans. The process copsists essentially of proliferation of 
the cartilage cells of the articular cartilage, especially at its edge, ossification of 
the deepest layers, and mechanical atrophy of the middle portions; in addition, 
gradual defibrillation of the articular cartilage and sclerosis of the underlying 
Dony substance, with progressive proliferation and ossification of the lateral por* 
tions of the articular cartilage. 

IV. Diagnosis. — The diagnosis is easy. In gout, the' great toe is 
particularly affected, typical gouty attacks occur, and arthritic deposits 
are found in the cartilage of tne ear and in other parts of the body. It 
may be difficult to distinguish the disease from certain forms of tuber- 
cular arthritis, but deformity of the joints is absent in the latter affec- 
tion. In chronic articular rheumatism, local inflammatory symptoms 
predominate. 

V. Prognosis. — The prognosis is good so far as regards danger to 
life, but it is difficult to effect permanent recovery. 

VI. Treatment. — Among internal remedies, the greatest reliance 
may be placed on potassium iodide; arsenic and cod-Uver oil are also 
recommended. The joints should be painted with tincture of iodine. 
During the summer, we may recommend sodium chloride, sulphur, 
iodine, or mud baths, or indifferent thermal waters. 

Oood results have been obtained from massage and galvanism (to tha 
sympathetic^ spinal cord> nerve plexuses, or the joints). 



SECTION X. 

INFECTIOUS DISKASKS. 

, INFECTIOUS DISEASES WITH TYPICAL LOCALS 
ZATION. 

PART I. 
ACUTE INFECTIOUS EXANTHEMATA. 

1. Measles. MarbtUi. 

I. Etiology. — Measles is an exquisitely contagious disease which w-^ 
convered only by contagion, although, as a matter of course, it must 
have developed originally in an autochthonous manner. 

Kxperimenta have shown that the contagious matter is conveyed in 
the blood, tears, nasal secretion, aputum, and fluid contents of vesicular 
eruptions which may form upon the skin. Attempts at infection with 
scales of epidermis after the subsidence of the eruption are attended 
generally with negative results, so that the majority of authors deny the 
infectious character of the diseaHe during the period of desquamation. 

The contagious substanco possessea the power of leaving the body of 
the patient and diffusing itself in the immediate vicinity. This is in- 
ferred from the fact that the disease may be contracted from mere' 
[tresence in the sick-room, without contact with the patient or any arti- 
cles which he has used. To explain the phenomenon, it is assumed that 
the infections matter leaves the organism through the exhalations from 
the akin and lungs. 

The vims of measles may also be conveyed through the medium of [ 
other individuals and inanimate objects. Ileuce, physicians may spread 
the disease from aEfected families to healthy ones. 

It is very important to know that the contagious property of the dis- 
ease exists during the period of incubation and the prodromal stage. 
[lence, during an epidemic of measles, all individuals should be quaran- 
tined who are apparently euSering merely from simple coryza, cough, 
Knd conjunctivitis. 

In Accordance irith the recent views concerning tlie origin of infeetious dis- 
<«Be8, we aasuiue that measles are producecl bj tow organiBma (bacteria, achizomjr- 
<*leBJ, but the bacterium has not been diaoovered with certaintv . Elabes and 
Corad, Braidwood, Murray, and Vacher, and Lebel, have recenUy claimed to 
IwTa (oond the bacteria of meaales in the expired air, blood, teara, nasal neon- 
" — — ■■ e of the internal organs. 



100 AOUTS INFECnOUS EXANTHEICiLTA. 

A unpooptibilitr to infoction with measles is possessed by the major- 
ity of indivVluttlff/ The greater number are exposed during childhood, 
fH) tbut the diitoAno is rogardod as one of childhood. But in isolated 
pluoiHi whioh liHTo louf? biHMi free from measles, and have been accident- 
mUy iuftH'tiHt by di«m««Hl tuiilors, it has been found that 3roung and old 
Alik^ iitt» dttiiiokYHtv A diminished susceptibility is attributed to the 
Hi^l nU uuMUh^n \x( \\U\ although cases are known in which children were 
nUiiok^Hl with iiu'tkiloei a few days after birth, or even at birth. Indeed 
U i« ^vvu \w\k\ tiiat tho fa>tus iii utero may pass through the disease^ and 
ilunvf\Mv r%Muaiu fn^ from subsequent infection. 

\W\wK dkMi>a8i^ at tho most delay the outbreak of measles. Immu- 
^(V,v U iu»t wnforrtnl by pregnancy or the puerperal condition. Measles 
Aiv •Huiiotiuu'^ HJittOciatiHl with another infectious disease. The known 
\H»iH^iuatu»im ai\> : measles with typhoid fever, variola, scarlatina^ ery- 
i«U»v)»4M, t\H)iheln, varicella, pemphigus, and mumps. The combination 
i»f mmuK^ aikd pertussis is not at all rare. 

Am Iii ti'uo 01 the majority of other infectious diseases, a single attack 
(»r luiH^tuii ooufera an immunity against subsequent attacks. Cases of 
(lutiliiu or triple infection are rare. In some epidemics, however, rein- 
fiuiUuii in relatively frequent. In some cases, many months or years 
iiUiimi ttutweeu tho two attacks ; in others, only a few weeks. Cases in 
ivItM'li. a fuw days after the disappearance of the eruption, another 
iiiMit'ulitiul urupiion develops are probably instances of a relapse 
(i;4UiUiiiily rare). Some individuals seem to possess a temporary immu- 
nity, liunpite opportunity for infection, they escape in one epidemic, 
iiiit may bu attacked in the next. 

'IMui (lisease occurs sporadically, more frequently in epidemics. In 
Ui^ii i:iti(iSi ujioradio cases are observed almost constantly. Such cases 
iii^uitiiduuily form the starting-point for epidemics. Epidemics appear 
mti iufruqiieutly at certain definite intervals (two, four, and six years). 
1 1. u|ipuurs us if a certain amount of ^^ measles material ''must be collected 
lipfiivo the (liseaao can spread extensively. The most favorable opportu- 
\k\i\ fur iufuotion is afforded by schools and places of public amnse- 
4MMUI" The danger of infection is less in the open air than in closed 

li!|ii(luiui()d are more freq[uent in the winter and spring than in other 

tPHbiiiid. 'IMiose occurring in the former seasons are often complicated 
ly ii:feiiiirHt(»ry diseases, while obstinate diarrhcsa is not infrequent in 
^miumir ujiiiiemics. 

An upuiemic generally lasts four to six months. As a rule, it rapidly 
Vuuuliiib Its heiglil, and at this period the cases are generally more sen- 
\^\\A i'huii at the beginning or end of the epidemic. 

At curtain times measles spreads pandemically, i. e., over large areas 
of i;(iuutry. A(uu)nling to Guttcet, tne whole of Bussia was ravaged, in 
]biU\t by an opidumio of measles. 

1 1 . is Y unoiiH A NO Anatomioal CHANGES. — If the vims of measles 
jti cun viiyuii to a healthy organism, a certain period elapses, during which 
liju |miiiun iunreiMieM and accumulates in the system before the first si^ns 
(it p<;jtiMniiip[ hn(M>mo noticeable. During this stage of incubation, which 
(ifi^U \iiu iluyH in typical cases, tho individual often feels entirely well. 

AjllMHiuli tliii liihgth of (hcMH^riod of incubation is tolerably constant, never- 
l|m)|<iio ^imIiiIIiiiim \\i\ ooour. T\\wo will depend, among other things, upon the 
aViMMi^t 01 m) V ii iilttnim of Uii« iH^imrn introduced, and upon the power oi resigtance 




AODTE INFBCmODS EXASTBEMATA. 

I This Stage is followed by the prodromal period, which lasts, on the | 
rerage, three days. It is characterized bv severe affection of the i 
mucous membranes of the nose, conjunctiTa, mouth, pharyus, larynx, 
trachea, and bronchi. Some writers consider these mflammations « 
co-ordinate with the BUbsequent eruption on the skin, and Rehn pro- 
poses to call tliis the stage of mucous membrane exanthem (onanthem). 

The third stage is that of the eruption, which appears upon the ex- 
ternal integument. In typical cases, it begins on the fourteenth day 
after infection, and lasts three or four days. 

The final stage is that of desquamation, which lasts, on the average) 
Be Ten days. 

During the stage of incubation, especially in the first half, the gen- 
eral healtli is often undisturbed. In the second half, there are sumo- 
times slight temporary elevations of temperature. The children be- 
come irritable and fretful, lose their appetite, suffer from eructatioiiB 
and foul breath, and a coated tougue; sleep is disturbed, or there is un- 
liuUBl somnolence. As the prodromal period approaches, the inflamma- 
tions of the mucous membrane become noticeable. 

'i'ho prodromal stage often begins with a single chill or repeated 
Alilly faelinga. This is followed by fever, which may reach 40° V. on 
lie 6rst night. On the two following days the temperature may return 
D the normal, or there is a slight elevation at night, rarely in the morn- \ 
g. Ileuce many patients feel sick only on the first day of the pro- ■ 
jomal stage. 

The innummationa of the mucous membranes, which are often oh- 
_ rved towards the close of the period of incubation, now Inci'ease in 
■Bverity. The injection of the conjunctiva increases and extends to the 
Ltoonjunctiva bulbi; subconjuuctival cedema (cheraoeis) sometimes de- 
velops. The lachrymal caruncle is reddened and swollen so that the 
tears cannot pass freely into tlie lachrymal canal, and in jtart flow over 
the edge of the conjunctiva, The patients dread the light, complain of 
itching, burning, and the feeliug of a foreign body in the evi's, rub the 
lidA often, and may suffer from spasm of the lids. Nasal catarrh is 
manifested by impermeability of the nose and a feeliug of burning and 
dryue^, which is soon followed by increased secretion. Frequent sneez- 
ing occurs, and this may be increased into a sneezing spasm. If tbe in- 
flammation extends into the frontal sinuses, tbe patients complain of 
pain and pressure in the frontal region. Pharyngeal catarrh produces 
a eenftation of dryness and difficulty in deglutition. Buccal catarrh may 
create a feeling of abnormal heat, burning and dryness in the mouth. 
Cough, hoarseness, burning in tbe laryngeal region, and a thickening sen- 
sation under the sternum indicate catarrh of tbe air passages. The 
cough may become spasmodic, or it grows hoarse and barking, and aa- 
snmes the sound of the dreaded croup cough. 

The objective changes on the mucous membranes are not always 
alike. In the majority they consist of diffuse redness. Certain parts, 
for example, the follicles on the palate, often tako an active part in the 
ioflammatory swelling, and become visible as small nodules. The injec- 
tion of the vessels may he unusually marked, and sometimes slight snb- 
mncoQB hemorrhages are seen. In other cases, the redness occurs in 
patches, but these patches may, and in fact generally do, coalesce and 
produce a diffuse redness, 

A few antopsicB seem to indicate that other mucous membranes may 
also become innamed. Patches of conseation have been found upon the 




.LOCTE larEonocs exahtbbkata. 

tuoibrBDe of the broncbi, etomach, intestinds. and genitalia, 

Xov«n upuo thv plean. In one case, Weil ab^^erved pleariay. 
A« th« eraptJTw stago approttches, the bodily temperature suddenly 
„jtftf to iy° C or m>M«. Ai ■ rule, the temperatare cootitiues to riae in 
ISiw n«xt tvu ti47s, anil U the find of the third or fourth day (usually at 
F^ubt) nUnw lit • ans» to ibe normal or even subnormal. Then the 
w nunrtir*"" If— — ttff^—"'"* ^py""*!- or there are oocaeioual slight rises 
[ wt tMBlpamtat*' n* k«gbl of the ferer generally coincides with the 

Tb» ■»>■>■> OB ^* Ain often appears quite suddenly, and this, 

ie«m iha !■— w l iacmse of temperature, sharply separates the 

iptire sCa^. In some cases, howerer, the 

The eruption appears first un the ohin, 

doon follows upon the scalp, the integument 

and the neck. In twelve to thirty-six hoars 

ttnbcant also cuvered. The {wtcfaea are most abundant 

luck, most acauCy on the lower iimba. The 



rjuihiiM^T'iy &«■»■ < 

j,tLaiillll •>■"' >w hu i i^ . and i 




'twiH|w(itUm' curtf la UDCompUcatHl 



1 of thi> limb are affected alike, the palms of 

"■-I ft't't are also attacked. Certain parts of 

i)r the eruption spreads in a different man- 

Tlii' occur re nee of the eruption is attended 

!ii,i red patchos,of around, elongated, or 

( jom two to six millimetres. On prea- 

^Nt^i', a yellowish or pale brown patch ia 

i<iitU'<ii ot exudation and even dlapedesis of red 

iii'iiiiiiry hyporiemia). The borders of the 

1. (tint not irifrcfjuentlv irregular and jagged. 

I, oltivaU'd. Tlie cL-ntre of well-deYeloped patches 
'lit imimli' ((irovided m many places with a central 
,ii|( nt ■wolling of a sebaceous follicle, and is some- 
Uii' than seen. Both forms are almost 
^< I. If there has been profose diapho- 
1 1. - tnay he raised in places into small 
I 1 lio pulehes may be so active thai the 
11*0 to small cutaneous hemorrhagea. 



ACUTE mFEOnOCS EXAlfTHXIf&TA. lOSil 

This pbenomenoii pOBseBsea do special signiScniice. The patches may 
coalesce in places (generally in the face, where it may give nse to cedema j 
of the faee and lids), but they never coalesce on all Bides. 

The eruption extends over the entire body in twenty-four to thirty- 
six hours, and remains at its height for twelve to twentj-fonr hours. 
The patches in the face have occasionally paled before the limbs are 
attacked. At the height ot the ernption we sometimes notice enlarge- 
ment of the peripheral lymphatic glands and slight enlargement of the 
spleen. The hoart presents systolic febrile murmurs. Diminution of 
the red and increase of the white blood-globules have been noticed. The 
tongue has a white coating. Thirst is increased, the appetite is lost. 
The urine possesses the characteristica of febrile urine; it contains occa- 
sionally traces of albumin, often furnishes the acetone reaction, and ia J 
said at times to contain sugar ( ?). J 

Various statements are made concerning the anatomical changes ttl!l 
the skin. Hebra and Mayr assumed, from analogy, inflammation audi 
swelling of the sebaceous follicles. Simon found the cutaneous glands n 
intact on microscopical examination. The epidermis and cutis were also 
intact, the latter being swollen into a papule, probably as the result of i 
fluid eiudation. Fine molecules, which did not dissolve in acetic acid, 
were fonnd between the cutis fibres. Neumann recently described dila- 
tation of the vessels of the cutis, emigration of white hlood-globulea 
and their accumulation on the outer surface of the blood-vessels, seba- 
ceous and hair follicles, and between the muscle cells of the arrectores 
pili, and dilatation of the hair follicles at the point of insertion of the 
arrector. 

After the eruption has reached its acme, the patches pale quite rapidly, 
^At first in those parts in which the eruption appeared earliest. The inten- 
•■tj of the color of the eruption occasionally varies slightly, the red- 
eem incroasing with the increased bodily temperature. The patches often 
. nve yellowish or light-hrown pigment spots, which persist into the sec- 
ond w'eek. I 
The stage of desquamation runs an apyrexial course. It occurs iuj 
very fine scales, earliest and most distinctly in the face. It is onlfl 
slightly indicated on covered, perspiring portions of the body, or i£l 
baths nave been employed. It la uften associated with pruritus. The I 
patient may be regarded as well by the end of the fourth week- 
Anomalies in the course of measles are often observed. One of the 
moat frequent is a change in the duration of the individual stages. The 
individual periods may be longer or shorter, and the eruptive stcge is so 
slight at times that care is requisite in order to recognize the Jisoase. 
The eruption may also be distributed irregularly and appear in relapses. 
There are numerous variations in the shape, color, abundance, and dis- 
tribution of the patches. Sometimes no eruption is observed. The pa- 
tients were subject to infection, and presented the symptoms of measles, 
but no exanthem was obsei-ved. Desquamation occurs, nevertheless, in 
Bomo of these cases. Iq other cases the eruption on the skin was present, 
but tlio inflammations of the mucous membrane remained absent. 

The disease is sometimes said to run an apyrexial course, but the 

IdiafDosis ia not always certain in such cases. In others, there is unu- J 
Roall^ protracted and high fever — a phenomenon which leads us to the I 
fiMafderation of the complications of measles, I 

t The stage of incubation aoroetimos begins with high fever, followe4]l 
■tfomnolencc, delirium, and epileptiform convulsions. These symptotnt^ 



■ft;? 



104 AOUTB INFECnOUS EZAaxmDCAXiu 

nffs not f rcqnont, and thoir deyelopment is fayoied by accidental inter* 
rtfirrMtit alTooiioui* 

Hio nurvouM symptoms referred to may also be obaenred in the snb* 
M3i|iM)iit (Miurno of measles as the result of abnormally high temperatures. 
Atmtoiiitual diwHwes of the nenrous system are rare, although meningitis 
liiMi ti0tiii ohmtrved in a number of cases. 

A s^ry Kmvu complication is malignant )iemorrha^c measles, which 
in oiiMirvtHl with rt^lutivo frequency in feeble, cachectic individuals. Hem- 
fii'flmi/DN am>oar« not alone upon the external integument, but also 
IfiiM iliM mihoutanoouB cellular tissue, and from the nose, air passages, 

t^f^ffl f'o iiitoMtiiml tract, and genito-urinary apparatus. The temperature 
n ijMttomlly higli. The patients often lie in a typhoid condition: tongue 
(it'Vi 11]^ 1411(1 tongue covered with sordes, abdomen distended, diarrhoea 
fi'Mfjtioiit. Inhere is rapid exhaustion and death after. symptoms of in- 
uwM^luU coUttpBO.^ Thfs is no doubt the result of a genend septic condi- 
Mon. 

Kvury organ may be the site of complications during the course of 
MiuhmIum. and some epidemics are characterized by the frequent occur- 
iMiiMti of curtain complications. 

|i!rythema of the skin is sometimes observed during the prodromal 
fiiid uruptive stages. Urticaria, more rarely pemphigus, may also be as* 
mir'miiid with the eruption of measles; herpes facialis is occasionally 
uhHuvvbd. After the disappearance of the eruption, gangrene of the skin 
or multiple abscesses and furuncles sometimes develop. 

The mucous membranes often present complications, such as phlyo- 
tiiiuular inflammation of the conjunctiva, epithelial erosions of the cor- 
II uu, keratomalacia or ulcerating keratitis, conjunctival blennorrhoea or 
diphtheria (the latter generally terminates in rapid loss of the eye). 

The patients complain not infrequently of impairment of hearing and 
ringing in the ears, on account of the extension of the catarrh from the 
iituio-pharvngeal space to the Eustachian tube and even the middle ear; 
thti catarrhal inflammation sometimes becomes purulent. If the middle 
ear contains a large amount of secretion, the patients complain of throb- 
bing and sticking pain in the ear. The membrana tympani not infre- 
(|ueiitly (ioiitains a slit-shaped opening, through whicn the secretion 
trickles, but this generally recovers spontaneously. If swelling of the 
nuinous membrane and impairment or abolition of hearing on both sides 
is left over, deaf-mutism may be produced in young children. Gottstein 
described des(}uamative inflammation of the drum membrane. 

Epistaxis is frequent, either in the prodromal or eruptive stage, and 
often affords a feeling of decided relief. 

The buccal mucous membrane sometimes contains superficial follicu- 
lar ulcers or aphthous changes. Sprue is observed in feeble and un- 
cleanly children. Stomacace, gangrene, or noma are rare. 

The tonsils are often swollen, occasionally there is phlegmonous amyg- 
dalitis, or even diphtheritic and gangrenous changes in the tonsils and 
pharynx. 

(ficerations have been found on the posterior wall of the larynx, and 
aisi) on other parts of the laryngeal mucous membrane. A very grave 
complication is laryngeal diphtheria (croup), which is unusually frequent 
in some epidemics. Bronchiolitis and broncho-pneumonia are not un- 
(uunmonj iihrinous pneumonia is observed less frequently. We often find 
i^tehictiMis and acute pulmonary distention, particularly on the anterior 
modian borders of tne lungs. Pulmonary abscess and gangrene and 



ACDTK ETFECnOCB EtAHTHEMATA. 



105 



be' 

M 

of 

tit 
rec 

K 



' BDJll 






pleurisy are rare co m pi i cations. Inflammatory changes in the lungs 
produce unusually protracted and high fever, and give nse to the danger 
of suffocation, or, at alater period, of incomplete absorption, tubercular 
infection, and caseation of the inflammatory prodiictB. Complications on 
the part of the respiratory organs are especially frequent during the win- 
ter. 

The heart is rarely affected (endocarditis or pericarditis). Demme 
described enlargement of the thymus gland. 

The diffestive organs are especially apt to be affected in summer epi- 
demics. The tongue may lose its white coating and, as in scarlatina, 
become diffasely red and papular from swelling of the papilltBs Fre- 
quent vomiting is not uncommon. There is occasionally violent diar- 
rbcea, of a cholera-like or dysenteriform character. I know of one case 

which a medical student died in twenty-four hours with choleriform 
uptoma, shortly after the eruption of measles had paled- 
Serious renal changes are rare, although albuminuria, together with 
the presence of castSf and hematuria have been described in a number 
of cases. 

Necrosis and gangrene of the genitals has been occasionally observed. 

Complications and sequelae of measles cannot always be sharply dis- 
tinguished, since the latter generally develop out of the former. After 
recovery from measles, previously healthy children sometimes remain 
weak, and do not regain their former health for a long time. Condi- 
tions of blood dissolution sometimes persist for weeks, and are shown by 
morrhagea into the akin and mucous membranes, particularly the 
Tne skin exhibits a tendency to chronic inflammations, and 
latinate eczema, impetigo, and furonculosis, etc., develop. Measles 
kce often the startiu^-point of scrofula and tuberculosis, enlargement or 
suppuration of the lymphatic glands, diseases of the joints and hones, 
chronic pulmonary phthisis, or uiiliary tuberculosis. Poorly nourished 
or feeble individuals are especially endangered. These conditions are 
probably the result of imperfect absorption and drying of the inflamma- 
tory products and proliferation of tubercle bacilli, on account oF the 
diminished power of resistance of the organism. 

Optic neuritis, chorio-retinitis, and amaurosis have been observed at 

les as seqnelEe; the amanroais generally recovered in a few days or 
'eeks. 

Measles sometimes exert a favorable influence on other diseases, and 
been known to cause the disappearance of chronic skin eruptions, 
epilepsy, chorea, even diseases of the bones and joints. Diseases of the 
reflpinitory (frgans are always rendered worse after measles, and the 
combination of pertussis and measles is almost always followed by severs 
pneumonic and oronchitic symptoms. 

Uncomplicated measles are rarely fatal, but complications may 
attended with great dangers. 

III. D[\OKosi3. — Tne diagnosis is easy if we direct attention,] 
alone to the eruption, but also to the remaining symptoms, particularly 
the fever and changes in the mucous membrane. 

Measles are distinguished from scarlatina by the fact that the skin 

ig not uniformly red as in the latter disease, by the absence of the 

" iHatina tongue and diphtheritic changes in the pharynx, and by 

le rare occurrence of nephritis. If measles and scarlatina are preva- 

:it at the same time, violent vomiting during the prodromal period 

'Oald favor the diagnosis of scarlatina. 



he 



106 ACUTE INFECTIOUS EXANTHEMATA. 

Boetheln is distingnished from measles by the absence or slight grade 
of the febrile movement. 

If variola is also prevalent, measles may be mistaken for a beginning 
variola, but in the latter affection papales and pustules very soon develop 
upon the patches; severe pains in the back during the prodromal stage 
favor the diagnosis of variola. 

It must also be distinguished from roseola due to other causes. 
Tjrphus fever has been mistaken for malignant measles. It is easier to 
exclude typhoid fever, since, in this affection, the roseola is not so pro- 
fuse. In both cases the face, and generally the limbs are not attacked. 
Patches of roseola occur occasionally with the menses, after gastric dis- 
turbances or the administration of certain drugs, but in such cases there 
is no fever, and the mucous membranes are not attacked. In syphilitio 
roseola, other evidences of syphilis are present. 

IV. Prognosis. — In uncomplicated measles the mortality is hardlv 
three per cent, but malignant epidemics sometimes occur and are much 
more fatal. The prognosis is so much more serious the younger the 
patient, the weaker his constitution, and the more unfavorable the sur- 
rounding conditions. High fever, bronchiolitis, broncho-pneumonia, 
croup, and severe gastro-enteric disturbances also cloud the outlook. 
Dangerous sequelae may make their appearance after the subsidence of 
the measles. 

V. Treatment. — Rational prophylaxis may limit the spread of the 
disease. The patients should be entirely isolated from healthy children^ 
even during the incubation and prodromal periods. 

If measles break out in a family, the most certain protection for the 
healthy members is to send them away to an uninfected place. As the 
disease can be escaped by very few at some time of life, and as it said to 
run a more severe course in adults, it has been proposed by some to per- 
mit infection if the epidemic is not malignant. Prophylaxis also in- 
cludes disinfection of the patient's clothing and bedding in hot vapor, 
thorough airing of the sick-room, and disinfection with sulphur vapor, 
and the addition of carbolic acid (5^) or corrosive sublimate (1 : 1,000) 
to the sputum, urine, and faeces. Bath-tubs employed by the patient 
should be thoroughly scrubbed before being used by others, ana their 
eating utensils should be kept separate. 

About one ounce of sulphur should be burnt for each cubic metre space in the 
room ; the sulphur is broken into small pieces, mixed with powdered sulphur, 
and lighted in a clay vessel. The walls and furniture should first be moistened 
so that the sulphurous acid may act more effectively. The room should be kept 
closed at least six hours, and then aired for a few hours. * 

Uncomplicated measles require no medicinal treatment. The sick- 
room should be capacious, and aired several times a day through the ad- 
jacent room. It should be slightly darkened, and the head of the bed 
placed towards the window to avoid a glare in the patient's eyes. The 
temperature of the room should be kept at IS*' R. In the winter, open 
vessels filled with water are placed upon the stove in order to keep 
the air moist. During the febrile period the patient should receive only 
fluid food : weak tea, milk, soup, lemonade, carbonated waters, or wa- 
ter mixed with a third claret. The bowels should be kept open daily, a 
mild laxative being given if necessary. The use of lukewarm baths 
(26° R.) is extremely important; they should be given between 8 and 9 a.m. 
and 4 and 5 p.^., duration fifteen minutes. After the bath the body is 



ACUTE ISFBOnOUS EXANTBEMATJk. 107 

quickly dried with warm cloths, and the shirt anJ bedding are also kept 
warm. We are convinced that measles run a milder and shorter coarse 
in many cases nnder this plan of treatment with baths. 

If the temperature of the body rises above 39.5° C. io the morning, 
or 40° C. at night, on account of the severe infection or complication 
with inflammations of internal organs, baths mnst also be given. We 
prefer lukewarm baths (for thirty minutes, two or three times a day) to 
cold baths for this purpose. But if the fever continues unchanged for 
forty-eight hours, we should order antipyretics. Antipyrin (gr. xxx.-lsv. 
to 3 ij. of lukewarm water per rectum) is preferable, on account of ita 
prompt and continued action, to quinine, salicylic acid, kairin, or thallin. 

In other respects purely symptomatic treatment must be adopted. 

After the fever has ceased for a week, the patients may leave the bed, ^^^ 

I and at the end of another week may go into the open atr if no residua ^^H 
of the disease are left over. ^^^M 

2. Scarlet Fever. Scarlatina, ^^^| 

I. Etioloot. — Like measles, scarlatina is one of the infections dis-^^^| 
e&Beg, and never develops autochthonously. It is often difficult, how-^^^| 
ever, to ascertain the source of infection. Close contact is not necessary 
to produce infection. It is sufficient to be in the same room with the 
patient, so that the poison Is evidently communicated to the air. Infec- 
tion may also occur through the agency of persons or objeots that 
have come in contact with Ecarlatina patients. Two facts must be 
noted in this connection: First, that very brief contact is often suffi- 
cient to produce infection, and secondly, that the virus possesses very 
great vitality and is capable of producing infection, through the agency 
of infected objects, at the end of ten years. 

The vims is supposed to be present in the blood, lachrymal fluid, 
nasal secretion, sputum, epidermis scales, urine, and perhaps the fiecea 
of the patient. Cases have been reported of successful inoculations with 
blood and the contents of miliary vesicles on the ekin. But such experi- 
ments are not always Buccessful, particularly those performed with scales 
obtained during the stage of desquamation. 

Scarlatina seems to be infectious in every stage, perhaps least in the 
incubation stage, most during the eruptive stage, next in the stage of 
dGS()uamation. As a general thing, the patient should be kept secluded 
until the eud of the sixth week. 



^_ (Kfte 



The nature of the Bcarlatlna virun is not known. Bacteria have been nought for, 
but with the exception of the recent atateuients of Pinkus, none point (vilb cer- 
taintj to the scarlaiinouB character of these orgaDisnia. 

Thesusceptibilty to scarlatina is not so general as that to measles. If 
nieaales and scarlatina are rife in any locality at the same time, it ia 
often found that children who had suffered from scarlatina are at- 
iked by measles, while many escape scarlatina entirely. As in the case 

measles, some individual's seem to possess a temporary immunity 
_^„.)inat scarlatina. On the other hand, certain accidental circumstances 
may create an increased susceptibilitv. Tliials true of injuries and recent ^j 
delivery, especially in primiparie. under Hucb circumstances, we miiat 
be cautious in making a diagnosis, smce erythemata (generally pytemio^ 
or Depticsemic) may occur and be mistaken for scarlatina. 




3 



108 AOUTB iBFBcnors BXAgrmnrATA- 

It it also said that deaf-mntea f om om ao incnaaed, phthlairal and acrafokMia 
Individual! a diminished, auaoepiibtUty to the "' 



Tho majority of indiyidnals suffer from scarlatiiui dunng childhood, 
l)tii more adults are attacked than in the case of measles. Scarlatina 
1h ruro in the first six months of life, most frequent from the age of 
two to Hoven years. It has been obsenred, howeyer, a few days after 
birth, and oven at birth. Cases of the latter yariety require the strictest 
eritiiMdin. since scarlatina may be mistaken for erythema neonatorum. 

In ohihUuHHl the sexes are affected alike; among adults females are 
nald tit be attaektHl more frequently. 

A «in]i;le attack generally confers permanent immunity, although there 
mv (KHHU^ional exit^ptions to this rule. Some indiyiauals have been 
known to MutTer mm many as four attacks at intervals of a few years. 

lteia|M«Hi within a few days or weeks after an attack are also rare. 
'Ihe teini iimMidt)- relapses is applied to those cases in which the eruption 
ivtiMn« U«K»rv iloMiiimmation nas occurred. 

Mi44iUViim N iHtnibiiHHl occasionally with other infectious diseases, for 
^%4ui|*le. Mii«H«tt)«. variola, varicella, typhoid fever, and mumps. 

M^M»i4(tio raM«i« (NHUir constantly in large cities. At times these do- 
V4iliii» tuhi iniUleinieM. which may spread orer a large territory (pan- 
iliiuV) tC|ii(leMil(M«of scarlatina run a longer course than those of measles, 
|tMMH«ul ui|»MHte(l is«ac4frtmtionB and remissions, and in isolated cases are 
(tUi.u |ii4«ti4«4iMl Mioro than a year. In some localities the epidemics are 
«(»iiti In 4|i|*i«4t at (Msrtain detinite intenrals ^ur to six years). The 
4MtO'**i^Y <*f i»|ii<luMii<M liegin in the autumn. They are sometimes ex- 
iii.aii.lv (Uugiuous. 

i I 1^1 Mi'MiMtt. Thd disease is divided into the stage of incubation, 
|iit«'iM'tu4U, iiiMjitidh, and dcsauamation. 

iUii aUuii (if Ihitubatiou often varies greatly in duration. On the 
•if i.titk^t*. <t fatts four to seven davs. In some it 'lasts hardly half a day, 
nil 1 iM <<thiu# It U rtsported to nave lasted two or three weeks or even 

'i'lif. |fiiiilHiMial stago is sometimes barely indicated; in other cases, it 
i*«.;U U(.ia^ M'Mi III forty -eight hours. 

iiMiihg thit AtuH<^ of innubation, the majority of patients feel almost 
t.idui.ii «yt«ll In Mdine, there is a general feeling of malaise, and there 
H(«(^ i"^ •( otiit^ht liae (if temperature, often only at night, towards the 
Ml') •<! UiU Uiihitl. 

'ric. |iiiiM((iiii4l ttliitfe often begins suddenly. It begins more fre- 
411' iitif WUi( ((>|i(t4toil (shilly sensations than with a single violent chilL 
Till. lMini(;iatii*(t ii»e« very rapidly to 39 or 40°, and even higher. There 
«.; M l.iiniiiijt$ fociinij in the throat, and often disturbance of deglutition. 
Tit'. ni'ifLdn-nto cf the Jaws are painful and swollen; painful glands are 
(tuttyl (n.iiind the unghis of the h)wor jaw. The pharynx is red, and its 
f'/lli' I'.t ritVdilMn- \i tii'iit the redness is sometimes found in patches, 
V'U'li \ii.yi,m Ht tiiM nvnla and then extend to the soft palate and its 
f'jVli'.} hilt lid MMt attu(tk the posterior wall of the pharynx. Gastric 
.!^i<i|il'*Hi»j aHJ dfteii jiKiininent, especially repeated vomiting. In chil- 
li/' it il<<< hiul( I'evei ddinetiines gives rise to delirium and convalsions, 
X^hi' h '(M. n^it niiiieoBuril.v (»f ^(rave omen. 

(Vl(< n lh>: aU^ii (if eru|ition begins, the exanthem appears first on 
III' h<.' I. in I 1m. iiiunm of the mastoid processes, and on the nape, and 
/!,. M . 4li.n(hi (iViii- IwM entire body. It is least distinct in the face, be- 



AaUTE IMFSKJnOUB EXUTTHGUATA. 109 

t oause it ia concealed partly by the flush of fever (thus offering a contrast 
to the ernption of measles), and the chin, angles of. the moutn and nose 
Ere apt to ue extremely pale (local spasm of the vessels). The back and 
chest are generally attacked with special severity. The extensor snr- 
faces of the limbs are more affected than the flexor Burfacee, vith the 
esception of the dorsal surfaces of the hands and feet. In little chil- 
dren, it is very evident that the scalp ia also covered with the eruption. 
The outbreak of the eruption is sometimes accompanied by slight prick- 
ing and itching in the skin. 

The eianthem begins in the shape of fine, deep-red or scarlet patches, 
80 that the skin apitears speckled. These central patches are surrounded 
very rapidly by peripheral zones which are less red in color. The patches 
are so closely aggregated that their peripheral zones unite, and tlie skin 
asenmee a diffuse red color, in which very flue, dark-red points are 
visible. The Integument is swollen and in places slightly cedematous, 
flo that, for example, the palpebral fissure may be diminished in size, as 
the result of (sdema of the lids. The eruption is sometimes preceded, 
I for a few hours, by temporary erythemata. As a rule, the eruption 

I spreads very rapidly from the neck over the entire trunk (often in twelve 

to twenty-four hours); sometimes it appears almost at once over the 
entire body (scarlatina lievigata). 

The eruption may present variations in shape. The term scarlatina 
papulosa ia applied to those cases in which the follicles of the akin are 
markedly swollen, and the patches have a papular appearance. Slighter 
grades of BweUing are observed almost constantly on the forehead and 
dorsal surfaces of the hands and feet. In scarlatina miliaris, very flno 
vesicles, with clear, alkaline contents, appear upon the skin. This form 
ia favored by profuse sweating, but may appear independently, and ia 
the result of active exudation between the rete Malpighii and epidermis. 
The little vesicles sometimes attain considerable size (scarlatina vesicu- 
losa a. pemphigoidea). In scarlatina heemorrhagica, extravasations of 
blood occur under the skin. This is a bad prognostic sign, if hemor- 
rhages also occur from the mouth, nose, stomach, intestines, genito- 
nrinary or respiratory organs. In some cases, the eruption of scarlatina 
I ^ appears in circumscribed hyperffimic patches (scarlatina variegata). 
^^^K The affected skin at first pales completely on pressure. I^ter, a yel- 
^^^Hfjrwish or even a dirty, hemorrhagic color is left, showing that simple 
^^^Hengestion has been followed by exudation and diapedesis of red blood- 
^l^^pohules. Despite the hypersemia of the skin, the irritabilityof the walla 
I of the vessels appears to be increased. On stroking the skin with a hard 

Bubstance, the irritated parts remain pale for some time. 

The eruption is most marked on tne second or third day. Variations 
in the intensity of the cutaneous redness occur occasionally and are 
chiefly dependent on the height of the fever. The redness can also be 
increased oy keeping the body warm. 

With the appearance of 'the eruption, the difficulty in deglutition 
and the redness of the pharynx increase in severity. The inflammation 
extends from the pharynx to the mncous membrane of the cheeks and 
lips, and there produces a burning sensation. Swelling of these parts is 
absent or very alight; increased secretion is more frequently noticeable. 
Here and there small extravasations are visible. Many of the follicles 
are swollen and project as little papules. 

The edges and tip of the tongue are very red, while the larger part of 
» rorface naa a more or less thick, grayish, or grayish-yellow coating, 




A 



jkocnc iHKnjninra RZAirrHraUTA. 

1 which the swollen fungiform papillee jiroject as bright-red papules. 

i few days the coating is shed, so tliat the entire surface of the tongue 

becomes bright red. The marked swelling o( the papilla? makes the 

snrface warty or nodnlar (strawberry tongue). The size of the organ is 

^nerally increased, as is evident from the impressions of the teeth upon 

^^ edges. 

^^m The bodily lemperatore rises still higher with the outbreak of the 
^H^ption. and, as a rule, exceeds 40° C. The rapidity of the pulse often 
^^Koeeds one hundred and forty beats a minute. Towards the end of the 
^Hnek the temperature diminishes gradually, not suddenly as in measles. 
^^Bem plication 3 may maintain the elevation of the bodily temperature for 
^Hraeks. 

^B The symptoms mentioned occupy the foreground. Dulness in the 
head, headache, and deliriDm are not uncommou. The appetite is lost ; 
thirst is generally increafied. Eructations and repeated vomiting are 
common symptoms. The urine is scanty (febrile urine), often showa 

























B^^^^^HIHHi^H 


r 


1 


1 



T^mperaRm curre ia ocarlaUoa ot moderate Tempeistiuv ci 



arlatioa of abort di 



the ferric chloride reaction ; Brieger found a large amount of phenoL 
Febnie systolic murmurs may be heard over the heart. The spleen and 
even the liver are sometimes slightly swollen. Aa a rule, the eruption 
first paleson those parts of the skin which were first attacked, and the 
stage of eruption is rapidly followed by that of destjuamation. Upon 
the integument of the neck and face, later on the trunk and limbs, 
appear fissures, and scales of epidermis are raised. Upon the faoe and 
sweating portions of the trunk the scales may be small (branny desqua- 
mation) ; on the limbs, particularly the hands and feet, the skin strips 
off in large shreds, and is sometimes pulled from the fingers like a glove. 
Small elevations, like vesicles devoid of contents, occasionally form upon 
the integument, and form the foci of subsequeut dosquamatiou. The 
patients experience the feeling of restored health very soon after the 
cessation of the fever, and are kept confined to the room with difficulty 
during the stage of desquamation. 
"* Tiie typical course of scarlatina may be changed by numerous anoma- 

IttComplications, andsequelee. 

^Tho individual stages of the disease mav vary greatly in duration. 
k oIIdIcoI history may consist merely of fever. Tasting a few honiv 






M 






AODTB iNTBcrnous kzabthsmatjl. 

t fleeting redseae of the Gkin, and msigutficantdiaturbancesof deglutition.! 
Fig. 18 ahowa the temperature curve of such a cose : audden repeated ' 
vomiting Ht 12 p.u.; next day, acarlatiua eruption OTcr the entire Dody ; 
tho day after, a few remains of the eruption on the limbs ; subaequently, 
marked desquamation. Such mild cases may be followed by severe 
eequelie, iiarticularly nephritis. Nephritis in children aometimea appears 
to oe of apontaneous origin, but on careful guestioniug it is found to 
have been preceded by brief redueaa of the akin, followed by desquama- 
tion. In other caaea, the etagea of the disease are unusually prolonged. 
For example, caacs have been reported in which desquamation continued 
for months. The intensity of the symptoms is also extremely variable, 
particularly with regard to the febrile movement. Thus other symp- 
toms may be well developed, although the temperature is normal or 
even subnormal. Again, febrile remissions are sometimes observed at 
night, exacerbations in the morning. The eruption may also present 
anomalies. It may appear first on the trunk and limba, or certain parts 
of the body remain unaffected. Desquamation often occurs several times 
OQ the same place. Or desquamation may also afiFect, in part, the nails 
and hair. It is aometimea barely indicated, particularly in old people 
with a dry, wrinkled integument. Here we may call attention to the 
fragmentary forms of scarlatina. These include scarlatinous angina 
witnoiit eruption, i. e.. a pharyngitis produced by infection with scar- 
latinous virus, unattended with an eruption, but capable of conveying 
Bcarlatina to others. Desquamation is said to occur uespite the absence 
of eruption. In ether cases, the eruption develops, but angina is not 
produced. 

Lelchtensteni believes ttiat certain forma of nepbrttis also belong to the cate- 

Kry of fraKinentaiy scarlatina. He thiaka that during epidemics nephrilia may 
produced by the action of the scarlatinous virus, without f ru[)tion or angiua. 
and tbat it may give rise, by infectioD, to fully developed scarlatina. Parotitis. 
gaatro-enteritia, and simple febrile conditioiis have auo been described as fiag- 
ueutary scartatina. 

The moat frequent and important complications are diphtheria, 
nephritis, and inflammation of tiio joints. 

Diphtheria of the pharynx ia almost constant in certain epidemics, 
and ia often more favorable than the primary diaease. In some caaea, it 
develops after the outbreak of the eruption; in others, it is preaent dur- 
ing the prodromal period. It may not produce very severe symptoma 
at first, so tbat its onset can only be recognized, in many cases, on in- 
tpeotion. Some caaea of acarlatina sine exanthemate appear aa diph- 
tneria acarlattnosa sine exanthemate. It ia often the starting-point for 
other dangerous comnlications. It extends not infrequently to the mu- 
ooiia membrane of the nose. At first, the children present the aymp- 
toma of ordinary coryza, complain of stoppage of the nose and a burning 
sensation. Then a scanty, serous secretion appears, then a stinking, 
light brownish-red sanguinolent ichor flows almost constantly from the 
noae, thus proving tiiut the coryza was the forerunner of nasal diphtheria. 
The nares and upper lip are irritated by the diphtheritic products, 
erythema and excoriations develop, and the upper lip is very much 
swollen. In unfavorable cases, there may be destruction of the nasal 
mucous membrane and necrosia of the bones. The diphtheria may also 
extend to the Eustachian tube and middle ear, giving rise to tinnitus 
ftnrium, impairment of hearing, violent pains in the ear, and uetially in- 



ii^ Acnx 

rreasei fever. Tliese maj erentiuLte in the production of pus, perfora- 
tioQ «if the membnuiift cjmDAnL chrombosiB of the sinnees^ meningitis, 
^'t^n^bnkl :ib(M!esB. anci}acroIIdJbIe hemorrhage, etc. In exceptional cases, 
che <iiphcherufc extends Co che Ltrrnx, trachea, and CTen the bronchL A 
mon? fr^^aenc ot}mpli<.':uion La mflammation of the submaxillary lym- 
phacii* x^jinits} cuid iurrijamiinjg eellolar tissue of the neck. The parotid 
And ^ubm^uiUiuy xuknd^ u« sometimes iuTolved. The inferior maxillary 
rvc^t^n la tir bacK it» the mastoid processes is swollen, hard, hot, and 
u*in"'iL A: Irsc. :he overiyin^r integument is often very pale. If sup- 
rra'ncon nrvurs jnd ^he pas Lsaboat to perforate the skin, the latter be- 
C*\>mi>« i(*f^. itiiuri^. :uid reddened. The pus often contains gangrenous 
siT.r^^iJf »c -^asie. Whuch is necrosed on account of the compression exer- 
"$^i y^' "le -jizbuned ntsue and the partial interruption of circulation. 
iri%* 7it& ^mecmetf tnakes its way into the mediastinum, pleural or peri- 
v:;irLui -%r*rr. jr ;c amy produce fatal hemorrhage by erosion of large 



v>«im*«w atlN^ « 6«» *^w <htfr scariatina merely creates a predisposition to 
ilc^l^w^v^ fT^vtiMifttfr ciii» liftmirui tlii0.dixect result of the action of the scarlatinous 
«« ii» itMij HI Cn eb« lactirr enrnt, it must be assumed that the diphtheria 
> ji^ntimitr dlllvciHil (h>m primary diphtheria. The former view 

^ _. -^«^«niMd. 4anc« LMtlmr founa the same micro-organisms in scarla- 

r^Zl ||.i^twic««k « vtt th« pciauftnr form. Attention has been called to the fact, 
V>«r«t««^ MM -^ 'x^>^ t!<Mtn« OIiAnt dinicallT, inasmuch as scarlatinous diphtheria 
-^wy «m««M^ ^ ^ i.^^twtu»rrr onpuw ana is still more rarely followed by diph- 
^Jyl^fv ^umv>««««> OiilM«« ciaiu Uuu th«re are also anatomical differences, that 
. ,«^i^,^^^<^». .it|iMk«nifc Q^ oMtttbcanw are thinner, that necrosed epithelium 

;mrt»^ >jmj^H :sjfeMM» «ttd tiitat fibrinous exudation can be traced deep into 



s <Nm> >fn\wwiv^ tvtt«l ohAUgee are almost constant; in others, they 
^v •^•^ •***'* ''*w*r ^v«rt^*cion with the height of the fever, intensity 
^ -K .M.s'vSK v«vl ^.^tiuuott* diphtheria cannot always be proven. 
\ , *. V K * **^v*t * >^» rv<*ilt of leaving the bed too early. 

r-K *i .U«t vtm v*f ?v«a1 disturbance is slight transitory albumi- 
,,.,.^ .%.»N*^ «xV tvi^v«vl ott tho (ever, the infection, or both. This 
'.\>^-v *->.h;i,> s^ ^Sv tl^t dd^v;^ of the disease, and disappears with the 

f\^ s-*^ *V\s* i»^***w\*tv wrious when abundant renal epithelium 

•V * V .v.^<*, ^• V uMt^Arv A\iiment, an evidence of a desquamative 
^s H-s> -• ^ V Ni-*v^^ l^ aviditiou^ there may be hyaline or epithelial 

\ ^ ^ ^ -'^x^ "X'V *»:^?r At\» Auaetimes very long, flat, convoluted, 
**"^ ^ ..^^x tvs^x-Ui^fwt v'^'^*^^^'^^ oyliudroids). These processes may 
* '\. \.N^*.v.* \ xs ^^x*^ arv *w^Hnated with albuminuria. In the 
;^ '* . \. , K^' H^v ^^'*v5v> vli^ipiHHir and form prodromata of an 

"^ ' ^^^ ,...^ V^ «^viH^ N^^yjk uttmervnis casts have been found, but 
^' ' ' .V .., ^ Kv»4 • V tx<>wU^ Baotoria have been found repeatedly 
; J \,^, , .,; V, ,% A^*H^\VK><!^ h^vv alA> been observed upon the casts. 

,%^*^ss .V i^ vtssOxV ttcphriti* often develop quite suddenly. 




\ 



\^ 



V > ' v\Nf A? ^**^; N^** to the urinary changes. Urhidrosis 



V , K ^N NN^^N^^v > xH v\MiWt of anuria, the urea being deposited 
^' \ \^ *S^ v\^H^^N>*ix^ the sweat, in the shape of a fine. 



acute: mrzcnovB EXurrHiauTA. 



118 



I tio 



' vhite crystalline deposit {vide Vol. II., page 261), In some cases, 
<£dema is the first suspicious sign, and may even appear before the urine 
contaiuB albumin. It has been found that, despite the existence of 
nophritis, the urine is temporarily free, in some cases, from albumin, 

gerhaps because certain parts of the kidneys functionate normally, while 
le secretory power of the diseased portions is entirely abolished. The 
I.^Kidily temperature sometimes rises with the onset of nephritis, and the 
Ionise is often diminished in frequency. 

Some writers believe that the kidneys are always affected in scarla- 
tina. While we do not coincide in this view, we admit, nevertheless, 
that the urine appears normal in some cases, although the autopsy re- 
veals considerable changes in the kidneys. 



It is assumed by iome authors that the kidnej-s excrete the scarlatina virus 
from the orguniBm. ari<l thita undergo inflammatory changes. Others coll atten- 
tion lo ihe relalion hft.weea diseases of the skin and kidneys, which is seen in 
I^Aher coDditiotis. Still othem look upon the nephritis, not as & complication, 



the direct result, like eruption and angiaa, of the scarlatinous v 



InAammations of the joints are much rarer than the renal complica- 
tions. They sometimes occur at the height of the diseaso, more fre- 
auentiy after the eruption has disappeared. The small joints of the 
ngers are especially apt to be attacked, more rarely the large joints of 
the limbs. The symptoms may consist chiefly of pain, or this may be 
imbtued with swelling, redness of the skin, and increased warmth. The 
ibenomena are similar to those of acute articular rheumatism, and, as in 
" le latter disease, the symptoms may jump from one joint to another. 
he effusion into the joints is generally aerouh, rarely purulent. The 
leaths of the tendons may also undergo inflammation. 




Fumlent arthritis in scarlatiaa \b sometimes the result of pyemic conditions. 

_._ '"*'iwd from the jomts, Hahrdt and Ueubner recently found coed ar- 

C these were bJbo found in the diphtheritic deposits on the tonsil^ d 
U, and in the blood. 1 

We will content ourselves with a brief description of the most import 
tant of the remaining possible complications of scarlet fever. 

The disease sometimes begins with such a high temperature that the 
patient is not alone thrown into delirium and convulsions, hut dies 
in a few hours from paralysis of the heart, before the outbreak of the 
eruption. The temperature may also reach a dangerous height in the 
further course of the disease, and the patient may tnen manifest typhoid 
symptoms (apathy, dry tongue, sordes on the lips, metcorism, diarrncea), 
in some eases early death, befoi-e the appearance of the eruption, seems 
to he associated with specially severe infection. Meningitis is one of 
the rarest complications of the disease. In the majority of cases, the 
eyes are unaffected. Mild conjunctivitis is occasionally observed. The 
gpaver complications are diphtheria, keratitis, koratomalacia, hypopyon, 
konttitie and iritis, choroiditis, and nenroretinitis. Sudden amaurosis 
irith preserved pupillary reaction, and the changes of retinitis Brightica 
'nve Doen observed occasionally in scarlatinous uraemia. The amaurosis 
lisappeared in a few days or weeks if the ureemic symptoms improved, 
iditory disturbances are frequent. Impaired hearing and tinnitus au- 
may be the result of occlusion of the Eustachian tube. Graver 






i; 



114 AOUTB INFBCnOUB EZABTHEMATA. 

conditions are produced by extension of diphtheritic and purulent inr 
flammation into the middle ear. 

The pharynx sometimes contains superficial erosions, resulting from 
destruction of swollen mucous follicles. More serious symptoms are 

Imxluced by parenchymatous inflammation of the tonsils with abscess 
urination. Tne Tiolent pain, high fever, and difficulty in breathing, 
Imnluooil by swelling of the pharyngeal tissues, torture the patient. 
)tin^)r of suffocation may arise from rupture of the abscess during 
iilH«p. and the passage of its contents into the larynx. Gangrene of the 

(iharvnx Honietimes develops, may spread widely, and prove taial from ex- 
tauntiou or the erosion of large vessels. Noma is rarer than in measles. 

i^aryngi^ttl and tracheo-bronchial catarrh is much less frequent than 
ill int^aHloM. Attention has been previously called to the extension of 
(iijihtlioria from the pharynx to the larynx and deeper air passages. 
(JK^iittiui of the ji^lottis aevelops occasionally, either as the result of neph- 
ritic and unoinia, or of inflammatory changes near the entrance to the 
litrviix. ('utarrh and fibrinous pneumonia are rare, pulmonary gangrene 
mimI Hl»f«M^riH uro still rarer. 

liilliMiiiiuitions of the serous membranes are not very uncommon; the 
U^\n',i iM iittackod most freouently, the peritoneum least frequently. 
iHili inflammations are usually purulent. 

Kjiilocarditis is not a rare complication, and the majority of cases of 
^Mlviilur leHion of the heart in children are associated with the endocar- 
(\\U» (if Hnurlatina. it sometimes appears as septic endocarditis, which 
tfiviitt rititi to embolic changes in vanous organs. Hypertrophy of the 
hi'iu't Hometimes occurs very rapidly during scarlatinous nephritis. I 
Uiivii aUo noticed the rapid appearance and disappearance of cardiac 
ijjltttution. 

Hevere complications are sometimes the result of changes in the 
UUaul, These reuult in extravasations beneath the skin and free hemor- 
rUiiUtm from various organs, and often prove rapidly fatal. 

7)\niUntit4i and threatening diarrhoea sometimes occurs, and may 
MMtUfjie a dy^nteriform character. Hsemoglobinuria and mellituria have 
}ti:*:h re|K>rted in a few cases. Serous, purulent and bloody discharges,. 
i^iftd:iiiiii, gangrene, diphtheria, and infiammation of the testicle have been 

lieis/^uamation is sometimes so active that excoriated and bleeding 
mi'Ui^'^^ of skin make their appearance; in rare cases, there is gangreoft 
of the f^kin or certain parts of the extremities. 

The complications of scarlatina cannot be distinguished sharply 
froni the sequeUe, since the latter often develop directly from the 
former. In some cases, general feebleness persists. The convalescent ia 
weak, even the mental powers are sluggish, and &tal diseases of the 
i-t^i^liiratory organs or intestinal tract are apt to supervene. Tubercular 
affections of tne lungs, lymphatic glands, bones and joints, rarely of the 
//jtijii4^es, sometimes develop after scarlet fever. Some patients suffer 
t^vm cljrouic skin eruptions (including furunculosis). Disturbances of 
i^iit'wH are freouent after scarlatina. If the disease is bilateral and 
<xcui'c in the first years of life, it may terminate in deaf-mutism. Ex- 
lUr^utivt 4efetruetion of the petrous portion of the temporal bone results 
t/ij^4i^wuiiiy in facial paralvsis. Foerster reported a case in which scmrla- 
jty;,4i hud given rise to bilateral deafness and facial paralysia, and, 
/f^f^/i^iMUd with the latter, bilateral ulceration of the oomea and blind* 
ffAf^, A/JMHum/ndAtive asthenopia is sometimeB obaeirad after acariatiiuL 



ACCTE ISFEOTIOUB EXANTHEMATA. 115 

Iiikc othsr infections diseases, it may also give rise to paralyses. Chorea 
has also been observed. Suppuration of the joints may result in auky- 
Insis. Yiilvular lesions of the heart are relatively frequent sequelae. 
The reanl changes generally disappear in cases which do not terminate 
fatally: chronic nephritis is a rare outcome, but I hare seen two cases of 
this kind. Ziun described a case of mellituria which lasted a loug time. 
WoUenberg observed albinism of the skin aud hair after very marked 
desquamation. 

Ill rare cases, scarlatina exercises a favorable influence on existing 
diseases. Thus. Gibney observed spontaneous recovery of an obstinate 
coxitis after scarlatina, and Tliompson reports that chorea disappeared 
in two cases. 

Ill, Anatomical Chancibs. — In the corpse nothing remains visible 
I of the eruption, but the skin is often peculiarly tense and cedematous. " 



Microscopical examination of the skin showa swelling of the cutis tisnue, 
antpullary dilatatloD of the veesela. BWelling of the cells in the rein Uaipi^hil, 
especiallj of the nuclei; in tlie deeper layers of the retti are Bpin(tle-Bliitpe<l. elon- 
gated cells, and Ijetweea tliem an accuiuulation of round cells and itnl blood- 
ElobuloB, and an accumulatiim of round cells aniund the excretory ducts of the 
follicles. Fenwick described hemorrliages into the sweat glands, and activs 
deequamation of their epithelium. 

The moBcular tissue is not infrequently very pale and brittle; the 
microscope shows cioady swelling and fatty degeneration of the muscu- 
lar fibres. 

There is not infrequently swelling of the entire lymphatic gland 
^stem: the peripheral and mesenteric glands, the solitary follicles, and 
Peyer's patcoes in the intestines. E. Wagner has described lymphoid 
new-formations in the liver, spleen, kidneys, and intestinal mucous 
membrane. The enlarged follicles of the intestines sometimes undergo 
nlceration. Klein found hyperplasia of the lymph follicles of the root 
of the tongue, the pharynx, tonsils, larynx, ana trachea; the mono- 
nuclear lymph cells were scanty, the multinuclear cells very numerous, 
BQ that giant cells were abundant. The veins of the cervical glands 
vere occluded by pings of fibrin. In the spleen, the microscope showed 
thickening of the sheaths of the arteries, hyperplasia of the muscle 
nuclei in the arterial walls, hyaline swelling of the intima, progressing 
to occlusion; changes in the Malpighian b^ies similar to those in tna 
peripheral glands. 

The heart is often very flaccid, pale, and yellowish in color, anjt] 
presents dilatation and hypertrophy. The muscular fibres are often ia 
a condition of fatty degeneration and cloudy swelling. The blood ie 
dark and its coagulability diminished; the white globules are not infre- 
quently increased. 

Diphtheritic changes are sometimes found in the intestines, more 

ir«ly in the cesophagus and stomach, to which they have probably 

^reuid from the pharynx. In hemorrhagic scarlatina, the intestines 

iometimes contain bloody masses. The liver often presents cloudy 

Rrelling and fatty degeneration, with proliferation of round cells in the 

^^teretitial connective tissue. Harley states that the solid constituents 

Baf the bile are diminished; the biliary acids are sometimes entirely 

*Ment. 

The kidneys are generally enlarged. In recent cases, extravasatioiu 



: 



AOUTB IHFECmorS EXANTHKHATA. 

are Tieible upon their surface aod upon cut sections; in older ones, the 
organ has a yellowish color, produced by fatty processes. 

Friedlaender describes three forma of scarlatina kidney, which are rarely as- 
sociated and never paaa into una another, a. Initial catarrhal nephrilis; this 
ap^ors with the eruption, or a Tew ditya later, soon disappears, and is charac- 
terized by cloudinaHH, swelling, and desijuanuition of the epithelium of the renal 
tubulos; a few round celts in itie interstitial tLsaue, b. Oloinerulo-nephritiB: this 
form ia almost characteristic of scarlnlina. The glomeruli are enlarged, llie 
nuclei of their walla increagied in number, the walls of the coils of vesseTs thick- 
ened, the epithelium of the capsule thickened, sometimea proliferated, e. Large, 
flabby hetnorrhagic kidney (septic interalitial nephritis). This depends lesa upon 
scarlatina than upon complicating ditibtheria and inflammation of tlie cellular 
tisBue of the neck, and generally pVovea fatal in a ahort time. The kidney is 
large, flabby, inflltrated with large and small lieinorrhagea, with numerous 
round cella in the interstitial tissue: micrococci emboli are frequent. Depoeils of 
lime salts in the tubulea have been deacribed. 

IV. Diagnosis, — The recognition of scarlatina ia eaa^, if HymptomB 
other than the eruption are also taken into consideration. Primary 
diphtheria of the pharynx is aometimea associated with erythematous 
cutaneous changps; hut these disappear rapidly, as a rule, and are not 
followed by desquamation. A similar eruption has been observed in 
acute articular rheumatism. The diagnosis from measles, rubeola, and 
medicinal eruptions is made according to the rules laid down on 
page 105. 

V. Prognosis. — The prognosis is always serious. Cases ■which 
have rtiu a mild course may prove fatal by complications and sequelse. 
Death sometimes occurs at the onset of the disease, on account of the 
high fever and severe infection, and not infrequently quite suddenly. 
In some epidemics, death is exceptional; in others, it is tne rule. Aa a 
general thing, the prognosis is so much more serious the yonnger the pa- 
tient. The greater the number of complications the less favorable the 
outlook. Urffimic symptoms, purulent inflammations of the serous mem- 
branes, and septic endocarditis render the disease especially grave. 

VI. Treatment. — The treatment is similar to that of merules. 
Prophylaxis ia extremely important. The patients must be strictly 
isolated, and all articles used oy them thoroughly disinfected, in order 
to prevent the spread of the disease. The patients may not be allowed 
to enter into general communication with others until at least a week 
after every trace of desquamation has disappeared. If possible, the 
other children in the family should also be isolated. As a rule, the phy- 
sician should visit his scarlatina patients last, and change his clothing 
on visiting patients who do not suffer from the disease. 

After scarlatina has developed, it requires the same treatment ae 
measles; wecan especially recommend the use of lukewarm baths. Other- 
wise, the treatment ia purely symptomatic. 

3. Roeiheln. Rubeola. 

I. Etioloot. — Some maintain that rubeola is a special form of 
measles; others, that it ia a mild and peculiar scarlatina; finally that it 
is a simple roseola. In our opinion, it is undoubtedly an independent 
infectious disease. It is most frequent in childhood, and rarely occurs 
in adult life. Nurslings generally escape. 

The disease is coutagiooa and is generally acquired by contact iritfa 



J 



AODTB mFEOnOCe HXUTTHEHATA. 



liT 



' other patients, or by remainiug in thosame room; but it can alsobecon- 
TeyeiJ indirectly by other peraoas or objects. Slight contact is some- 
times snfficieiit. 

One attack almost always confers immunity against another. Re- 
lapses are rare. The disease does not afford immonity against moitsles 
or scarlatina — an evidence of its distinct character. 

In large cities roetheln is often sporadic, and at certain intervals epi- 
demics break out (generally during the first half of the year). Their 
dnration varies. Schools and overcrowded houses fnrnish the most 
favorable localities for the spread of the disease, which is probably con- 
tagions ill all stages. 

II. Symptoms. — The period of incubation varies from two and one- 
half to three weeks. 

Prodromata are sometimes entirely wanting. In other cases, the 

r patients complain of malaise and anorexia for one to three days. Slight 
fever (38 to 39° C.) may develop, the patients complain of slight dif- 
ficulty in deglutition, congh and sneeze a good deal, complain of slight 
Vpiph'ora and photophobia, A few hours later the eruption appears. 
I But as we liave remarked above, prodromata may be entirely absent, 
jud the symptoms mentioned then appear with the eruption. This 
consists of pale-red, roseolar patches, from the size of a pin's hejid to 
that of a bean, which are slightly elevated, and grow pale on pressure. 
The patches are generally round, with indistinct borders, and often 
send prolongations into adjacent patches. In places they coalesce. 
Emminghaus observed erythema as a prodrome of the eruption. In 
rare cases a few miliary vesicles and petechiffi are noticed. 
The eruption appears first on the face and scalp, and then extends to 
the trunk and limbs. It has generally paled in the face by tlie time that 
the lower parts of the body are afiectea, since the eruption only lasts a 
few hours. 
Some patients complain of slight itching of the skin. The turgor 
of the skin increases, and there may be alight cederaa of the face. The 
nenpheral glands are often swollen, particularly the cervical and auricu- 
lar glands. 

rhc eruption is sometimes followed by slight desquamation. 
I Tlie outbreak of the eruption is constantly accompanied by slight 

catarrhal inflammation of the mucous membrane of the pharynx, respira- 
I tory organs, and conjunctiva. The pharyngitis often appears in patches, 

^^^ particularly upon the middle of the uvula. It never attains the severity 
^^L of the pharyngitis of scarlatina, and disappears as the eruption pales 
^^H (one to three days). 

^^P The temperature may remain nnclianged ; a slight rise is often no- 

^^" ticed at the outbreak of the eruption. 

' The general condition is often entirely undisturbed. Albuminarf 

has been observed in a few cases, and tedema of the subcutaneous celliS 
lar tissne and tonsillar hypertrophy as serjuelce. 

III. D1AONO8I8, PROONOSia, Treatment.— During epidemics, the 
dia^osis is easy. In sporadic cases the differentiation from measles, 
scarlatina, and roseola is not always possible, 

^^^ The prognosis is good : a fatal 'termination is exceptional. 
^^^1 Treatment is purely dietetic and symptomatic. 



118 ACUTE INF£0TIOn8 BXASTHEICATA. 

4. Typhus Fever, ExantlhenuUic Typhus. 

{Spotted Fever, Petechial Fever,) 

I. Etiology. — The mode of infection in typhus fever is the same as 
in measles and scarlatina^ t. e., by personal intercourse and contact. 
The more intimate and prolonged the contact the greater the danger of 
infection. Hence^ in hospitals, nurses are affected most fi*equently, 
next the house-staff, and lastly the visiting physicians. 

The patients must be kept in separate wards, since the disease is 
sometimes conveyed to adjacent beds, and thence to other wards. When 
the patients are quarantined, the danger of infection is so much greater 
the larger the number of patients, the smaller the ward, and the less it 
is ventilated. Further infection is sometimes prevented by keeping 
the doors and windows open. 

The infectious matter adheres not alone to the person of the patient, 
but also to his clothing and other articles of use. In hospitals, those 
nurses are often attacked upon whom devolved the duty of storing away 
and disinfecting the clothing. 

Intermediate persons may also spread the disease. Some individuals 
possess a temporary or permanent immunity, but nevertheless may carry 
the infectious matter in their clothing, and thus convey the disease to 
healthy individuals. 

In all probability, the virus is contained in the exhalations from the 
skin and lungs. Experience seems to show that the disease is infectious 
in all stages, and pernaps during the first part of convalescence. 

The nature of the virus is entirely unknown. No schizomycetes have been 
found in the blood, and attempts to convey the disease to animals have always 
been attended with negative results. 

Tvphus fever is endemic in certain regions. Ireland is, in a measure, 
the classical home of the disease, and it often follows Irish emigrante to 
England, Scotland, and America. The European continent also con- 
tains abiding places of typhus, for example, certain parts of Russia, Oal- 
icia, Hungary, and Italy. It is a disease par excellence of the lower 
classes, so that foreign workmen and tramps must be regarded as 
its propagators. It has often been found that workmen on railroads, 
etc., who have come from typhus districts, have spread the disease in 
their new home. 

It has been ascertained, in a number of instances, that large cities are 
converted artificially into endemic sites of typhus fever. Thus, Berlin al- 
ways contains a few cases of the disease, which are derived from filthy, 
crowded lodging-houses. A tramp who leaves such a lodging-house may 
be attacked b^ the disease two or three weeks later in some remote lo- 
cality, and this explains the fact that many cases appear te develop an- 
tochthonouslv. 

In our opinion, the disease never arises in an autochthonous manner. 
If we assume that it is the result of specific lower organisms, this in it- 
self excludes an autechthonous development. Such a mode of genesis is 
supposed to be proven by the fact that the disease occurs in epidemics 
during times of war and famine, in crowded prisons, ships, and hospitals, 
which were supposed to favor processes of decomposition. It has been 
repeatedly shown that this interpretation is false. Thus, it was demon- 



» 



iaUTB INFEOnODS EZABTHEHATA. 

Btrated, with regard to an epidemic in East Prussia, that the failure of 
the crops corresponded merely in point of time with the epidemic spread 
of the disease, and that this liad been preceded by the appearance of a 
few cases of typhns which had been imported by worltmen from Upper 
Silesia. 

The disease is mainly one of personal intercourse, so tUat climatic 
and telluric inflnenceB are not noticeable. Nor is any influence exerted 
by the character of the soil, the height of the locality above the sea, and 
the character of the water. As a general thing, seasons exert no influ- 
ence, although epidemics are somewhat more frequent in winter and 
apring. 

Men are attacked somewhat more frequently than women, probably 
because they are more exposed to infection. In some epidemics, how- 
ever, more women were attacked than men. It is said also that the fe- 
male sex predominates in childhood. 

The largest number of cases occur belrween the ages of 16 and 35 
jears. The disease ia rare before the age of five years, and only a single 
Cwc has been observed in the first year of life. It grows infrequent be- 
yond the age of 45 years, although cases occur even so late as the age of 
eighty. 

The lower classes are the chief sufferers, hut the disease may also be 
conveyed accidentally to the higher classes. In the latter event it is 
said, as a general thing, to run an unfavorable course. 

Privations, grief, worry, and excesses of all kinds probably increase 
the susceptibility to the disease by rendering the organism more accessible 
to the vims. 

As a rule, only a single attack is experienced, but a few cases have 
been reported in which individuals were attacked two or three times. 
One or more relapses have also been observed, i. e., the symptoms were 
renewed a few days after the subsidence of the fever. 

Epidemics of typhns fever arc often associated with typhoid and re- 
lapsing fever, since the conditions which favor the spread of typhus act 
in like manner with regard to typhoid and relapsing fever. In some in- 
stances an epidemic of typhoid fever diminished in a striking manner, 
while typhus fever began to spread. In a number of coses, the 
patient suffered first from typhoid fever, and immediately afterward 
irom typhus fever. Niemeyer observed the coincidence of intermittent 
and typhus fever, and the combination of small-pox and typhus has also 
been described. The latter has also been known to develop immedi- 
atelj after scarlatina. 

11. As-iTOMicAi. Changes. — Typhus fever presents no specific ana- 
tomical changes. In general the ap|>earaucea are merely tnose of an 
acute infeotions disease. 

Rigor mortis lasts but a short time, and decomposition begins 
rapidly. 

In addition to livores mortis, the skin sometimes contains indistinot 
bluish-red patches andpetcchise. The lips, gums, tongue, and nose are 
covered with sordes. The body appears well nourished. 7'he muscles 
are dry, dark-red, of the color of nam. Neumann found Zenker's de- 
leneration of the muscular fibres, in addition to granular and fatty 
' igene ration. The muscles may contain hemorrhages, and the rectus 
idominis may he the site of hemorrhagic inflammation, as in typhoid 
~er. 

Similar changes occnr in the heart muscles. The blood is generally 




120 AODTE UrFBCnOUB EKABTHBKATA. 

dark red^ and exhibits little tendency to coagulation. There are eyi- 
dences of bronchitis^ atelectasis, hypostasis^ catarrhal and fibrinous in- 
flammation of the lungs. Larsen also observed siaall pulmonary hemor- 
rhages. 

The gastro-intestinal mucous membrane is not infrequently swollen 
and hypersemic. Virchow found fissures in the nstric mucous mem- 
brane which had eiyen rise to hemorrhages. The solitary and agmi- 
nated follicles of the intestines are not infrequently dightly swouen ; 
whether they ever undergo superficial ulceration appears to us to be 
doubtful ; at all events, this occurs only in exceptional cases. The mes- 
enteric glands may also be swollen and hypersemic. The spleen is gen- 
erally very large, dark red, and soft, sometimes almost diffluent. In 
Salomon's case it weighed twenty-three ounces (nearly three times the 
normal). It occasionally contains wedge-shaped and simple hemorrhagia 
infarctions, sometimes small abscesses as in relapsing fever (?). 

The liver is usually enlarjged, its cells are m a condition of cloudy 
swelling and fatty degeneration ; nuclear proliferation is noticeable in 
the intralobular and interlobular connective tissue. Similar changes 
are found in the kidneys. 

Menigeal and cerebral hemorrhages and oedema may be found in 
the brain. Popoff noticed infiltration of the ganglion cells with round 
cells, round cells in the periranglionic spaces between the nerve fibrea 
and ill the adventitious lymph sheaths ; also pigment infiltration of the 
nglion cells. Similar appearances are also found in typhoid fever, 
mall multiple lymphomata were found in two cases. 



fn 



Beveridge recently observed swelling of the ganglia of the cervical sympa- 
thetic. 

III. Symptoms. — The stage of incubation has a variable duration. 
In some cases it is said to have lasted only a few hours, in others as long 
as one to three weeks. According to Naunyn^ it is shorter in children, 
than in adults. 

As a rule, the prodromata begins with a single chill, or repeated 
chilly sensations. In some patients, there is frequent vomiting, others 
complain of anxiety and oppression in the epigastric region ; children 
may suffer from eclampsia. The temperature rapidly rises, and very 
soon reaches 40°, 41° or even more. At the same time the pulse becomes 
hard, and its rapidity may exceed 100 beats a minute. The patient 
grows so weak and dizzy that he soon takes to bed. In a short time un- 
consciousness supervenes, and very soon afterwards delirium develops. 
The patients complain of ringing in the ears and impairment of hearing* 
Tlie face is reddened and turgid, the eyes fixed and glassy^ the conjunc- 
tiva injected. The tongue has a gray or grayish-vellow coating, and, 
like the lips, soon become sticky, dry, and fissured. They bleed read- 
ily, the blood dries, and sordes form. The patient suffers from un- 
quenchable thirst, while the appetite is almost entirely lost. The liver 
and B])leen are generally tender on pressure, the latter organ enlarges 
very rapidly. At the end of a few days the urine often contains albu- 
min. The bowels are generally constipated, later slight diarrhoea may 
occur. 

The prodromata are often preceded for one or two days by vague 
general svinptoms, such as malaise, a feeling of dulness in the h^^^ 
want of desire for mental and physical activity, loss of appetite, etc. 



ACUTE ISTKTTtOJJS BXAWTUEKATA. 



ISI 



After the prodromal stage has lasted three to five daya, it is followed 
by the stage of eruption. 

The eruption appears first on the breast and abdomen, and then ex- 
tends to the trunk and limba. The face does not escape, bnt in many 
cases the eruption is here distinctly yisible only in individuals with a 
delicate, pale skin {particularly children). It is often very profuse upon 
the limbs, particularly on the extensor surface of the forearm. The 
eruption consists of round, pale-red patches (roseola), which at fij-st 
grow entirely pale on pressure. After two to four days, the redness 
changes to a livid color, the boundaries of the patches become indistinct, 
and yellowish or brownish spots are left after pressure. The primary 
hypertemia has evidently been followed by exudation of serum and dia- 
pedesis of red blood -globules. The patches often number several thou- 
■iMnds. They generally lasts ten days or longer, t. e., into the period of 
t eonvalescence. Their disappearance is followed by very fine desquama- 
tion, rarely by desquamation in larger patches. 




^;e° 



In some cases, the roseola presents almost the shape of acuminated 
papules; small vesicles develop occasionally in their centre. 

Petechiffi and vibices sometimes appear upon and near them. Drasche 
observed herpes labialis in two cases. Miliaria appears as the result of 
sweating, particnlarly at the crisis. 

The bodily temperature is important in diagnosis. It does not rise 
gradually, aa in typhoid fever, but suddenly, and also falls rapidly and 
critically to the normal. The fever is continued, and not infrequently 
rises to 40" or 41°. A slight remission sometimes occurs towards the 
end of the first week, but at the beginning of the second week the tem- 
perature generally rises again (sometimes higher than before) and, as a 
rule, sinks in a crisis to the normal on the fourteenth to the seventeenth 
days. The cnsis sometimes occurs as early as the eighth or tenth day, 
eometimes as late as the twenty-first day, or even later. 

The crisis, which is attended with profuse diaphoresis, often termi- 
nates within twelve hours. In other cases it occupies two or three da^ra 
irotraoted crisis), and sometimes defflrvescenco occurs almost in a lysia. 
onset of the crisis may be preceded for a few hours by enormous rise 






. TMiarfflatfi^ iflrr 




I 



The pate k genenllj i new M e d ia bcmcsqr <100 to 130). Gone- 
■yondinc to tte tempentKn of the bodr. li il> npiditr «tceed> UO a 
minttte the jwognoas » rer; p»fc^ "fhie pobe ■■ soatCiBM imgnlar 
and alow; dtcroiim h noeh am thaa in tiphoid firm-. AAer the 
«iis«, the imbe u gaenSlj mtrmai, atanaoaa&j nbnoraaL 

Coaadomttitm is almost alvaTv distoHied, pnthr m the resalt of the 
h^ ferer, vmtiSj on ■e w w a t of the infoctioit. At ink thoe is riolrait 
h»daiebe un meamoallj weQ-develaped BeanUa. bat aoaa the aeuao- 
mra beconea doaded; some of the patieDta ueqnirUTm a dreamr 
atate, othen are noleatl^ ddirioaa. The bowcb an oRcn eracoated 
tSTolnntarilf, or the patunta experienee no deare to Brinate. and the 
Madder a dateiided to the lunbOtena. Tremor o( the tongue and boe, 
beaitaiK^ in apeeeh, picldng at the bed-<^othea, and nboBtas tradinan 
are not mfreqaenL 

The lipa, loogne, and nares are genemDT drr and fisimd, bleed, and 
become oorered with Bordea. Moeler foand that the parotid salira, dis- 
charged tbroogb a canula, was acid; be recoauaends catheteriiatioa of 
Steoo's dact to prevent parotitis vfaich, in his opinioD, is often prodnoed 
by oGclDsioR of tbe duct with secretioo. Conjanctiva], nasal, and pbar- 
TDgeal catairb are sotice«b1«, and if oooacioasness is sni&dciillT clear, 
the patients complain of photophobia, dryness and bnminf iu tlie nose 
and pharynx. The papils are geoerally narrow; according to Schneider, 
often nneqnal. There is generallv impairment of hearing and rinnng 
in the ears, partlv from tabal catarrh, partiv from catarrh of the middle 
ear and inflammation of the dmm membrane. 

The thorax almost alwajs presents signs of dry bronchitis. The 
heart is not infreqaently dilated towards tbe right. Oocasioaally, we 
majT hear febrQe svstolic mormare; in aerere ranm, the first soond may 
be inaadible (weakness of tbe heart). 

Tbe spleen and Iirer, partJcalarlT the former, are enlarged and 
tender on preaaure. Slight meteorism and tenderness in the epigastric 
region are obaerred in rare cases. Xaasea, singoltas, and Tonuting are 
alio rare. 

The Drine presents the characteristics of febrile nrine: smali quantity, 
daric-red color, rerr acid reaction, high specific grsrity, increased 
Bfflonnt of nrea, aric acid, and kreatiain, diminution of chlorides. 
(JnrDh foand that the amount of urea was considerable shortly before 
the crisis, fell on the day of the crisis, and became uansnallr high two 
or three days later. Moderate albuminuria is frequent. ' Griesinger 
found casts and epithelium of Ihe tubules and bladder in the sediment. 
Fietichs fonnd lencin and tyrosin. 



J 



AODTB IKTEOTIOtia EXAin^SKlUTA. 



ISffl 



Tbiret ia always increased, and even apathetic patients will eagerly j 
drink water. Tiie appetite is loet, the bowels are generally constiputea. I 

The skin is said to have a peculiar mouldy smell. It is generally I 
dry and hot; in rare casee, there is diaphoresis apart from the crieiE. I 

Death may occur from excessive rise of temperature before the out- I 
bre^ of the eniptioii, or it takes place at the height of the disease, or 1 
shortly before or after the crisis. It is generally the resnlt of heart I 
failure. I 

Among the anomalies may be mentioned typhus without eruption; I 
also abortive cases of short duration. In other cases, finally, the symp- I 
toms are very mild and Srief. I 

Complications and sequelte are not uncommon. Eclamptic attacks I 
are sometimes observed at the height of the disease. Purulent menin- I 
^tis was recently described by Uugueoin, who also observed embolic I 
changes in the brain. Impaired memory and imbecility sometimes per* I 
.sUt for a long time after the disease. Faraplegiie have been observed, I 
Apparently of myelitic origin. Badiat neuritis has been described, and 1 
it IS also possible that purely myopathic paralyses may develop. Clonic I 
twitchingB, aphasia, and neuralgias have oeen reported as sequelie. I 

Chronic purulent inflammations of the ear and deafness may occur; I 
the former may extend to the cerebral meninges. Amaurosis lias also I 
been mentioned in a few cases. I 

Moers observed hemorrhages from catarrhal nicers of the pharynx. | 
Epistaxis occurs occasionally, llfemoptysis set in in one case, although < 
no pulmonary abnormalities conld be discovered. Wojciechowski de- 
BCribed hiBmateme:]iE. Intestinal hemorrhages are rare (six times in 
seven thousand cases, according to Murchison). Necrotic and diph- 
theritic changes in the intestinal mucous membrane sometimes cause 
dyaenteriform evacuations. Peritonitis is a very rare complication. 
Murchison described acute vellow atrophy of the liver in one case; Horn 
reported rupture of the spleen. Cystitis and pyelitis are rare. Diph- 
theria of the pharynx and larynx has been observed in a few cases, also 
laryngeal ulcerations. Hypostasis, inflammation, embolism, abscess, 
gangrene, and miliary tuberculosis of the lungs have been described; 
likewise pleurisy, pericarditis, and endocarditis Degeneration of the 
beart muscle and death from heart failure are not uncommon. In such 
cases, the extremities often become cool and cyanotic, while the interior 
of the body retains its elevated temperature. 

Embolism and marantic thrombosis may occur in the peripheral 
reins and arteries. Bed sores may develop, despite the utmost care. 
Among the complications we may^also mention furunculosis, multiple 
abacesacB. ervsipelas, parotitis, pyiemia, septioemia, suppuration of the 
lymphatic glands, noma, or gangrene of the skin. 

IV. O1AQNO8I8, — The disease is differentiated from typhoid fever 
by its sudden onset and termination in a crisis, and by the fact that the 
eruption is more profuse, especially upon the face and limbs. Further- 
more, diarrhwa, ileo-cscal gurgling and pain are rare in typhus. It is ' 
distinguished from measles by the fact tnat the latter generally attacks 
children, and thai conjunctival, nasal, and pharyngeal catarrh is rery 
prominent. 

V, Proonosis. — The disease U always very grave, although the 
prognosis depends mainly on the character of the epidemic (the mor- 
tality varies from five per cent to more than sixty per cent). The prog- 

I U BO much more grave the highei the fever, the more rapid the 



^BUU IS 



ACCTE JMWWCTUfUB 

pn\m, tlM WMker the oonstitatum, the mare adTBiioed the age, and the 
iMrrimtT the eomplicatioiiB. As a general thing, a profoae erration indi- 
mUm a mfftns coune. The rigor of the hearf b action mnat be taken 
npMnnllj Into consideration in r^ard to prognoaiB. 

Vr TaKATMEHT.— The spread of typhns can only be pierented by 
th0t t^rif^/tui quarantine. 

If trphns has appeared in a lodffing-hooae, prison, etc, the phM» 
nhhn\i\ m closed, all its utensils which possess only slight Talae should 
)m hnruMl, more cxiiensive ones thoroughly disinfected snd the rooms 
(i\iAuiMiUn\ and airea for a long time. 

Ttiit tmtients should be strictly quarantined, and have their own 
unrmnt uuirmils, and physicians. The latter should risit their typhus 
imilnniN IttMt, then carefully disinfect themselyes, and cluuige their 
itioililti((. The patients may receiye no Tisits, and not enter into oom- 
tnnnloiitiffn with the outside world. Burial should be strictly priyate. 

AliU)hol in largo doses (brandy, wine, champagne) or other stimu- 
latiU, and antipyretics must be administered. Among the latter, we 
|ir«fhr lititin^rin ( 3 i.-iss. by enema). Treatment with cold baths pro- 
ilniuiM vitry liitlo good effect. 

In othor respects, the treatment is purely symptomatic. 

Ttu) rules concerning nursing ana diet, which will be laid down in 
Ax^amiug typhoid fever, also hold good. 

5. Erysipelas. 

I. Etiolooy. — Erjrsipelas may develop whenever, after a wound of 
the skin or mucous membrane, certain bacteria (erysipelas cocci) gain 
auoeHs to tho lymph vessels, and set up a specific inflammation of the 
skin. Tlie disease belongs, therefore, to the domain of surgery rather 
than to that of internal medicine. 

Until recently, it has been held that erysipelas sometimes develops spontane- 
oiiviy. It will be granted by every physician that cases sometimes occur in 
which a wound cannot be discovered, but it is also true that the more thorough 
thti Hearoh the more frequently will lesions be found, so that we must ask our- 
selveu whether, in the former event, the primary lesion may not have healed and 
uMoaped diii(u>very. 

Home writiTs speak not alone of erysipelas of the skin, mucous or serous mem- 
braneH, l>ut also of erysipelas of the viscera, for example, the lungs (vide Vol. L, 
imge SOU). 

KrysipclfiR sometimes appears in epidemics, particularly in the spring. 
Thoy nniy extend over an entire city or only to a few houses. 

h is HonietiiuoH found that operations are followed by erysipelas when 
new wiirds aro opened. In some hospitals, certain rooms and beds are 
ni)i(»rionH um the abiding places of erysipelas. 

Thn inirodiiotion or a single case into a hospital may lead to its fur- 
thtii' (tproiMl. In other cases, its frequent occurrence is connected with 
ovon rnwdinpf and bud ventilation of the wards. Koening described an 
ij|/i<li!niiM which took its start from the operating table, inasmuch as the 

t>ill</w hml lHu«n Maturated with blood and secretions from a patient suf- 
ui\\\\i, from nryriipehiH, and had not been changed in along time. In- 
biMiiMDMU and handagos may also serve to convey the disease. 

Il \H ifimerally aitM\iined, but not positively proven, that the virus is 
i;w/>vu>ud iMily a slight distance in the air; infection takes place verj 



ACUTE ISPEOnODfl ESASTHBHATA. 1 

readily throngli the agency of intermediate peraons and inanimate ( 
jeets. During an epidemic, a very trifling wound {leech bite, hypoder- 
mic injections, etc. ) may be followed by eryaipelaa, 

ErrBipelas very often follows chronic iDflummations and eczemas of the naaal 
mucous membrane, and ia apt tu retapao a number o( times in the course of a few 
months or years. lu flam mjit ions of the lachrymal snc and duct are a frequent 
starting-point of the disease. It is aometimea oasocjateij with a eum-boil, ecMma 
of llie ext«rnal ear and auditor; canal or other parte of the IkmIj, and ulcers of 
the leg. 

It occurs occAfiionally an ii puerperal complication, etarting from the uterua, 
and, in the new-born, may follow tying of the cord. ' 

Vaccination erysipelas is a special form which will be dtscusGed later. 

Erysipelas is one of those infections diseases which, instead of c 
ferriu^ immunity against a subsequent attack, produces an increased s 
reptibility. It sometimes complicates typhoid and typhus fever, relapsii 
fever, intermittent fever, diphthnria, dysentery, pneumonia, etc. Oct 




Temperature curve 




ot (sclsJ orTsipelu. 



sionally it eierciaes a favorable influence on other diaeasea, for example, 
syphilis. Erysipelas has been known to be followed by the dtsappear- 
auco or diminution in size of cancer, fibroma, niBvi, tumors of the 
lymphatic glands, phagedcenic ulcers, elephantiasis, and lupus. Kop9 
recently described a case of acute articular rheumatism which rapidly 
recovered after an outbreak of erysipelas. 

A number of Huocesaful inoculations of animals have been made, partly with 
the oontents of vesioles, pnrtly with blood. FehleiHen recently inoculated buouui 
beings with artillcinl cultures of erynipelas cocci. He found that i( a second in- 
oculation was mode soon after a succes.tful one, it wae attended with negatire 
rf«ults and only proved successful after a certain lapse of time. Jaeniscu and 
Neimer obaerTed a fatal result after inoculation, with eryeipeloa cocci, ot a woman 
suffering from cancer of the breast. 

II, Symptoms. — The duration of the period of incubation varies from 

one to eight days. Hoiberg claims that, during au epidemic in Rostock, 
he observed au elovution of temperature two hours after making a surgi- 
cal incision. 

Prodromata arc oftun wanting. Some patients complain of maliUBflr 
Uiorezia, and [Mtus in the limba. 



3 



^ 



128 ACUTE IKFKOTrOCe EXASTHEMATA- 

The BymptoniB often begin with a chill, or repeated chilly sensations. 
This is followed by fovcr. which may reach 40° C, or more in & few 
hours. This generally runs a continued course bo long as the cutsneoua 
changes last, and usually termitiates iu a crisis (vide Fig. 20). The oc- 
currence of the crisia is sometimes jtreceded by sudden; marked eleva- 
tion of temperature, delirinm, chill, etc. If the disease termiuat«s un- 
favorably, the temperature not infrequently rises very high before death 
and sometimes even for a little while aft«r death. Relapses may be ac- 
companied by auothei' rise of the normal temperature (vide Fig. 31). In 
a few coses mild erysipelas runs an apyrexial course. The elevation of 
temperature is attended with increased frequency of the pulse, anorexia, 
and increased thirst. 

In cntaneous erysipelai>, the patients complain of pricking, itching, 
and pain in the aSectcd parte. The skin is (edematous, devoid of folds 
and shining (inflammatory osdema). and is hot and red. The epidermis 




k 



ia often, though not always, raised in larger or smaller vesicles, whose 
contents are at first serous, later cloudy, or even purulent. Some writers 
claim that vesicular elevations of the epidermis are always visible with 
the aid of a magnifying glass. Excessive tension of the skin may be fol- 
lowed by gangrene. The skin then assumes a blackiah-red or greenish- 
black appearance, the vesicles become filled with hemorrhagic contents 
and rupture, resulting in necrosis of the parts. 

Erysipelas always exhibits a tendency to spread, and in some cases 
may finally extend over the entire body. The extension occurs along 
the folds r.nd furrows of the skin. A sallow, yellow oedematous zone 
first forms, and is followed by hyperiemia of the part. 

Red stripes, which correspond to inflamed cutaneous lymphatics, 
very often start from the periphery of the erysipelatous patch. The ad- 
jacent lymphatic glands are generally swollen and painful. 

Upon non-hairy integument the extension of eryaiyelas is directly 
risible ; it may be assumed to be taking place on the scalp when the Ir*^ 



ACUTE INFBCTlOrS EIAirTHEMATA. 

ter becomes painful, ewollen, and hot. UpoD separating the baire, red' 
ness ia sometimea vi§ible. Marked swelling of the skin often produces 
great deformity. For example, the eyelirtfl may be swollen to euch an 
extent that the patient ia unable to open them ; the noatrila are not in- 
frequently narrowed and impermeable ; and the ears and lips may be 
converted into ahapeless maases. 

As anile, the eryaipelatoua changea reach their highest developmenit V 
on the third dav after their appearance. The rednessand swelling then J 
diminiah; finalfy desquamation takes place. The veaiclea which hav«3 
been present dry into thin scales and cruats. 

At the height of the diseafle, the fever and cutaneous changes a ^^ 

companied by other aymptomB, partly as the result of fever, partly of-^^ 
infection. The acnsorium is often affected, and delirium or somnolence 
and coma may appear very eai^ly. The tongue is often dry, fissured, 
browniah-yellow, or covered with sordes, as in typhoid fever. Catarrhal 
angina ia often present. The patients suffer not infrequently from re- 
peated vomiting, and complain of gastric pain. The spleen is often, the 
liver less frequently, swollen and painful. The bowels are usually con- 
stipated, diarrhcea is rare. Febrile albuminuria is common. The urine 
presents the chara^tGriatics of febrile urine: increase of urea, and phos- 
phoric acid. Brieger found an increased amount of phenol. Nepveu 
claims to have found micrococci in the blood, moat aoundantly in the 
blood of those parts which were attacked by the erysipelas. 

The disease sometimea lasts only a few days, m other cases several 
weeks or even months. 

Among the rarer complications are changes in the skin itself, such 
ae herpes facialis, roseola, or impetigo. In some cases, there are multi- 
ple cutaneous absceaaes, after opening which the eryaipelatoua changes 
may Bubside in a sort of crisia. In one case. Holms described vaso- 
motor disturbances (bluish-red color and aniestheaia) of the phalangeaof 
the fingers, followed during convalescence from the ery^peliiis bysponta- 
ncous gangrene of the parts in question. 

Fatal purulent meningitis sometimes develops during an attack of 
erysipelas. Gangrenous erysipelas near the eyes may terminate in 
panophthalmitis and phthisis bulbi. 

Accidental (febrile) cardiac murmurs are not uncommon. Yerm-- 
cose or ulcerative endocarditis, myocarditis, and pericarditis sometimea 
develop. Jaccoud maintains that pericarditis never occurs without en- 
docarditis, and that the latter attacks only the veuous valves. 

Sndden oedema of the glottis occasionally puts an end to existence. 
Bronchitis, pneumonia, pleurisy, and mediastiultia are occaaional com- 
plications. Violent episbixis occurs in some cases as a sort of crisis. 

Icterus, dysenteriform stools, and intestinal hemorrhages are occa- 
■ionally observed as the result of round duodenal ulcers or ulceration of J 
the intestinal lymph follicles. Peritonitis has been described in a few ] 
cues, especially in eryainelaa of the abdominal walla. 

Acute (hemorrhagic) nephritia may develop, and aometimes termi- 
nates in cnronic Brigbt'a disease. Bahde observed glycosuria which 
laateil three days. 

Ctcutrices aometimes remain as sequels, particularly in gangrenous 
eryaipolaa which has led to deep destruction of the skin. When erysipe- 
las often relapses in the same locah'ty, it ts apt to give rise to hyper- 
plaatio and hypertrophic changes in the subcutaneous connective tissue 
^elephantiasis Arabum). Anfestheaia or hypersesthesia is sometimes 



1S8 



HaUTM laFBOnODa SZAHTHraiATA. 



obserred on the site of erysipelas. Obetinntc neuralgias are sometimes 
left over. In one case, Broadbent desRribed atrophy of the skin associ- 
ated with an^ethesia. DefluTium capillitii is quite a constant symptom 
of oryaipelaa of the ncalp, on account of nutritive diaturbances of the 
hair folhcleB, but the hairs generally grov again after a certain lapse of 
time. 

Joint changes have been described in a number of cases. They con- 
Gi't of pain, or multiple painful swellings, or of purulent inflammation. 
Ritzmann observed a fatal termination in two of these cases. Puru- 
lent parotitis is mentioued in a few cases. 

Tlie ocular changes are important. Abscesaes sometimes form inthe 




Er^pelaicc 



Enlu-god m times. Immenlon tens. 



lids, or the latter are partially destroyed by gangrene of the skin. There 
may also be indammation of the orbital cellular tissue which, in Knapp's 
case, gave rise to compression and thrombosis of the retinal vessels. 
Keratitis is an occasional sequel. Amaurosis sometimes develops very 
rapidly) and is found to be the result of atrophy of the optic nerve and 
retina. Opacities of the vitreous humor and glaucoma have also been de- 
scribed. These changes sometimes undergo gradual resolution- 
Erysipelas of the mucous membranes may develop primarily and 
gradually spread to adjacent integument, or it is secondary to erysipelas 
of the skin. The disease is occasionally confined to the mucous mem- 
brane, but it may then be difficult to recognize its character. It occnre 
most frequently in the pharynx, nest in the nasal mucous membrane or 
oa that of the lachrymal passages. In the puerperal state, it sometimefi 



ACUTE rHFECnOUS EXiBTHEMATA. 

develops on the imicoua membrane of the vagina and uterus, whence it ■ 
mav pass through the tubea to the peritoneum and give rise to peritoni- 
tis.' 

The principal changes are swelling and rednesa of the mucous mem- 
branes, mflammatton of the adjacent lymphatic glands, formation of 
veaides and abscesses. The diagnosis ia rendered positive if erysipelas of 
the skin is also present. The clinical history is the same as that of cuta- 
neous erysipelas. 

HI.— As.iTOMiCAL Chasoes. — There is no longer a doubt that 
eryaipolaa owes its origin to the proliferation of lower organisms. The 
erysipelas cocci are round bacteria (micrococci) which are often 
arranged in pairs or in chains of six to twelve (vide Fig. 22), Fehleisen 
cultivated them and inoculated them successfully in human beings. The 
size of the cocci is 0.3 to 0.4 >*. They are found only in the lymph ves- 
sels of the skin, more rarely in the lymph spaces, but not in the blood- 
vessels. They appear only at the borders of the erysipelatous patch, 
and in the healthy periphery, not in the most intensely affected portions 
of the skin. Numerous round cells are found along tfie lymphatics, and 
the blood-vessels are congested. The changes affect not alone the cutis 
proper, bnt also extend irregularly into the subcutaneous adipose tissue. 

It must be remembered that in the corpse the redness of the skin 
disappears, leaving only the swelling. 

The general symptoms depend, apart from the fever, perhaps only 
eecondarilj npon certain toxic substances which are produced by the active, 
proliferation of the micrococci, since Fehleisen never found bacteria i- 
tfae blood. 

The changes in the viscera include enlargement of the spleen, cloudy 
swelling of the heart, liver, and kidneys, swelling of the intestinal lympn ' 
follicles, and, at times, ulcerations of the intestinal mucoas membrane. 

Kleba and Reiner have raised the question whether erysipelas ia always pro- - 
duoed hy cerCam definite bacteria. In the erysipelatous akin of patients aulIerinK ' 
frooQ typhoid fever, they found bacilli, and believe that theae bacilli, if carried 
into the lymphaticsof the akin, may set up erysipelas. 

IV. DIAOKOSIS. — The disease ia easily differentiated from others 
by the redness, heat, and swelling of the skin, inflammation of the adja- 
cent lymphatics and glands, and the serious impairment of the general 
condition. 

It is distinguished from cataneous phlegmon by the fact that in the 
latter the infiltration of the skin is as hard as a board, and exhibits a ten- 
dency to the formation of abscesses. In acute purulent indema. thn skin 
also exhibits a doughy infiltration, but general symptoms often remain 
absent for a long time. 

V. PaooNOSls. — In uncomplicated erysipelas the prognosis is not 
very bad, and many individuals survive a large number of attacks. But 
it siiould not be forgotten that unforeseen complications may arise, and 
that the severity of the genera! symptoms, particularly in tlie old and 
decrepit and those addicted to alcohol, sometimes result with astonishing 
rapidity in a fatal termination. Rapidly fatal collapse is not iufrecjuenc 
in gangrenous erysipelas, and the disease is also very grave in puerperal 



_^i 



VI. Treatment. — As a prophylactic meaenre, all wounds, however 
must be thoroughly disinfected with carbolic acid (five per cent) 



VSO AOUTB OrFBCnOUB EZASTHEIIATA. 

Mxd kept scrapnlougly clean. In hospitals, strict attention most be paid 
to yentilation and cleanliness as regards clothing, bedding, Ixindages, 
waJl«, and floors. During endemics or epidemics, all operations, even 
vaccination and hypodermic injections, must be avoided. The erysipe- 
las patients should oe isolated and have separate attendants. 

iir^sji>elas requires local and general treatment. The best local ap- 
plication, in our opinion, is carbolic acid dissolved in turpentine (3 
Ajcid. carbolic, 3s8.; ol. terebinth., 31. M. D. S. To be applied ex- 
ternally every hour). It should not be applied in places where vesicles 
have burst, and the skin is deprived of epidermis. The application 
should \)Q made two to five centimetres beyond the borders of the ery- 
sipelatous region. If the skin is very tense, small incisions may be made 
to relieve the tension and prevent ^ngrene. But if gangrene occnrs 
desf)ite our efforts, the part should be dressed with acetate of alumina 
(ona to two per cent^. 

The patients are kept in bed in a large, airy room, receive flnid food, 
and lemonade to relieve thirst; a daily evacuation from the bowels should 
be secured. Fever is best treated with antipyrin ( 3 i.-iss. by enema). In 
many cases, the disease runs its course spontaneously in a few days, so 
that antipyretic measures are not always necessary. 

Complications require purely symptomatic treatment. 

The following local measures have also been recommended : subcutaneous in- 
jections of carbolic acid (one to two per cent) especially in the still healthy sur- 
rounding parts; application of turpentine every ten to fifteen minutes; ferric 
chloride solution, collodion, tincture of iodine, faradism (I), aether douche, ice- 
water or lead-water compresses. 

Withers recently extolled the internal use of potassium iodide (gr. vij. every 
two hours). 

6. Herpes. 

Herpes gives rise to the formation of small vesicles which are ar- 
ranged in groups upon a reddened base. At first the contents of the 
vesicles are clear and serous, later they grow cloudy and pus-like, and in 
two to four days dry yito thin crusts. The latter fall on without leav- 
ing a scar, but the spot remains red and pigmented for some time. 
Many vesicles are more or less umbilicated. 

Iterpes may appear upon the integument or mucous membranes (soft 
palate, prepuce, conjunctiva, tongue, larynx, cornea). 

The opportunity for the development of herpes is always afforded by 
Inflammations of peripheral nerves. These may be the result of injury, 
compression, etc., or of infectious agents. The latter may be primary 
or secondary, according as we have to deal with an independent infec- 
tious disease or with a complication with a previously existing infectious 
disease. 

a. Herpes Facialis. 

I. Symptoms akd Etiology. — Zimmerlin observed an instructive 
series of oa»os of primary infectious herpes facialis in the Basle Citizen's 
Hospital. Thirty patients — all in the same wing of the hospital — were 
attaokod within three months. 

Tlio secondary infectious form is more frequent. It is observed in 
many febrile infectious diseases, most f re<}nently in fibrinous pneumonia, 
also in relapsiug fever, malaria, meningitis, but only in exceptional cases 



ACUTE INFKOnon'S EIANTHEMATA. 181 

in typhoid or typhus fever. The vesicles develop generally at the boan- 
daryoetween tbe skin and the mncoits membrane of the lips (herpes 
labialis). As a rule, only one-half the lip is affected, more rarely it ex- 
pends over the entire upper or lower lip, or on one side of boln lips. 
Occasionally the entire circomfereuce of the mouth is surrouoded by 
groups of vesiules; the lips are then swollen, and later become covered 
'with more or less thick, gray, brown, or bloody crusts. In certain cases, 
ibe vesicles also appear, at the same time, on the same side of the mu- 
cous membrane of the cheek, or the hard and soft palate. Unilateral 
berpes of the tongue (glossitis herpetica) has also been observed. 

Herpes nasalts (on the alee nasi), herpes auricularis (ou the concha), 
herpes infraorbi talis, palpebralis, conjunctivalis, and cpiscleralis aii 
much rarer than herpes iabialls. In a case of pneumonia, Thomas oh- 
aerved herpes sncro-ischiadicus, in another case herpes facialis and herpes 
man us. 

Herpes facialis also occurs not infrequently in gastric catarrh, also in 
some women at the period of menstruation, and occasionally as the re- 
salt of violent emotions. 

Nothing is known with certainty ooncerning the relation between herpes and 
febriJe infectious diseoaw. According to Qerhardt, the tever givea rise to dilata- 
tion of tbe blood-vessels, and thus to meohanical irritation of branches of the 
trigemtnuB within narrow und unyielding hun^ canals in the skull. But since 
ail febrile diseases do doI give rise to lierpcs facialis with Uke frequencj, it seems 
more plausible to us to assume that a neuritis is associated with the infectious 
process, and that the bacteria of one infections disease Eod a more ready entrance 
Co the peripheral nerves than tliose of another diseuse. 

II. TebatmEKI. — Treatment is hardly necessary. If the entire cir- 
«amference of tlie lips is affected, painful rhagades sometimes form; 
these mav be brushed with ol. amygdalar. every two hours to accelerate 
tbe exfofiatton of the crusts. If the patients complain of pain in the 
mouth, bad taste, and fcetor ex ore on account of vesicles in the buccal 
cavity, we may order a gargle of liq. alumini acet. (5 : 100, one table- 
spoonful in a cup of lukewarm water) every two hours. If potassium 
calorate is preferred, it should not be given in too concentrated a soln- 
tiou (5 : :iOO). 

i. Herpes Zoster. Zana. | 

I. £lioiA)QY. — It has long beea known that some forms of herpes 
aoster are infectious iu their origin, since it often occurs in epidemics 
dnring the spring months, and generally attacks an individual only 
once in a life-time. 

In addition, there arc non-infectious iorma of herpes zoster. They 
are associated most frequently with nervous diseases (brain, spinal cord, 
and j>eripheral nerves), either from disturbances of certain trophic 
nerve tracts, as in diseases of the braiu and spinal cord, or from direct 
injury to the peripheral nerves. Tims, herpes zoster often occurs in 
cancer or tuberculosis of the spine if the iutervertebral ganglia, which 

kpoasesa trophic functions, are compressed and inflamed. It appears not 
infrequently iu phthisis when it becomes complicated with tuberculosis 
ot the vertebne. Among 1,000 cases of phthisis, Loudet observed 1? of 
]ier|>e8 Eoster. In other cases, affections of the peripheral nerves can he 
dBni oust rated, for example, in adhesive pleurisy, mediastinal tumors, 
ilicuriam of the aorta, injury to the poripberal nerves, or comprossioa 



I 
I 

I 



132 ACUTS INFSCnOIIB KXAgTHElffATA. • 

by CAllnii* According to Dayid, dental operations or injories may 
caaie hcrpen of the cheeka and gams, and this may also be produced by 
the emfytion of a wisdom tooth. In two cases, Glerharat obseired 
herpes of the chin after galvanization of the mental nerre. 

The Almum ha* been observed after poisoning with carbonic oxide an^ after 
Ihe nue <rt Mtmnio, Hutchinson attributes some cases to syphilis, and wimntAiwi^ 
thai thiA is «iiii»«9ciaily true of bilateral herpes. Haoflf observ€Nd herpes zoster 
aft«rr arnjt^ srtKMilar rheumatism. According to some writers, pregnancy pre- 
Mnptmm Uf heriies. 

T)uy (lifioaso occurs at every ago (Boehm observed it in two in&nts 
hgt^l Ti atul 7 months respectively), bat it is most frequent from the 
iwnlft'ti Ut twonty^fifth vears. 

It. HYMrroMH.— In herpes zoster, the herpes vesicles develop along 
i\w (MMirmi of (MM'tain nerves. It is generally unilateral, but occasionally 
ntdii fiiiiltlplo, »'. e», it appears along several distinct nerves. It is most 
trpmwul iipcin the trunk. 

11' fiiuy 1)0 divided into different varieties: herpes zoster capillitii, 
tm*Ui\, uui'Um, hruchialis, pectoralis, abdominalis, and femoralis. 

1MiM tnoNt frequent form is herpes zoster pectoralis. The vesicles 

([KMMrfilly o(!(:upj^ one to four intercostal spaces. In typical cases, they 
mii]h lit the spine, then descend along the course of the intercostal 
um'yun, liinl on the anterior part of the thorax again descend. They 
Vury tttUiii extend a little beyond the median line, both anteriorly and 
intaUiriurly, In some cases the groups of vesicles are scattered, not 

'Vim changes begin with diffuse erythema, upon which develop small 
red pii|[)ules, which are soon converted into clear vesicles, from the size 
uf a pin's head to that of a lentil. The individual vesicles sometimes 
uottlesce. The vesicles belonging to one group pass through all the 
changes simultaneously, but different groups often appear at different 
times. Fully developed vesicles may not form in certain groups. 
Ju others, the vesicular contents assume a hemorrhagic black color, 
and deep destruction of the cutis and cicatrices result. In such cases 
the disease may last two or three months, while it generally runs ita 
course in two to four weeks. 

'i'he eruption is often preceded by prodromata. In herpes zoster 

1)ecti)raliH, intercostal neuralgia develops, and may last four to six weeks. 
Jhill, fever, and gastro-enteritic symptoms may appear a few days pre- 
viously. Furthermore, the patients coniplain not infrequently of pain, 
tremor, and spasm in certain muscles. In herpes zoster of the scalp or 
face, delirium and vomiting have been observed in addition to neundgi& 
of certain branches of the trigeminus. 

Tiie eruption rarely appears without prodromata. The patients com- 
plain of severe stitches and painful prickling in the skin, and then notice 
the eruption. 

'i'lie nnuralffia and fever often subside after the appearance of the 
vcsj<:k'tf. In other coses, the neuralgia increases and gives rise to obsti- 
i^MiA^ insomnia and nocturnal excitement. In the most favorable cases, 
tl;c vt.'«)<;l(iii ht«al in one to two weeks. The disease lasts longer if the 
ilifftifL'hi iiroii]m of vesicles follow one another at long intervals, or if 
iu^^ji/irhttgeM oc(;ur into the vesicles with extensive destruction of the 

UQi^ltim of the ilmt branch of the trigeminus (herpes ophthahnicus) is 



ACtPTE DTFECnOna ESAlfTQEU&TA. 



133 



of the 



ll(Hn9times attended with severe ocular diaeasea. In 80 caaee collected 
ly Cocks, the eye was affected 46 times (left eye 40 times). The ocular 
complications consist of herpes upon the conjunctiva and cornea, ausea- 
theaia of the cornea, iritis, diminution of intraocular pressure, even 
panophthalmitis. Hutchinson states that ocular complications never 
occur unless herpes vesicles appear upon the upper part of the nose, bati 
several exceptions to this rule have been observed. In herpes zoster (^1 
the second branch of the trigeminus, vesicles form upon tlie mucoutil 
membrane of the cheeks, hard and soft palate. In some cases, thafl 
herpes of the mucous membrane is primary, and is followed by herpeu 
of tne face, or the former may exist alone. It is sometimes followed byB 
falling out of the t^eth and atrophy of the jaw. ^ 

Seqnelre are not very rare. They include obstinate neuralgias which 
may not begin until tao vesicles have healed. Paralysis of the facial 
nerve or the limbs haa been observed, but almost always disappears at 
the end of a certain time. Duncan reports hemiplegia in two old wo- 
men, and explains it as the result of a reflex influence exerted through 
the sympathetic (?). Atrophy of the muscles, hyperhidrosis, anhidrosis, 
ansBsthesia and paresthesia, and falling out of the hair are observed oc- 
casionally in the affected nerve tracts. Falk recently described diabetes 
mellitus as a sequel of herpes zoster. J 

II. AiTATOUiCAL Changes, — In herpes zoster pectoralis, Baeren- I 
sprung first observed inflammation of the intervertebral ganglia. In a V 

herpes ophthalmicus, Wyss found inflammation of the Gasserian ' 
n. These lesions tally with the theory of the trophic properties 
parts in question. 

As a matter of course, herpes zoster will also develop it the trophic 
fibres in the peripheral nerves are inflamed, and this lesion has been j 
found iu some cases. In the vicinity of the vesicles, however, secondary ■ 
cbanses may develop in the cutaneous nerves. I 

The following arc the stages of development in the anatomical struc- j 
ture of the vesides : dilatation of the vessels of the cutis, serous exuda- 
tion, emigration of white and a few red blood-globules — elevation of the 
epidermis from the rete Malpighii by serous exudation, and the forma- 
tion of vesicles (the latter are chambered, the individaal septa consisting 
of compressed epidermis cells) — formation of nests of wandering cells 
within the rete Malpighii by division of the epithelinm cells, transfor- 
mation and partial destruction of their protoplasm — drying of the fluid 
contents and regeneration of the stratum corueum througu the agency 
of the remaining rete Malpighii. 

III. DiAOVosm, pRousosra, Tbeatmest. — The diagnosis is eaay 
if we bear in mind the characteristic grouping of the vesicles, and their 
distribution along definite nerve tracts. 

The prognosis is almost always favorable. Death occurs only in ex- 
ceptional cases, as in Wyss' cases, in which it followed panophthalmitis. 
Treatment should not be active. The vesicles should be brushed 
every morning with ol. olivar., ol. amygdalar., or ol. hyoscyami, covered 
with cotton batting, and protected against pressure and friction. 8ub- 
itanoons injections of morphine may be made in violent neuralgia. If 
- neuralgia persists after the vesicles have healed, we may order qui- 
' (gr. 15 to 30), Fowler's solution (5 to 10 drops t. i. d.), the con- 
current, or morphine subcutaneously. The faradio current may I 
ployeil if paralysis and atrophy ensue. 



Ihenc 



1.84 ACUTE OrFBCHOCB EZJJBTEXMAXA. 

c. Herpes ProgenUalU, 

I . Stvkfoms and Di AGK0SI8. — In herpes pro^enitalis, the vesicles 
ampear vjll thie geuitab. Aa a rale, they are few in number. In men, 
tut^v au^ uaoet frequent on the inner sarfaoe of the prepaoe, bnt also ap- 
jiuM* on tlxe glau« and dorsum penis. They appear rarely on the anterior 

rt vf tbe urethra, and may then give rise to blennorrhoic discharge. 
w^Mueu, tliey ap{)ear on the prepuce of the clitoris or inner surface 
<ji tb/e labia miuora, rarely on tne labia majora. 

Tl^ {>atients complain generally of a peculiar prickling and itching. 
ExMrnUmtion usually shows shallow ulcers but no vesicles, which may 
iw:rtii6ii in tjize if the patients have yielded to the desire to scratch. 
Th^y then form deep, suppurating losses of substance, which may 
readily lie mistaken for soft chancre, or, if the base is inflamed, for 
bard chancre. Balanitis, balano-posthitis and oedema of the prepuce 
may also develop. The true explanation would be apparent at once if 
the lebions appeared spontaneously and without previous intercourse, 
but the statements of the patient cannot be relied upon in this regard. 
Giilargement of the inguinal glands would favor the diagnosis of chan- 
cre. Finally, herpes heals in a few days without special treatment. 

II. Etiology. — Some individuals suffer from herpes progenitalis 
after almost every act of coitus. It occurs often in cases of phimosis or 
if the smegma is abundant. It may appear in epidemics, particularly 
in the spring. The disease exhibits a great tendency to relapse. 

III. Tbeatment. — The individuals must abstain from coitus until 
the eruption is entirely healed. The sores are covered with borax 
vaseline, carbolized oil, or zinc ointment. Phimosis, or an abundant pro- 
duotiou of smegma must receive suitable treatment. 

d. Herpes of the Pharynx. 

{Angina herpetica.) 

I. Etiolooy. — Herpes sometimes develops in the pharynx as an in- 
dependent affection. It is attributed to colds and menstrual distur- 
baucort (at the onset of the menses). A few years ago, I observed an epi- 
deniio of pharyngeal herpes in Goettingen, and at the same time herpes 
nneputialis and erythema nodosum were also remarkably frequent. 
Uerzog states that the infectious character of the disease is not demon- 
strablo. 

II. Symptoms and Treatment.— The disease often begins with a 
violent chill which may be followed by high fever and malaise. At the 
end of the tlrst or second day of the disease, the pharyngeal mucous 
meinbruue is found to contain yellow, slightly elevatea patches with 
red bonlers; their size is but little larger than that of a pin's head. 
They are most frequent on the arches of the palate ; in one of my cases 
thev were situateil on the posterior surface of the uvula, and were only 
vidi'ltle with the aid of the laryngoscope. They are unilateral, and thus 
diatiuguishtHl fix>m pseuvloherpes, which forms a diffuse, irregularly dis- 
tributed vesicular eruption in the pharynx, and is not infrequent in 
inveterate smokers. lIeriH)s pharyngis is sometimes associated with 
herpes facialis, or it may alternate with herpes prseputialis. 

The }>atients complain of pain in swallowing* burning in the throat, 
often of a very bad taste in the mouth. The fever subsides on the third 




ACUTE INFEOTIOCe BXANTHEHATA. 



189 



.jiirth dftv, the yellow patohcB are exfoliated, learing behind shallow, 
j&trtzJDg ulcsre. Great proatratiou sometimea persists for a very long 
time. In one caae I noticed paralysis of the velum palati. Perforation 
of the velum palati or pillara of the palate, and pseudo-momhranouB in- 
fiommation have also been observed in rare caaes. 
i Treatment; gargles of potassium chlorate (5 : 200). 



, Herpes of the Larynx, fferpen Laryngis. 

{Laryngitis Phlyctmiulom.) 



^^K Treal 

^^^^fatud diseaso is rnre. It i;en«rally begins witii fever, and is associated witK 1 

^^^^nes of the exierniil slcin or oilier inucKiua inembraneEi, The larjnt^al mucous 

^^^Rnibraoe Hrst presents upitlielial opacities, later seeicular elevations, wliicli ter- 

' minute in hIiuIIuw ulcers. Tliu latter are surrounded by a red £ime, and lieal in 

one to two weelcs. Tlie diagnosia can only be made with tlie aid of tlie liiryng»- 

scope. p8eurluher|)es may also occur upon the laryns, but, unlike herpes, it is 

va\ unilateral, and is confined to parts in whicli the mucous giandi are abundant. 



1. Febris Miliaria. 
Suieating Hickness, 

I. Etioixwy.— The existence of febris miliaria has been diaputed up t 
present time. From tlie reports of others, it appears to us that it is an ind^ ] 
penilent mfectious disease. I 

The first epidemics nppeared in the fif teeutli and sixteenth centuries, and then I 
not until the eii^liteenth century. Since IIihii, the disease has appeared from ] 
time to time in England. France, Italy, and Oermany. 

The majority of epidemics occur in the summer. Their development I 
favored bj damp, cluiugeable weather, perhapn by a roarHhy soil. As a rule, I 
few epidemics last more than two to six weeks. It occurs muat frequently^! 
between the ages of twenty to forty years. I 

Women are affected more frequent!;^ than men; also individuals of a strong I 

OOnstitution. Tiie character of the virus is unknown, but some regard it as ^ 

latic in origin. The ciroumacrlbed character of the epidemics is a, notablo 1 

e. The s;iioe individunl may experience a number of attacks. I 

STUPTOUs. — The disease is preceded by general malaise for two or three 

_ itlents who went to bed without speciiil local symptoms awake during th«- I 
aif^t batlied in perspiration, toKetlier witli a feeling of oppreseion in the pre- 
cordial region, headache, dizziness, palpitation of the heart, occasionally crampa 
ia the calves. The temperitture is more or less elevated, the pu I ae accelerated, 
mtpirutiuns rapid and uyspnceal. The sweating is sometimes so profuse na to 
drench the bed. On the third or fourth day. iniliaria appear, at first miliuria' 
crystailina, then rubra, finally miliaria alba. The appearance of the eruption i 
often associated with prickling andnumbnesaof theakJti. The pstlenta suffer 1 
from anorexia, iiiciyised thirst, nausea, vomiting, constipation, and scantf f 
diuresis. The spleen is g>-nerally enlargeij. | 

Death may occur in coUapae or from piiralysis of the lieort or brain, or from 
complications (diphtheria, pneumonia, diarrhceu, dysentery, purpura, and di^ao- 
luUon of the bloud). ] 

When uncomplicated, the disease lasts six to eight daya. but the period of I 
convalescence is sometimes protracted. The disappearance of the eruption is I 
followed by desquamation of the skin. The average mortality is ten per cent, ia J 
some epidemics as higl> as fifty per cent. 

"* ' ii. Cha ""' 



W< 
I oonstii 



III, Anatomical Chasoes.— There U almost conatantly a tendency ti 






lya 
decomposition of the boiJy in the fatal cases, the blood Is thin and black, tlie 
spleen large and soft. 

IV. TilR.iTaEHT,— The lied covering should be light, tlie room kept at a tem- 
perature ot Vt" R., and cold w»ter mlxei.1 with claret or bruudy given as a drink; 
onljr fluid foorl aliould be allowed. To check the diaphoresis, we may give suIt 
-•—■- of MTOpia (gr. i : Z '»}■. one syringeful aubculaneoiulyj. 






tStf AOUn DTFBOnOUS BLABTHPfATi. 

8, SmalUPox. Variola, 

V lfh:u)L0OY.—Small-i>ox patients are the most frequent sources of 
in^vMini. In formor times, oefore bovine virus was used in vaccina- 
ku»n. iM^liviiluaU woro often inoculated with the contents of pocks 
Uik\)n tr\M\\ iHittout», because experience taught that the disease, when 
iH*<|umHl lit thuH way* was more apt to run a mild course than when ac- 
i|uii-tHi (uvutotUallv! The scabs leftover after the pustules have dried 
p«>Km'K(« iMfiH'tiousi pi\>portios. oven if kept for a long time. The phvsi- 
\»Ioi^toiil Htvtvtton^ at\<> iu>n-infei.*tiou8; whether the blood of the patients 
^KMHi'rtMfrt ttirvvtKUi9 pn.>(K'rtios still remains doubtful. 

llio vtii«i)Hcti» aIjA» ap|K'ars to be infectious even during the period of 
uiou)»H( uwi. 8i'hHfK'r rt«|H>rts a case in which a piece of skin was removed 
n<«*iik ;iM .-ipfHitxntUy houlthv man for the purpose of transplantation. A 
Xk>^ hoitiH Itiicr tho prvnlromata of small-i)ox appeared. After a certain 
|H»i»t»J, i?i\» iiutivulual upon whom the skin had been transplanted was 
»tU» «iuok\Hl with HmaIUiH)X. 

Tho \ II u 4 ililTiiMi^M ilMOjf in the vicinitv of the patient, and infects the 
•«»» , .«! \ uAk^a \^t \'lothiu>;. and utensils, llie danger of infection increases 
I'lir ^m^(«Um Oio titiiubor of ])atients in one room, and the less the room is 
i4(i«.(i t>iiiitig llio luMt great epidemics (1870 to 1873) it was noticed in 
i^itii* iiwi'OiooN that when small-pox patients were placed in quarantined 
hitii vtr^i, (ift«i4'<) (U*voh>|HMi in neignboring, but not immediately adjacent 
hiiiMi'M. |»4ilii'Mlai'l^ if the windows of the sick-rooms were constantly 

tiih.ilioii iiiiiv aUo ho conveyed by intermediate persons who escape 
lii>. ilUi.a4i» Tho virUH iri generally absorbed through the respiratory 
,.(^uMi> U\ iM(H^|itioiiul OKHos by direct inoculation of wounds. Infection 
ii.». .iUii lii^nii (ifiAOivod from handling monev, rags, etc., with which 
i.^iiitii^i li^'l roiiiif ill contuet. In many cases, it is extremely difficult to 
iii-.i. Mill iit'ithi iif iiifootion. 

I li>. «iiit« i4 ni(|tpoM(Ml to consist of bacteria. Gohn describes, in the 
...iMti.ii.r Ihii |iUHluhiK, lino f^ranules which are divided in twos, fours, 
• .^Jii.;. >.!•. . uMi unouiiiuluted 111 groups of sixteen, thirty-two, or more, 
idi'l I'll Hi lai|$i)i Modghim niOHHos. They are generally immovable, and 
I, (iit.iiiio.a fill 111 Kmiiiy-like chains. Klebs states that the tracheal 
)((M-.ti.i t.iiitUiho iiitnnioiMM'i 0.5 /i in diameter, which are partly arranged 
U\ (niiiu 111 itid ahujio of a Hquare, but are nevertheless separated from 
\ik\u tiiiuUiiii |Mii(-.i<i(Hi(M)iiri ({lUidrigeminus). 

VU^ i.iiiiUiiito (if tht) puHtuloH may not alone infect human beings, but 
.4l.;.i i.iuLaiii uiiiiiiuU (cow, calf, horse, ass, sheep, pig, dog, monkey). 
Tl«<. h'iiU i'f Ihiiuiiiiiiiil noHriori<403 tho power of weakening the injurious 
^iP.|ii.iLii^ti ijf liKiimii Miuull-pox (vide remarks on vaccination). 

.'\liiiiioLL:Vi''ry iiitlividuiil poHsesdos a susceptibility to small-pox, but it is 
^<.(«M.illr uliuliahiiil (ir ilimiiiirihod in infancy by vaccination. In many 
i)> ,.:/i«q thu udldui'.y (if vaooiiiation does not last longer than ten years, 
y, tl..«l iijV'icuiuutiiiii bhouhl ho performed at least every ten years.* Very 
r / |.<.>«|/i>. |iiuoout punuunout immunity from small-pox witnout previ- 
M» . \.f'.<;n4iitliiu. 

in ilii 1.1. 1 hut It ib toiuporary immunity; they escape during one epi- 
I ir'f- I'll I liM. ultui-liod in tiio noxt. 

\ ., ml'.. «<iitiiiU4itk iisiiifors life-long, acquired immunity, although 
{i ..4' <<<.i..i.)ii<iiul ti^ouptitiiiH to tho rule. It is said that some indi- 
ct f I )«.i .'•. uiilfijiuil fiuiu an many as six attacks. 



I 



AOUTE OTIFBCTIOTIB EXANTHEMATA. 

Oertsin oooditions may increase the susceptibility to tbe disease, 
I is particularly true of pregnaucy and the puerperal state, under 
which circumstances the disease is often of the hemorrhagic variety. 
It ia claimed that driukera, feeble individuals, aud those who are ex- 

fiosed to heat (coolcs, firemen) also exhibit a tendency to the hemorrbagio 
orm of BmalJ-poz. 

Age and sex exert no influence on the frequency of the diaeaaa. j 
Preeuant women, suffering from small-pox, have been known to give I 
birth to children whose skin was covered with small-pox pustules, and, I 
on the other hand, the disease has been observed in very old people. I 
Nor does climate exert any influence in this direction. It is said that | 
negroes are especially predisposed to infection. 

Where vaccination is common or obligatory, the disease generally oc- 
curs sporadically or is imported from without. Under other condi- 
tions it occurs in epidemics. It ia said that epidemics in large cities are 
apt to recur at definite intervals, whicli vary from five to twelve years. 
The seasons exercise no special influence upon the occurrence of epi- 
demics, although they are somewhat more frequent in the cold months 
than in the hot summer mouths. The spread of epidemics is sometimes 
favored by external conditions, for example, the crowding together of 
many individnals in ware under bad hygienic surroundings. 

Small-pox is sometimes coincident in one individual with other infec- 
tious diseases, such as measles, scarlatina, syphilis, erysipelas, pemphi- 
gus, typhoid fever, intermittent fever, phthisis. In other cases, these 
diseases immediately precede or follow small-pox. . 

II. Sr MPTOMB. — The duration of the period of incubation varies from 
ten to fourteen days. After inoculation, the period of incubation ia I 
generally shortei' than in natural small-pox. 

Curschmaiin states that, in one case, the period of incubation only lasted fire I 
days, aud according to Zuelzer, its average duration in malignant oemorrhagio 
anuill-pox is aix to eight days. 

The majority of patients feel perfectly well daring the period of in- 
cubation. In a small number of cases, slight general disturbances ap- 
pear towards the end of this stage: slight rise of temperature, chilliness, 
aBorexia, headache, malaise, etc. 

The prodromal stage begins, in many cases, with a single severe chill 
or repeated chilly sensations. The bodily temperature rises very rapidly 
and, in a few hours, reaches 39°, 40°, or more. At the same time, the 

f'ulse becomes very rapid (100, or even 180 beats a minute). The respira- 
ions are increased in frequency, and many patients complain of dyspnma, 
generally of nervous origin. Mild delirium, epileptiform convulsions, 
and meningitic symptoms are apt to set in in children and excitable, 
feeble adults. The majority of patients complain of a feeling of dul- 
nesB in the head, of vertigo of such intensitv that they are unable to 
stand erect, and of annoying headache which, as a rule, is referred to 
the forehead, in some cases to the occiput, and is distributed unilaterally 
or. along the course of certain branches of the trigeminus, The con- 

i'nnctiva is often injected, and there is photophobia with increased seore- 
ion of tears. The tongue is coated, fcetor ex ore is often noticeable. 
Thirst ia increased, the appetite is entirely lost. Tlie patients often 
complain of nausea and eructations, and repeated copious vomiting 
B with unusual frequency. The bowels are constipated, the urine 



^JB^TB « 



• j^ AOUTK IKFECnorS EXASTHEXATA. 

«.*^-T ;r :in\{ Mt nrateil. The right yen tricle becomes dilated ; the first sound 
ji \:w itcarc is otUm muffled, blowing, and replaced bj a srstolie mnr- 
ru 1 * I ho tiiomx may preflent evidences of dry bronchlcia. The spleen 
:s iMi^ittv otUtir^iHt. 'The liver ia of ten tender on pressure and slightlj 
v•n;ii^x^^^ :it rt vrrv rarly jKjriod. A verv constant symptom is the rio- 
tiiii!- yiii\\.< \n (lio Imrk, which are referred to the loins and region of the 
■iubio^M. Soiiio attribute these pains to renal congestion, others to 
^vi^;<''A( ivii K*t llin lumbar meninges. The latter view is more probable, 
Nvan.^* tlio |iHiii!4 oftrn rudiute into the lower limbs or abdominal walls, 
4M.t 410 ft«s<H*it»tiMi o(*f:ariionully with anaesthesia, hypersesthesia, or paraes- 
i.Ui^t k t»l' tho li»wrr liiiilH. 

s>iii)ihiiii< of |iliitryti^cal and buccal catarrh (diffuse redness or hy- 
^wviiii'4 <*t itio niucouK membrane in patches) are often foand very 
,^ti\ Si*iiio |ii«tintil.-4 MufTtir early from hoarseness or a burning sensation 
lu >•)»«» ii>*^\ h)|h*i»1(m1 irpintuxiri may also occur. 

ti» 11*411 V rfi<t^4. u prodromal eruption appears upon the second and 
lU.i.i ik^ 'riii4 iiitiy roiiHist of diffuse erythema, as in scarlatina, of 
4,it»ii .ill iiiiwe4 iiImtiI coii^<*Mtious (roseola variolosa), or of wheal-like 
i.<»i.. )i...) Siiiioii ttliowrd that they are very often found on certain defi- 
»•.«.. |vi*U 4>r Mm b<Htv (lower ))art of the abdomen, the sides of the abdo- 

., Mi I >tip<i Id hi^h up lu) the axillae, and tV.e outer surface of the leg, 

.^i ..4^1 ih.i tv^inicoi halhici.-i). Their frequency varies according to the 
». M<^ ••"» "F Mm r|ij'liMiiir. It is not true that the site of these prodro- 
.,. J .titptniiiq loiintiiifi frei) from the small-pox eruption proper. On 
, .....t J I Im «li<Liihutioiiof the prodromal eruptions along certain nerve 
I . .« .1. . L)..., ti.fc>» timiii attributed to paralysis of the vaso-motor cutaneous 

I K . I Iniiiial ntii^Mi, Oil tho average, lasts three days. 

!• . . r.ii.««ntt iiv Mit) Hiii^i: of eruption. The first cutaneous changes 
.y^. .41 .11 i)t>. r.irn itiid ptnilp, but upon the latter they are onlv visible if 
.1, !..«.. it jti.Mi iiu«l thill. At tlioendof twenty-four hours, tney extend 
..!»,. I.. 11. 1., .iiiil liiiiill\ to tlio limbs. The eruption also appears in the 
ii. .. ,..^ i.iMii«. iMicit, tiiid coiijunrtiva, opening of the urethra, vagina, 
.....i |. .iti*!! or tim iitrruH. Tiic eruption passes through various 
. ,,. ,>i.. .ti t^ill III) ilrirribiMi later. 

I. ...4 .. .titvmttiv fiM-t that the 8i>vere general symptoms diminish 
^ ., ...4.t. iir %vtiti ilui a|t|)ruraiice of the eruption, and many patients 
4.. .1 . . -I. .. .1 ili.it ttmv consider tliemselves recovered. The tempera- 
I .. I..!!. |,i l<. I'l^, -M) and ahproaehes the normal, and the frequency 
.1 • I. . |...i • and i«i.a|iirati«in.4 also diminishes. 

Im 'I* - ill t ••! iiiit»tihu' rtta^e of tho eruption, the face contains patches 

ii. ... .1 iiii.idtn, piiitieularlv upon the forehead and the bouudarv 

I.-. 1. and c.lieekrt. 'iMiese patches grow pale on pressure, an^ 

I. .p 1 . it. I... 1. hi additinu, the integument is irdematous, so that 
I . i. t .ii>. k^iilliit and the pal pehiiiUissu re narrowed. Smallpatches 
i . J .•!. •■ i> .|iii' Kl> within the p:itehes, and are very often, though 

... lii.ii, j^', I Mil I liul ar<»und the hair follicles or sweat glands. 
I t- ... Lii . LiiiiiK tho Ofiti-he.-i and papules develop later, and are more 

, , 11. .f till, luoio aliiindant on the limb^, particularly the extensor 

..!.. ill .o ihr. iinv;ui-d. Thtso changes are often attended with 

,. ■• II 1 i I III iijb/ ■ 

II. |...i...iai .ii.wii tifi) an a\era>;o duration of two days. On the 
I. 1 i., ,1 11. . :i.i^.. ••! .'MipiiMii. c. (\. the sixth day of the disease, the 

.1.. Li... tr^iu: \( iho aiH'.x of the papufes the epidermis is 



i.k 
I. 



ACDTK ISFECnODS BZAlTTnEHATA. 188 

raised from the rete Malpigliii iiitheformnf aemull, trausparent vesicle, 
at first iipoD the face, later upon the trunk and iimbs. In the next few 
dajs, thu vesicles increuee gradually in size, and many of them become 
umbilicatpd. 

If a TesicJo is ptinctiiretl, its contents escape gradually. The vesicles 
are often distributed along the (olde of the skin or the course of the 
cntaiieoiia nerves. This stage generally lasts three days. 

Ou the ninth day begiiia the pustular stage. The temperature and 

the frequency of the pulse and respiration again im^rease, and chilis and 

delirium appear in some coses. At the same time the contents of ths 

• Teoiolfls become more iind more opaquej cloudy, and purnlent. Their 

OMS increases. The edge of the pustule is reddened and infiltrated, and 

^^^Oiind this there generally forms a slightly swollen, reddened zone, jiro- 

^HkoBd mainly by hyperiemia of the skin. As pustulatiou increases, the 

^™- Tio as 



f& 



ambilication disappears. Ptmtnlation begins in those parts in which the 
papules first appear. ('. e., the face. The skin is often considerably 
swollen, so that the patients are unable, for days, to open the eyes. The 
pustules are very numerous upon tlie fingers, and many patients com- 
plain of violent burning pains in these parts. On account of the thick 
epidermis, fully developed pustules are hardly ever found on the palms 
of the hands or soles of the feet, and the eruption appears there as red 
or brownish-reil translucent papules, or lar^e vesicular elevations. 

In about three days, this stage reaches its end, and the stage of de- 
MDcation begins, on the average, on the twelfth day. The febrile symp- 
toms diminish ; some of the pustules rupture, and their contents are dis- 
charged and dry into yellow, gray, and brown crusts. .Some pustules do 
not rupture, but their contents gradually dry, the pustule becomes 
fiabby, and finally is alra converted into a crust. The majority of the 
patients experience iutolcrable itching, scratch the skin, and tliua delay 
recovery, 

""'he crusts gradually fall off at about the sixteenth day of the dia. 



^^h 



L t4Q 



AOUTB ISFKCFIOtTB SZA9THBMATA. 



^ 



ease (stage of decrustation). Brownish-red pigmented patches renuun, 
or, in those places in which the pustules penetrated deep into the cutis, 
browniah-red pigmented cicatrices form, and are coureited later into 
irhite cicatrices. 

The cutaneous lesions just described are associated with correspond- 
ing ones on the mucous membranes. 

The pharynx is affected very early, often in the prodromal period. 
The mucous membrane ia very red, and pustular formations develop upon 
it. These begin as congested papules; then the overlying epithelium is 
raised in the shape of a white or mother-of-pearl gray Vesicle; finally, the 
epithelium is shed, leaviug a subepithelial loss of substance. At the 
same time the patients complain of difficulty in ileglutitiou, and some 
are hardly able to swallow even fluids. 

Annoying salivation generally occurs when the buccal mucous mem- 
brane is aSected, If the tongue is involved, it may increase consider- 
ably in size, and appears wedged in between the teeth (glossitis vnrioloBa). 
The ernption niayiilso form on the mucous memSirane of the uesophagns. 

In some coses, the changes e.itend to the Etistacbiiiu tube und miadle 
ear (giving risa to tinnitus annum, pain in the ears, etc.), and also to 
the mucous membrane of the air paaaagea. 

The eruption has also been observed upon the urethral meatus, 
yaginal portion of the uterus, and rectum. 

The individual stages of the eruption are not always distinctly 
separated from one another, and the transition between them takes placa 
gradually. 

Variola without eruption is a very mild form of the disease. The 
patients, who have been oJtposed to infection, experience the characteris- 
tic prodromata. but the eruption does not appear, and the disease 
terminates with the prodromal stage. 

In afebrile variola, the eruption is distinct, but there is very little 
or DO fever. In abortive variola, the eruption terminates in the papular 
or squamous stage. In variola siliquosa, the vesicles contain air, but no 
fluid. 

The majority of cases of small-pox run a much milder course than we 
would be inclined to believe from the abovo description. The milder 
form is culled varioIoi[[, in contra-distinction to true variola. The more 
vaccination ia adopted the more frequently small-poi occurs as varioloid, 
and the more rarely as variola. As a i-ule, even those who have been 
vaccinated a long time previously suffer merely from varioloid. The 
latter runs a milder and more rapid course; the eruption is scanty; com- 
plications, especially severe eye diseases, are rarer; and, as a rule, nn- 
aightly cicatnces are not left over. 

Hemorrhagic small-pox is the result of unusually severe, generally 
fatal infection. The occurrence of a few small hemorrhages between 
the papules ia very frequent and innocuous, and does not constitute hem- 
orrhagic small-pox. In the latter, abundant hemorrhages occur during 
the eruptive stage, sometimes in the shape of papules, sometimes aa ex- 
tensive suffusions and infiltrations, and are attended with grave collapse, 
hemorrhages from the nose, mouth, air passages, stomach, intestines, 
kidneys, and genitals. These often prove fatal before the eruption has 
developed. In other cases, the hemorrhagic character is manifested at 
a later stage. After the vesicles or pustules have formed, their contents 
become bhicldsh-red and bloody, and hemorrhages also occur upon the 
"■'""11 and mucous membranes. 



^V ACUTE DTTGOnOim EZANTHEUATA. 141 I 

Wm -Renauld states that he hat found UecolnruCion of th^ red blood-globulM and 
'rSllmiatin crystoLs in the blood serum in hemorrhagic stnnU-pox. 

Conflnent small-pox is anothor severe form of the disease. Itgenerally 
begios with severe prodromatu. The patches and papules hts bo abundant 
that they coalesce in places. This is true to a stnL greater extent of the 
pustulea and crusts. There is very extensive inflammatory oedema of 
the skin. During the pustular stage, the face, forearms, and fingers 
are covered as if with a maak. The crusts often retain masses of pua 
which exude after ruptnre or perforation of the cnist. The patients 
often emit an unpleasant odor. The general condition is grave: delirium, 
hyperpyrexia, perhaps death from heart failure. Dangerous comi»lica- 
tions often make their appearance. 

The complications of small-pox attack the most various organs. ■ 

Erysipelas of the skin somettmea develops during the stage of puatula- I 
tion or desiccation. Gangrene of the skin develops occasionally in the ' 
vicinity of the effloresce aces. Multiple abscesses appear at times in the 
skin, and may be the result of pyiemic infection; this is also true of ab- 
Bcesees of the intermuscular oonnectivo tissue. Inflammatory swelling, 
snppuratiou, and ankylosis of the joints have been observed, porCicularly 
in the large joints of the limbs. 

Delirium is one of the most frequent symptoms on the part of tho 
nervoua system. Marked psychopathic conditions occasionally develop, 
QBually of a maniacal, more rarely of n melancholic character, sometimes 
associated with a suicidal tendency. These symptoms may appear , 
before the outbreak of the eruption, or they form sequelte and become 
permanent. A combination with purulent meningitis, encephalitis, 
encophalo-malacia, aad cerebral hemorrhage is rare. A number of cases 
ofaphseia or dysarthria following hypo^ossal paralysis have been re- 
ported. Catalepsy, disseminated myelitis, acute ascending paralysis, 
and acato ataxia have also been observed. Peripheral paralyses are rare. 
Oubler and Laborde mention paralysis of the detmsor vesicn at the 
beginning and also at the end of the disease. Diabetes insipidus and 
diabetes mellttus have also been included among the aequelce. 

Very aerions changes may develop in the eye. Conjunctivitis is an 
almost constant symptom; this sometimes results in the formation of 
pD8, particularly if the lids are swollen and occluded, and the removal 
of inflammatory products thus impeded. Hirschherg described diphthe- 
ritic patches upon the conjunctiva, which sometimes result in the loss of 
the eye. Small-pox pustules appear occasionally upon the conjunctiva, 
eenerally on the bnlbar portion, and sometimes extend to the cornea, 
though they do not develop upon the latter. Adler observed pustules 
on the conjunctiva prior to their eruption on the akin. They are small, 
and form yellowish papules which are surrounded hv a zone of injected 
vessels. Subconjunctival hemorrhages may occur in liemorrhagic small- 
pox, also hemorrhages into the choroid and retina. Ulcerative changes 
of the cornea are not uncommon. They appear most frequently as 
superficial circumscribed keratitis, which may terminate in liypopion, 
destruction of the cornea, prolapse of the iris, and thus in anterior 
svnechia, and even phthisis bulbi. This does not often develop before 
toe stage of desiccation. Rarer complications are diffuse interstitial 
keratitis and kcratomalacia, the latter possessing an unfavorablo prog- 
□ostic significance. Iritis and irido-choroiditia are rare, and should be 
^^ndaded among the soquelie rather than among the compUcationB. 



142 ACUTE INFBOnOUS EXANTHEXATA. 

Opacities of the yitreoas or the posterior surface of the lens often de- 
yelop. Acute glaucoma, retinitis, and neuro-retinitis have also been 
observed. 

Aural changes are yery common in small-pox. In one hundred and 
sixty-eight autopsies, Wendt found only two cases in which the auditory 
ap{)aratus was intact. The pustules form upon the concha and the carti- 
laginous portion of the external auditory canal. They have not been 
observed upon the bony parts, the membrana tympani, internal ear, and 
Eustachian tube, but the mucous membrane is often congested and 
swollen. The hypersBmia often results in hemorrhages, and the circum- 
scribed swelling forms polypoid proliferations of the mucous membrane. 
The petrous portion ox the temporal bone sometimes undergoes inflam- 
matory changes. 

In addition to inflammation, pustulation, and hemorrhage into the 
nasal mucous membrane, ulcerations of the mucous membrane, bones, 
and cartilages sometimes develop and give rise to adhesions, deformity, 
and disturbances of function. 

Inflammation of the salivary glands is not very common. The sali- 
vation which is observed so often is usually a reflex symptom of inflam- 
mation of the buccal mucous membrane. Metastatic inflammations of 
these glands may occur in pyaemic conditions (generally, however, as 
sequelae), and may bo associated with phlegmonous changes in the sub- 
maxillary cellular tissue. Noma, retropharyngeal abscess (sometimes 
followed by erosion of the carotid and death from hemorrhage), necrotic 
or diphtheritic changes in the pharynx, and phlegmonous oesophagitis 
have also been observed. 

Bronchitis is such a constant symptom that many writers do not look 
upon it as a complication. Laryngeal catarrh is also very common. 
The situation becomes very grave when signs of (edema glottidis appear 
or necrotic changes develop in the laryngeal cartilages. The latter may 
prove fatal at a late period, or produce permanent hoarseness as the re- 
sult of ankylosis and deformity. When the bronchitis extends to the 
finer air passages, it is spmetimes complicated with broncho-pneumonia; 
fibrinous and hypostatic pneumonia or pulmonary gangrene occasionally 
develop. (Edema of the lungs is sometimes the immediate cause 6t 
death. Pleurisy, very often purulent, is not a rare complication. Dan- 
gerous pulmonary hemorrhages occur in hemorrhagic small-pox. 

Pencarditis may develop independently, or it is secondary to pleurisy. 
Endocarditis, occasionally septic in character, is sometimes observed. 
The frequency of myocarditis has been ffreatly exaggerated in some cases. 
According to Verstraeten, the white blood-globules increase, the red 
globules diminish so much more rapidly in numbers the more violent 
the disease. 

HsBmatemesis is not infre(][uent in hemorrhagic small-pox. Diar- 
rhoea is a not favorable complication, and the bloody stools of hemor- 
rhagic small-pox have a bad prognostic significance. 

Menstrual disturbances are frequent in women. The menses gen- 
erally appear too early or too abundantly. Pregnancy is a grave com- 
plication, since the patients are attacked, with relative frequency, with 
the severest forms of small-pox. Premature delivery or abortion is 
frequent. In rare cases, the children present the small-pox eruption at 
birtn; more frequently they are attacked a few days later. 

It is sometimes found that, in twin births, only one child is attacked. Jases 




ACDTE WFEOTIOCS KXANTHEMATA. 

bsre also been leportedit 
attacked with small -pox. 
looked in the mother. 

Orchitis has been observed in men; it is either parenchymatous of 
affects chiefly the co?oriog8 of the testicle. 

Albuminuria is very common, and appears at times in the initial 
period; it may be febrile in character or the result of infection. Acute 
nephritis is not very common. Hfeoiaturia has been observed in hemor- 
rhagic small-pox. 

DurinR the febrile period, the urine presents tlie ordinarj characteristics o( 
febriU' urine. In one case of hemorrhagic amall-pos, Brieger found a very Bmsll 
amount of phenol in the urine. Leucin, tyrosin, and fatty acids have been fouud 
In the urine. 

The complicationa and seqnelfB of emall-pox cannot be sharply dis- 
tinguished from one another. Cutaneous cicatrices not infrequently 
persiat for life, and sometimes cicatricial tumors (keloid) form, and 
must bo removed with the kaife. The hair often falls out, as after 
other severe diseases, but if the pustules have destroyed the hair folli- 
cles, restoration of the hair doe^ not take place. The nails may ba 
exfoliated. j 

Pemphigus and acne rosacea have been desoribed as sefjuelte. Oa- ^ 
cheetic cedema may develop, occasionally cedema of one Itmb from 
marantic thrombosis of the limbs. Paralyses, disorders of the special 
Beuses, diseases of the heart and kidneys, may also be left over. Psy- 
chopathy may also develop. In one of my cases violent maniacal attacks 
occurred from the start, and persisted after recovery from the small-pox. 
Phthisical processes in the lungs develop occasionally as sequels. Small- 
pox i:icatricea in the cesophagus may produce coustriction of that organ. 

The disease very rarely attacks the same individual twice, and stili 
more rai-ely do relapses occur. In Michel's two cases, another violent 
ontbreuk of the eruption appeared upon the eighteenth and twenty- 
second days. 

Small-pox sometimes pxercises a favorable inflnence on other dia- 
easee, for example, chorea and whooping cougb. 

III. Anatomical Changes. — Bacteria play a part in the anatomi- 
cal changes of small-pox. They are found in the superficial and 
deep layers of the connm, either arranged in groups or in a tube-liko 
Mtape. and occasiuually in the blood-vessels. In tiie later stages of the 
""' Baee, thoy disappear. The blood-vessels of the cutis dilate in places 
_^ itches of nypermmia). Coagulation necrosis of the epithelium cells 
Monra btmeatn the groups of bacteria in the deepest layers of the rete 
Malpi;;bii. and the cells are converted into non-nucleated clumps. At 
the mmss time, there is a circumscribed increase in size of the epidermis 
(panulos). Between the nocrotic cells are formed cavities, filled at first 
wild serous, later with more purulent fluid. The necrotic cells form a 
meah-work in which the fluid is inclosed. The meshes aro often least 
distensible in the centre, so that the surface of the epidermis becomes 
depressed and nmbilicated. The umbilication may also lie produced by 
the development of the efHorcscence around a sweat gland or hair folli- 
cle, the epidermis remaining firmly adherent in such places, and not 
easily removed as at the periphery. According to Anapitz and Basch, 
■welling of the periphery may also produce apparent depression of the 




centre of the ofBoreaconoe. According to Unna, the pock first forma 
between the layers of the stratum luciiinra. 

It is onl^ when the effiorcscence extends into the cutis that perma- 
nent deep cicatrices are left over. 

Bacteria have also been found in the lymphatic glands, liver, kid aeys, 
and spleen. They are often surrounded by a double-contoured mem- 
brane, and in the liver and kidneys were situated in veins and capillaries 
(loops of the glomenili). The surrounding cells are either intact or in 
a condition of coagulation necrosis; there ia sometimee on accumu- 
lation of round cells in the vicinity. 

The muscles often have the color of liara, and may be in a condition 
of cloady swelling and wax-like degeneration. 

The hlood is sometimes fluid and has a tarry color. 

Tlie spleen is enlarged and soft; on section its follicles are often 
found to be unusually larg* 

The heart, liver, and kidneys are generally in a condition of cloudy 
swelling or fatty degeneration. Necrotic and diphtheritic changes are 
found in the intestinal mucous membrane. The mesenteric glands are 
often swollen. 

Oophoritis and perioophoritis are observed not infrequently. 

Small-pox efflorescences have been found ou the mucous membrane 
of the larynx, trachea, bronchi, cesopbagus, and stomach. 

In hemorrhagic small-pox, extravasations of blood are found in vari- 
ous organs, even in the medulla of the boues and sheaths of the peri- 
pheral nerves. The cutaneous itemorrhages are the result of diapedesia 
of red blood-globules. 

The corpse remains infectious, probably on account of mechanical 
desquamation of the skiu. 

IV. D1AGNOSI8. — The diagnosis is easy, particularly during an epi- 
demic. Under other circumstances, it may be mistaken for impeti^ 
contagiosa, but in the latter the general condition i^ less aSected, paio 
in the back and vomiting are absent in the initial stage, and recovery ia 
more rapid. In the variola-like eruption produced by inunction with 
tartar emetic ointment, the general condition is not seriously affected. 
Similar eruptions caused by syphilis disappear rapidly under the use of 
potassium iodide and mercury. 

If epidemics of small-pox and typhoid fever are prevalent at the same 
time, violent pains in the hock during the prodromal stage favor the 
dia^osis of small-pos, pains in tbe lege that of typhoid fever. 

The differentiation between measles and small-pox is difficult or even 
impossible during the papular stage. We must then wait twenty-four 
hours, and if vesicles then appear upon the papules and if the mucoiu 
membrane of the mouth and pharynx contains vesicles, a positive diag- 
nosis of small-pox may be made. 

V. Pboqsosis. — The prognosis is best in varioloid, more serious in 
confluent small-pox, moat grave in the hemorrhagic form. Old aud de- 
crepit individuals and drunkards possess slight resisting powers. Preg- 
nancy is a grave, often fatal complication. 

VI. Treatment. — Prophylaxis includes not alone the strict isolation 
of the patient, but also the aboUtion or diminution of the susceptibility 
to the disease by vaccination (vith bovine Ijinph. Revaccination should 
be performed at least everv ten years, if possible every five years. 

Isolation is best secured in small-pox hospitals. The patient's house 
and furniture should be disinfected with sulphurous aciu, the clothing, 



AOCTE ISFKcrnOCS EXANTHEMATA. 

i bedding by dry heat or carbolic acid (fire per cent). If the patient ' 

18 kevit at home, aU those dwelling in the house should be quarantined, 
and later the entire house must be diainfectod. The patient hiinaeU 
may not communicate freelj with the outside world until desquamation 
has entirely ceased, and before eevemi warm batbs have been taken. 

Small-pox corpses should be placed in hermetically sealed coffiuB. and 
then buried as qnickly as possible in vaults. The funeral should be 
strictly private. 

Tho treatment of the disease itself ia purely dietetic and sympto- 
matic. 

The patient should have an airy room, at a constant temperature of 
15" R. The diet should be fluid: milk, eggs, soup, wine; a daily evacua- 
tion from the bowels should be secured. 

A protracted lukewarm bath (28° R.) 'should bo taken morning and 
eTCiiiug. 

Disturbances of deglutition may be treated with gargles of potassium 
ciilornto (lit : 300) after each meal; acetate of alumina (one per cent) is 
prefemlile if there is fietor ex ore. Pieces of ice may be swallowed by 
the patient. 

It there is constant high fever, lukewarm baths (2G° E., twenty to 
thirty minutes) are indicated, in combination with antipyriu ( 3 i.-iss. 
by enema). 

If there is violent delirium, heachache, and meningitic symptoms, an 
ice-bag to tlie head is indicated. 
I Hemorrhagic small-pox requires stimulating treatment: large doaea 

of alcohol, etbev, camphor, or musk, with haemoatutics. 

The following measures have been recommended to favor the healing 
-of the pustules and prevent tho formation of cicatrices: application to 
the face of indifferent fats, collodion, tincture of iodine, carbolic acid 
solution, incision of the pustules and cauteriaation witli nitrate of silver. 

tCold compresaes or warm poultices are the most agreeable to the patient. 
fWitli 
«iea 



Vaccinalion. 



, Variolation consisted in the inoculation of healthy individuals 
rith the contents of small-pox pustules. This was done either through 
'■tneans of a puncture or cut beneath the epidermis, or the contents of tne 
p&Btnle were applied to the corium, which had been laid bare by means 
of a fly blister. 

But the dangers of this procedure must not bo underestimated. Ac- 
cording to Ferro. there was one fatal ease among eighteen variolations, 
I according to Wilson, one in 6G3 eases. 

A etiU graver objection was the danger to surrounding individuala. 

L few cases of variolation afforded a favorable opportunity for the out- 

feok of an epidemic of small-pox. Hence it was entirely justifiable to 

rohibit variolation by statute. 

II. Exanthemata, like small-pox, also occur in certain domestic an- 

;. such as sheep, horses, and cows (ovinola, equinola, vaccinola). 

Sheep-pox (ovinola) is very similar in its clinical history to the smaU- 

lOX of the hnman species. It begins with general febrile disturbances, 

d» to an eruption of pocks on the skin, is conveyed through the air to 

tber animals, and often produces great mortality. To diminish its 

"ingers, farmers inoculate healthy animals with the couteuts of the 



146 ActTTE i>rTEcnor8 exanthemata. 

pocks, but this ia only permitted at the approach of an epidemic, because 
the inoculated flocks may prove a source of infection for heattby ones. 

lu horse-pox (eqiiiuola), a pustular eruption appears upon the pae- 
ternSv and gcDeral syniptoms are wunting or very slight. 

The mildest course is run by cow-pox (vacciuola). This is localized 
on the udder, especially on the dug. The infectious matter is pieseut 
in the contents of the pustules alone, and is not conveyed through the 
air. General disturbances are entirely absent. 

The contents of animal pocks may be iuoculated successfully in mao, 
monkeys, the camel, ass, pig, goat, dog, cat, and rabbit. 

The contents of human pocks, when inoculated into animals, alwajrs 
produce that form of the disease which is peculiar to the animal m 
question. If a cow is inoculated with variola-lymph, a pustular eian- 
them is alone produced on the udder of the animal, and if the contents 
of the latter are reconveyed to man, the same effects are produced as by 
vaccination with the natural cow-pox. 



oculat«d cows with rariola, anil. < 

Some authors maintain that all forms of animal pox and human 
small-pox are the products of the same virus. This has been supposed 
to consist of certain micrococci, although inoculations with artificial cul- 
tures have not proven successful. The close relationship between ani- 
mal and human pox is also shown by the fact that vaccination of human 
beings with any form of animal pox prevents infection with human 
pos. 

III. The inoculability of man with cow-pox has long been known. 
Farmers were long aware that milkmaids wore apt to suffer from pustu- 
lar eruptions on the fingers if they milked, with sore fingers, cows whose 
dugs were covered with pox pustules. It was also known that, during 
epidemics of small-pox, those individuals who had been infected with 
cow-pox either escaped or suffered very slightly. Jenner first proTed 
Bcientilically that vaccination guaivia against variola. On May 14th, 
1796, ho inoculated Junies Pliiiis with the contents of cow-pocks taken 
from the arm of the milkmaid Sarah Nolmess, After the cow-pox pus- 
tules had healed, ho inoculated the boy with the virus of small-pox and 
found that the latter was inactive. 

IV. Three varieties of bovine lymph may be employed in vaccina- 
tion, viz. t humanized lymph, primary bovine lymph, and retrovaccina- 
tion lymph. 

Hnmanizcd bovine lymph is the term applied to the contents of 
pustules of cow-pox, produced by previous vaccination in man. Vacci- 
nation may be performed from arm to arm, or with artidcially preserved, . 
humanized bonne lymph. Formerly, the contents of the pustules were 
dried between cover glasses, or coated over whalebone tips, but this has 
given way, in great part, to preservation in fine glass tuoes, which pos- 
sess a spindle-shaped dilatation in the middle. The lymph is collectol 
in a carefully cleaned watch glass, the two closed ends of the tube are 
then broken ofl! with the fingers, aud the tube held almost horizontally, 
with one open end in the fluid. The lube then fills with lymph, and 
the ends are again closed over a spirit lamp. Care must be taken that 
the tube contains no air, in which event fungi are apt to develop and de- 
compose the lymph. The efficiency of the lymph may not be relied 



AODTE mvstjnona kiawthbmata. HT 

upon for more than six to twelve montha, anil it shoiilil bo kept in a 
oool. ilark place. The lymph is ineffective if it containa opacities and 
clouds. 

It should be taken only from healthy children who como of 
healthy familiea. Special at^tention must be directed to the presence of 
plitliisis, scrofula, or ayphilia in the family. The pustules, whoso con- 
tents are gathered, must po.ssesa all the charucteristica of a regularly de- 
veloped cow-pox pustule. Tliose which possess a very brjad zone of in- 
flammation must be avoided, since vaccination with their contouta 
sometimes causes extensive mflammation, and even erysipelas. The 
pustules should he taken from children who are vaccinated for the first 
time, since the lympli from pustules of revacclnated persons is less cer- 
tain in its effects, and often produces doubtful efflorescences. The best 
time for collecting the contents of the pustules ia the eightb or ninth 
daj[ after vaccination. Under no circumstances may lymph bo emplored 
which contains macroscopic amounts of blood. If the child unfor- 
tunately happens to bo syphilitic, the simple contents of the pustule will 
not convey syphilis, while this may bo expected if there is a distinct ad- 
mixture of blood with the lymph. On microscopical examination, 
however, all lymph contains a few red-blood globules. 

Mueller's glycerin bovine lymph has been much discussed. Mueller 
found that if the lymph is greatly diluted with glycerin it loses none of its 
virtues, and these become more permanent. Uo recommended that tha 
pustule be opened, its contents removed with a clean brush, placed in a 
carefully -cleaned watch-glass, and mixed with four times the amount of 
a mixture of equal parte of glycerin and distilled water. This is kept 
in jilosB tubes. An addition of sutphuto of soda, salicylic acid, or thy- 
mol has been recently recommeued to increase the stability of the 
properties of the lymph. 

It has been claimed that the employment of humanized bovine 
lymph may convey diseases to healthy children, and also that, if the 
rsccioation is continued from man to man, its efficacy would finally be 
exhausted. The first objection is met by employing great care in the 
choice of the child from whom the lymph is derived. It ia true that 
some children suffering from hereditary syphilis present no signs until 
the ago of three months, but danger in this regard la avoided by employ- 
ing children who arc past the age of six months. Experience in n<? I 
wise justifies tho fear of the gradual impairment of the eflloiency of the 1 
Ijmph. 

The emplojTnent of primary bovine virus is also not free from objeo- 
na. In the first place, the disease itself is not very common, so that 
r lymph cannot bo obtained whenever desired, and in addition, the 
,._mary lymph may produce violent symptoms in mau ; often great 
JVelling of the arm, erysipelatous redness, and not inconsiderable 
febrile movement. Jf tho animals suffer from garget, the inoculation 
at tiil>erouloiti8 ia possible, so that the animal should he killed, and the 
itealthy condition of its organs rendered certain before vaccination is 

fierformed, Tho aymptoms are milder if the animal has been inocu- 
atwi by vaccination with primarj^ bovine lymph. 

In relrovaccioation, the bovine lymph is revaccinated from man _ 

upon the udiler of calves, and vaccination in man is then continued ^^^H 

with the coutent^i of tho pustules produced in the animals by the vacoi- ^^^| 

QAtinn, In this case, also, only those animals should he employed who ^^^| 

^^^jpeeent healthy viscera after death. ^^^| 



148 ACUTE INFECTIOUS EXANTHEMATA. . 

Tho virus of bovine lymph probably consists of bacteria, but these 
are not known with certainty. Osrich recently claims^ however, to have 
successfully employed artificial cultures in vaccination. 

V. In vaccination by puncture, a lancet is inserted quite horizontally 
beneath the epidermis, so that it enters between the horny and mucous 
layers as near as possible to the corium. Superficial injury of the latter, 
and the appearance of a small drop of blood are immaterial, but deep 
perforation of the cutis is to be avoided because this is apt to be followed 
by the formation of a furuncle. The tip of the lancet is then smeared 
with lymph, and the latter wiped off into the opening of the puncture. 

Others prefer incisions which should be made close to the cutis: 
crossed incisions may be recommended. Some scrape off the epidermis 
superficially, and then introduce the lymph. Special apparatus for 
vaccination is, to say tho least, unnecessary. 

Many physicians claim that a single well-developed pustule is a suffi- 
cient guard against small-pox. Our personal preference is for several 
vaccinations, but we believe that three or four will suffice. 

Girls are often vaccinated upon the thighs in order that tho cicatri:^ 
may not be visible. We generally vaccinate on the outer side of the 
arm, a little below the insertion of the deltoid. The sites of vaccination 
should be about two centimetres distant from one another to prevent 
coalescence of adjacent pustules. 

As a general thing, children should be vaccinated after the age of 
six months, although vaccination may be performed without risk even 
in the new-born. If there is danger of the outbreak of an epidemic, 
the children should be vaccinated irrespective of age. Those wno suffer 
from rickets or scrofula, or who are teething, and feeble, anaemic children 
should not be vaccinated until health is restored. 

The instruments and lymph should be kept scrupulously clean; if a 
large number of vaccinations are performed at one time, the lancet 
should be cleaned in a five-per-sent solution of carbolic acid after each 
vaccination, and the arm of the vaccinated individual should also be 
cleaned with a solution of carbolic acid before the operation. 

Intrauterine vaccination is the term applied to vaccination of pregnant 
women, after which it is claimed that vaccination of the child does not take. 
According to the majority of recent writers, this method is, to say the least, un- 
reliable. 

VI. The immunity conferred by vaccination diminishes year by year, 
and cannot be assumed to last longer than ten years. Hence the neces- 
sity of re-vaccination. 

During epidemics of small-pox, every one should be vaccinated if a 
longer interval than ten years has elapsed since the last vaccination, or 
if previous vaccinations have not taken. In many cases, vaccination 
takes even after much shorter intervals. On the other hand, vaccina- 
tion, in rare cases, never takes. Immunity against vaccination is some- 
times presented by children whose mothers suffered from small-pox 
during pregnancy. In such cases, the new-born may or niay not present 
cutaneous evidences that they have suffered from variola in utero. 

Vaccination confers immunity only after the pustule has passed 
through all its stages. If the individual has been infected with small- 
pox prior to vaccination, the variola will develop, but often runs a 
milder course. 

VII. The following is the clinical history of vaccination: 



iilDTS niFBcnoiIS EXUfTHRHATA. 149 

During tbo tiret few dave after vaccination, hardly any change Is 
noticeable. On lliti fourth day, a red papule appears on the site of yoo 
ciaation. On the fifth day, eerum accumulates beueath the epidermis , 
of the ])apule. bo that a email vegicle apiieais. On the sixth day, this , 
iuoreases iu size, its contents become cloudy, and ltd periphery la eur- 
ronnded by a red zone. On the seventh day, the vesicle is converted 
into a pustule; its contents are purulent, its red border alightly intil- 
trut«d, around it is a hyperfeiuic zone shading gradually into tne healthy 
parts. The pustule i»ci-ctt»WH in sizo in the next few days, and attains 
its greatest development on the tenth day. On the twelfth dav, the 
contents of the pustule begin to dry, and a crust forma which falls o9 
on the twenty-first day. At first ite site is occupied by a lattice-shaped 
red cicatrix, which gradually becomes white, and persists for life. 

General symptoms are usually absent. If careful measurements ard 
made, the bwiiiy temperature will be found slightly elevated during the. 
first three days (prodromal fever) and from the seventh to ninth days 

ianppurative fever). If the temperature rigea to 40" C. or more, other 
ebrile symptoms also develop: increased thirst, anorexia, a tearful 
mood, restless eJecp, upd ev^u convulsions and delirium, 

mi variola efHorescences are, la 

VIII, The pathological accidents of vaccination may be local or 
general. 

In n very few cases death has resulted from hemorrhage from the site 
of hemorrhage. Strongmeyer and Henoch observed this in a hs-mophilic 
child. Polk in a Icuk-puiic child. As a rule, however, vaccination ia well 
toleniled iu hmmophilia. 

A painful faruncle. attended with febrile movements, sometimes de- ' 



retops at the site of vaccination, especially if the incision luis been mode i 
too deep. . J 

Vaccine ulcer is the term applied to those cases in which the pu9- ' 
tule develops normally until the tenth day. after which it ruptures and 
cUscloiios a painful ulcer. Thi^ is accompanied by general febrile dis- 
tnrlianoes. It is relatively frequent after racciuation with primary , 
bovine lymph. 

The term vesicular pocks is applied to llioee caaes in which large veai- 
0l6s with watery cuutenta arc formed. Thin crusts are produced, and 
fall off without leaving a cicatrix. 

In eczema pocks, a aeries of vesicles form around the site of vaccina- 
tion, and terminate in a weeping eruption. This is observed with rela- 
tive frequency in aiitemic, rachitic, and scrofulous children, especially if 
they have suffered previously from eczema. 

In two coses, Bednar described gangrene of the site of vaccination, 
and death from collapse. 

Vaccination erysipelas may develop early or late. The former ap- 
pears two or three days after vaccination, and is much more dangerous 
than the late form, which appears from the tenth tn twenty-first days. 
The erysipelas is the result of the wound, and extends over tlio arm, and 
even the larger portion of the trunk. It is often fatal. Its production 
is favored b^ uucleanliuess in vaccination, racainatiun in the hot months, 
the vpidemic occurrence of vacciuation eryei])elas, the removal of lymph 
trom pocks which arc surrounded by a brooid zonu of iufiammation, or 



150 ACUTE INFECTIOUS EXANTHEMATA. 

from erysipelatons children, and yaccinatiou with primary bovinelymph. 
If several cases of erysipelas develop, vaccination should be discontinued 
for some time. The treatment is similar to that of other forms of ery- 
sipelas. 

Vaccination is sometimes followed by the appearance of pock-like 
vesicles over the entire body, but this seems to be the result of accidental 
combination with varicella. 

Roseolar patches which often last only a few hours, and sometimes 
appear from the third to eighteenth days after the Operation, are known 
as vaccination roseola. 

The adjacent lymphatic glands are often tender, but in exceiptional 
cases they undergo suppuration, or become swollen in distant parts, or 
the salivary glands enlarge. Lymphangoitis is occasionalljr ooserved. 
Bediiar states that he has observed peritonitis ^ter vaccination in sev- 
eral cases. 

10. Varicella. Chicken-pox. 

T. Etiology.— Chicken-pox is a disease of childhood, and occurs so 
rarely in adults that it must arouse the suspicion of varioloid. The sus- 
ceptibility to the disease generally disappears at the age of ten years. 

The youngest case was observed by Senator in a child aet. 11 days. Among 
584 cases collected by Baader, 

882 occurred from 1- 5 years. 

191 •* ** 6-10 years. 

7 ** ** 11-15 years. 

2 ** " 16-20 years. 

2(?) ** *' 20-40 years. 

Cases of congenital varicella are unknown. 

Sex exercises no influence on the disease. 

There is no doubt that the disease is contagious. It often occurs 
cndemically in schools^ asylums^ or families. Sporadic cases are almost 
always to be found in large cities. At times it appears in epidemics 
which seem to be independent of meteorological influences. In many 
cases, the epidemics end iu a few weeks, in others they are protracted for 
several months. 

Positive results have been obtained by inoculating healthy children with the 
contents of varicella vesicles, although some writers obtained negative results. 
It is probable that infection may also be effected by the expired air. 

Tschamer claims that he has obtained, from the urine and dried crusts, fungus 
cultures which he regards as the virus of the disease. He describes and draws 
branching threads, which grow smaller at their free ends, and carry gonidia (?). 

As a rule, the disease occurs only once in a life-time. Exceptions to 
this rule are rare. 

Epidemics of varicella often follow, precede, or accompany epidemics 
of measles, scarlatina, variola, or whooping-cough. A child is some- 
times attacked at the same time by varicella and measles, scarlatina or 
whooping-cough. Thomas observed the development of varicella on the 
second day of a pleuro-pneumonia. The combination of chicken-pox 
and small-pox is hitherto unknown. 

II. Symptoms axd Anatomical Changes. — The period of incuba- 
tion averages thirteen to sixteen days, occasioAally it is as short as eight 
days or prolonged to nineteen days. 




bi 



AOtlTE IXFEcnora EXANTHEJiATA.. 

Kroenlein describes the following case which iUuatrates the length of th« 
"-"odof iociibaiion, January 4th, ]884, achild wan received into tUe surgical 
d or the Zurich Hoapital. and on Janoarf 6th, was attacked with varicella. 
January 20th. at noon, tvro other children were taken aick, and the llrat efflorea- 
oencea appeared on the eveninfc of the same day. In vaccinationa, the period of 
incubation is generally short (about eight da^s), and in one case. Flelscbmana ob- 
eerved the eruption on the second day after inoculation, 

A prodromal stage is entirely absent in many cases, but some chil- 
drpn guifer from irritability, anorexia, eructations, vomiting, aud irregn- ' 
laritv in evacuations from tlic bowels. Canstatt mentions tenesmus of 
the bladder and pale urine: disturbances of deglutition have also been ob- 
served. Delirium and eouviilsions occur in rare cases. As a rule, the 
bodily temperatnro is unchanged; but ocoaaionally it rises to 39° C. or 
even more. This stage lasts only a day or two, the elevation of torapera- 
ture only a few hours. 

The stage of eruption begins, in rare cases, withn fieetiug erythema. 
The B|)ecil]c eruption appears first in the face, and rapidly extends to 
the trunk and limbs; the scalp is often affected. 

The eruption appears first as red patches, of the size of a lentil to 
that of a finger-nail, rarely larger. They grow pale on pressure, and are 
gradnally elevated slightly above the level of the skin. In a short time 
(six to twelve hours) vesicles form in the centre of the patches, and increase 
to the size of a lentil or pea; in rare cases they may measure four centi- 
metres in diameter. The large vesicles are always isolated. They are 
generally oval in shape, and, as a rule, do not occupy the entire circum- 
ference of the prodromal roseola, so that they are generally surrounded 
iyf a red zone {hyperemia of the cutaneous vessels), 'fhe vesicle is 
situated in the upper layers of the epidermis and is only covered by a 
thin layer of epidermis.- The centre is not infrequently slightly de- 
pressed and less transparent, so that, according to my esperience, the 
vesicles may be umbilicated. The contents of tne vesicles are clear and 
watery, but after the second day they become cloudy from the admix- 
tnre of cellular elements. Vesicles with purulent contents may develop 
in rare cases and are exactly similar to well-developed pustules of suialf- I 
pox. I 

If a vesicle is punctured with a needle, a clear fluid slowly escapes, 
an alkaline or neutral reaction, and poor in cells. Hence the vesicle 
Diul til ocular. If this were not so, the contents would be discharged 
once. 

When the Tesioles are left to themselves, slight collapse occurs from 
absorption of the fluid contents, perhaps in part from evaporation, and 
the top of the vesicle is wrinkled. About the fourth day, the contents 
dry and form a thin, horn-yellow, or yellowish-gray crust. Two or 
three days later, this falls oS without leaving aiiythtng beyond a red pig- 
mented patch which persists for a few days. In rare cases, a few vesi- 
cles extend to the deeper lavers of the epidermis and even to the super- 
ficial layers of the cutis, so that permanent cicatrices are produced. 

The desiccation of the vesicles is attended not infrequently with 
flovore itching, so that the children scratch the vesicles and produce ex- 
coriations even in their vicinitv. Very tense vesicles may burst sponta- 
.ueously, and dry up after partial discharge of their contents. 

"" " icles are generally distributed irregularly; they are sometimes 
groups, as in herpes. Their number varies greatly (from 
hundred or even more); they are most abundant upon the 




152 ACUTE lOTECnOU8 EXANTHEMATA. 

trunk. Confluence of adjacent vesicles occurs very rarely. The patches 
and vesicles appear by fits and starts in the coui'se of a few days. To- 
wards the end of the disease^ roseola alone may appear. 

It is said that the vesicles sometimes have bloody contents, and occasionally 
they contain air bubbles, as the result of rupture of the epidermis. Crocker 
states ttiat in children with a tubercular predisposition, varicella is apt to be 
attended with extensive gangrene of the skin, which is relatively often fatal; ac- 
cording to Hutchinson, this may lead to loss of sight from purulent irido-choroi- 
ditis. In a few cases the eruption is abortive, and roseola alone develops. 

In rare instances, the eruption appears on the mucous membranes (enanthem), 
most frequently on the hard and soft palate, alno on the tongue, cheeks, lips, 
nose, and conjunctiva. On the palate, the vesicles have a characteristic shape; 
on the remainder of the buccal mucous membrane, they generally burst rapidly 
and leave a shallow ulcer with red borders. The vesicles have also been observed 
upon the prepuce and labia, where they give rise to a sensation of burning during 
urination. According to Ck>mby, the enanthem sometimes precedes the ex- 
anthem. 

In not a few cases, the disease consists merely of the eruption. In 
others, moderate fever, with morning remissions and evening exacerba- 
tions, appears during the first few days. Considerable rise of tem- 
perature (to 41° C.) occurs occasionally, and may even be associated 
with delirium and convulsions. 

Mild pharyngitis is frequent; enlargement of the submaxillary and 
cervical lymphatic glands has also been described. Dry bronchitis is 
frequent and is easily recognized by the sonorous and sibilant r41es. 

The disease almost always runs a benign course. Its average dura- 
tion is one to two weeks; occasionally it is protracted for six weeks, fie- 
lapses are occasionally observed. 

Erysipelas, in a few cases peritonitis, and otitis have been observed as 
complications. 

Prolonged pallor and chronic feebleness are sometimes left over as 
a sequel. Pemphigus and urticaria have been observed as sequelae. In 
four cases, Henoch observed acute nephritis one to two weeks after 
recovery from the disease, one case terminating fatally from oedema of 
the lungs. 

III. Diagnosis.— The disease is distinguished from pemphigus by 
the fact that, in the latter, larger vesicles are produced and run a slower 
course. In miliaria, there has been preceding diaphoresis, uncovered 
parts of skin remain free from vesicles, the vesicular contents are acid, 
and the vesicles disappear very rapidly. In herpes, the vesicles are 
always arranged in groups. Eczema vesiculosum is associated with violent 
itching, and the integument between the vesicles is almost always in- 
flamed. In adults, the disease must be distinguished from the syphilitic 
eruption known as varicella syphilitica; in these cases, other syphilitic 
changes are present on the skin, mucous membranes, and genitals. 
Variola is differentiated by the severe prodromal symptoms, and by the 
fact that vesicles form upon small papules. 

IV. Prognosis and Treatment. — Th^ prognosis is almost always 
favorable, and treatment is generally unnecessary. If there is no fever, 
the patient need not take to bed, but it is well to be careful in diet, and 
to guard against taking cold. Exfoliation of the crusts may be accelerated, 
and the itciiing diminished by baths at 28° R. In other respects, purely 
symptomatic treatment. 

The spread of the disease can only be prevented by strict isolation^ 
but, on account of its innocuous character, this is rarely necessary. 



IBFS0U0U8 OiaSASBS IKTOLTIBO THE MOTOR AFFABATCS. 



I INFECTIOUS DISEASES IN WHICH THE MOTOR APPAKATCTS 
(JOINTS OR MUSCLES) IS CHIEFLY INVOLVED. 

1. Acute Articular Rheumatism. 



{Polyarthriiis c 

I. Etiology.— The view that thie is a 
hy specific bacteria, is ^riulually | 



:uta.) 



so till 
I qiici 

^■mot! 

Bpbtl 



I 



1 iufectioiis disease, prodaoed 
ground. In onr opinion, tlia 
term articular rheumatism should be discarded, and the disease should 
be called iDfectious arthritis or polyarthritis. 

In furnishiug groundit for our view US to the infectious nature of ar- 
ticular rheumatism, we need not rely upon Pocock's case, in which a 
pregnant woman suffering from the disease gave birth to a child which 
also presented evidences of articular rhenmutiam ; nor upon that of 
Thoresen, who claims to have observed the spread of the disease by per- 
souul contact. On the other hand, I would call attention to the fre- 
quent occurrence of the disease in epidemics. In Zurich, I have often 
noticed that a large number of cases entered the hospital in a few days, 
~ that I have repeatedly had mure than a dozen cases in my wards at 
e time. Tlieee epidemics are more frequent in the cold, changeable 
■ireatber of winter and spring. As is true of other infectious diseases, 
the character of the individual epidemics varies greatly, but caeos occur- 
ring during the same epidemic present great similarity to one another. 

Kdlefacn found that, in Kiel, acute articular rheumatism is a 
house diHease," like fibrinous pneumonia and typhoid fever, so that> 
~ example, 728 cases occurred in 493 honses. 

This writer also found that the frecjuency of the disease does not ' 

"~.d npon the temperature or variability of the weather, but upon 
nount of riiiu-fall, increasing with diminished rain-fall, diminish' 

, with increased rain-falt. 

According tu Thoresen, the disease does not flourish abovo certain 
Its proper habitat is the temperate zone, especially on the sea- 
ooasts. 

Another circumstance indicative of its infectious nature u xu inti- 
mate relation to other infections diseases, especially euducardkis and 
meningitis. Autopsies in cases of thie disease also produce the imprea- 
aion of an infectious process; hemorrhages into various organs, cloudy 
swelliug of the heart, liver, and kidneys, soft large spleen, etc. I 

The majority of patients, it is true, state that the disease is brought 
on by a cold, but, on careful examination, there is only a very small 
itropurtton of cases in which this is probable. Not that we deny the in- 
jurious effects of a cold, but, iu our opinion, this is secondary, and 
merely preparatory for the bacteria. 

Some patients mention bodily or mental exertion as the cause of the 

Ueredity sometimes appears to play a certain part. Perhaps, in auaU. j 
I, the power of resistance of the joints is diminished. 




154 LVFKOTIOUS DISEASES mVOLYINa THE KOTOB APPARATUS. 

Males are Attacked more freqaently than females. It is also more 
comiuon in those who work a good deal in the open air. 

The diriotiso occurs most freauently between the ages of 15 and 30 
yeui'd. it is rare in old age and childhood, but has been observed at 
birth, or a few days after birth. It presents a marked tendency to re- 
lapses. 

Many distinzuish primarv and seoondary articular rheumatism. The former 
occura independently, the latter follows other infectious diseases (scarlatina, 
gonorrhoea, diphtheria, syphilis, dysentery, typhoid and relapsing fever, erysipe- 
las, puerperal fever, erytbenia nodosum). In our opinion, however, we have to 
deal, in secondary rheumatism, with true metastases. 

11. STMPT01C3. — Prodromata are absent in the majority of cases. In 
rare cases, the patients suffer from general malaise and wandering pains 
in the limbs for two or three days previous to an attack. 

As a rule, the disease begins suddenly with a chill or repeated chilly 
sensations. An irregular type of fever sets in, rarely exceeding 40** C. 
The frequency of the pulse and respirations is increased. The iongue is 
coated, the appetite lost, thirst increased. The bowels are constipated. 
The urine is scanty, dark-red, often deposits a sediment of urates, and 
its specific gravity is increased. It is often extremely acid and not in- 
frequently contains small amounts of albumin. 

The amount of urea and uric acid is increased as in febrile conditions gener- 
ally. Jaksch found peptone in the urine in twelve cases, but only after the 
swelling of the joints was absorbed. It is probably the result of the absorption 
by the blood of the exudation cells in the inflamed joints. 

The skin is generally covered with profuse, sour-smelling perspira- 
tion, which often gives rise to the development of miliaria. 

Rapid diminution of the red blood-globules and increase of the white 
globules have been observed. Salomon did not succeed in finding lactic 
acid in the blood. 

Changes in the joints appear almost simultaneously with the onset of 
the fever. The large joints (knee, ankle, shoulder, wrist, and elbow^ 
are attacked most frequently, but the smaller ones (fingers and toes) 
are also often involved. The symptoms often begin in one or a few 
joints, disappear in three or four days, and then re-appear in other 
joints. The change sometimes occurs in the course of a single night. 
Occasionally almost all the joints are attacked, even those of the 
maxilla, vertebras, the sterno-clavicular joint, and the synchondroses of 
the ribs, symphysis, and ileo-sacral articulation. Painful affection of 
the joints of the arytenoid cartilages has also been described in a few 
cases. 

The diseased joints are thickened and swollen; the overlying skin is 
red, smooth, and shining. It feels hot, and a more or less distinct 
groove is loft after pressure. In fact, the visible swelling of the joints 
IS the result, not so much of an abundant exudation into the joint cavity, 
as of (Bdema of the surrounding soft parts. The slightest movement of 
the parts is attended with the most violent pain. The patients keep the 
joints slightly floxed, and if the disease is extensive, are rendered nelp- 
less. Tlie situation is especially distressing if the joints of rotation and 
flexion of the head and of the jaws are also attacked. 

Creakinjj is sometimes felt on passive movement of the joints. This 



^^^V ISFBOTIOUS DISE^ES liTTOLViyO THE BKnOB AFPABATUB. ISH 

^^HpBB not always ori^nate in tiie joint cavity, but results occasionalln 
^^^fom inflammation of adjacent sheatha of tendona. M 

r>rosdoS states that, in examination wiili moiat oleotrodes, the electro^ 
cutaneous xensibility oi'er the affected joints is ilimtnished or even Hbolishedifl 
Abramnwaki fuund tiie Hensibility increased when dry electrodes were uaed<fl 
Drosdoff objerreil diminiafaed presiure sensibility, and increased temperatura 
and (nctite sensibility over the inflamed joints, the local rise of temperatunfl 
variea fr^m 3 to 3° C. M 

The duration of the diaeasB varies from a few days to four, eight, or 
twt'lve weeks, There arp frequent reraJBaioua and exacerbations, the 
latterbeing produced eapecially by too early or incautions use of the joints. 
The diseaae may confine itself to a certain joint in which it continues 
with great obstinacy'. The longer it lasts the less marked the fever, J 
cutaneous and urinary changes become. Eecoverj' generally occurg* 
frradually, rarely in a sort of crisis. The epidemiis over the swolleal 
joints often becomes wrinkled, and desquamates actively. m 

Attention has been called to latent articular rheumatism whickl 
oconra as neuralgia, often periodical, osually of the trigeminus; it is as- 1 
sociated with endocarditis, and leaves the joints free, but rapidly dis*a 
appears nnder the use of salicylic acid. M 

Complications are remarkably frequent in this disease, I 

Endocarditis often develops, sometimes even the ulcerative form.. J 
It is so much more apt to occur thegreater the number of joints aSectedfl 

Kle Vol. I., page 69). J 

Pericarditis ia somewhat rarer (endocarditis in about 30^, peri carditis 4 
L4'C of the cases). Both diseases are not infrequently comoined. 1 

Dilatation of the right ventricle is of teu observed, and systolic febrile 1 
rmnrs are frequently audible. The heart muscle is sometimes aub^l 
1 to embolism, secondary to endocarditis (embolic myocarditis),] 
ne authora also assume the development of non-embolic myocarditis. J 
lera speak of rheumatism of the heart, to which they attribute sud-I 
den, sometimes fatal attacks of cardiac pain and heart failure. V 

Cerebral complications are the result, in some cases, of the high] 
fever which gives rise to disturbance of couscioitsness and delirium ; or, I 
the fever rises bo rapidly that death occurs from hyperpyrexia. Thad 
temperature sometimes rises above 43° C. and may even continue to J 
rise for a short time after death. Meningitic symptoms may appear, 1 
although the autopsy may show merely congestion, hemorrhages, or rede- 1 
ma of the nieniuges. Cerebral embolism may give rise to paralysis and 
aphasia. The cerebral symptoms are sometimes the result of uriemio 
poisoning. Psychopathic conditions have often been observed as se- 
quela). All the symptoms mentioned were formerly called cerebral rbeu- . 
tnatism. m 

The complications sometimes start in the joints themselves. The9 
inflammation may become purulent, and terminate in rupture, pyemia, n 
or ankylosis. Absceasesof the muscles have been observeu in a few cases. 
Myalgia is more common, and may occur In the muscles adjacent to the 
inflamed joints or in remote parts. 

Koseola, urticaria, erythema, facial herpes, erysipelas, and gangrene 

of the skin have been observed. Purpura and eechymoses have also J 

been described ; upon the latter are sometimes found vesicles with ■ 

serouB, aero-purulent, or sanguinolent contents- IlauS observed herpes I 

~IDter at the level of the lower angle of the scapula. Papules some- I 



^joDtei 



156 INFBOTIOUS DISEASES INYOLYINa THE MOTOR APPABATUS. 

times form upon the skin, especially of the forehead and occiput, and 
disappear witii the joint changes. 

Irido-choroiditis and cyclitis have been observed in a few cases; 
paralysis of the motor oculi occurred in one case, but was probably asso- 
ciated witli meningitic changes. 

Catarrhal angina may appear as a prodromal symptom, or during the 
later course of the disease. 

Bronchitis is of very common occurrence ; pleurisy is not infrequent ; 
it is usually unilateral, more rarely bilateral, and occasionally associated 
with endocarditis and pericarditis. Fibrinous pneumonia has also been 
observed. 

Peritonitis is rare. Acute nephritis and haematuria develop at times ; 
anuria may be produced, and may lead to uraemic symptoms. Hsematuria 
is sometimes the result of renal embolism, not of acute nephritis. Op- 
pert described hemorrhages from the intestines and uterus. 

An unfavorable termmation in acute ai'ticular rheumatism is always 
the result of complications, such as rapid rise of temperature, pulmo- 
nary embolism, meningitis, pericarditis, heart failure, pyjemia, etc. 

Many complications pass directly into seouelse, for example, an- 
kylosis, which is sometimes followed very rapidly by muscular atrophy ; 
paraplegia and paralysis of the bladder from implication of the spinal 
cord ; hemiplegia and monoplegia from cerebral disease ; valvular le- 
sions, etc. Chronic nephritis sometimes develoi)s. Chorea and psy- 
choses merit special attention. Both beo^in not infrequently during the 
course of the disease as a comjilication, extend beyond the primary dis- 
ease, and persist as sequelae. Chorea is more frequent in childhood, 
psychopathy at a later period. 

In 1874, Simon collected 61 casein of psychopathy complicating rheumatism. 
He distinguishes three forms, viz., melancholia cum stupore, recurrent insanity, 
and imbecility. Maniacal attacks are rare. Relapses of the joint affection are 
apt to be attended with relapse of the psychopathic, more rarely by recovery of the 
jMychopathic, condition. Recovery generally occurs in two weeks to four months. 
The insanity seeiu.-t to result from anaamic changes dependent on complicating 
heart affections (?). 

III. Anatomical Changes. — Little is known concerning the ana- 
tomical changes of acute articular rlieumatism, because the majority of 
Eatients recover. In one of my patients, in whom death resulted from 
yperpyrexia, hemorrhages were found in the mediastinum, epicardium, 
pleura, spleen, beneath the peritoneum covering the intestines, and into 
the meninges; also parenchymatous hemorrhages into the heart, liver, 
and kidneys ; in a<ldition, cloudy swelling of the heart, liver, and kid- 
neys. Spleen large and soft. 

The joints sometimes contain very little fluid : it has probably dis- 
appeared in part after death. In other cases, the contents are abundant, 
fiocculont, cloudy, occasionally purulent. The synovial membrane, car- 
tilages, and even the ends of the bones are injected and sometimes con- 
tain hemorrhages ; the cartilages are occasionally eroded. 

The microscope shows proliferation of the cartilage capsules and 
cells. The fluid exudation contains pus-corpuscles. Targe cells with 
several nuclei, and grauulo-fatty cells. The flocculi consist of fibrin and 
mucin. 

Fibrinous deposits are said to have been observed on the inner surface of the 
joints (arthromeningitis crouposa). 



UTFECnOCS WBEABES CSrOLTISG THK MOTOB APFAKATUS, 



157 



IV. DIAONOSIS. — As a nile, the diagnosis is easy. Thed ._ 

^stingiiiBlied from gont by the fact that the latter generally runs an 
apjTexial course, uiid affects the great toe joint. In pysemic joint dis- 
eaaes. the articular changes are secondary. 

V. Prognosis. — The prognosis is goo<l, inasmneh as there ib rarely 
(in hardly 3* of the cases) any immediate danger to life. It may be 
rendered 'unfavorable bv the complicationM and seqnelfe. 

VI. Treatment. — ^The patient's room should be large, well aired, 
and kept constantly at 15° R. ; if possible, it should contain two adjacent 
beds, one for the day. the other for the night. Lemonade may be taken 
as a drink. If fever is present, the patient should take only fluid food. 

Among medicinal agents, salicylic acid has displaced almost all others. 
This drug, or salicylate of soda should be given in doses of gr. vij. every 
hour until tinnitus aurium is produced. The remedy is again given 
after the tinnitus has ceased. In many cases, the pains subside very rap- 
idly and disappear within twelve hours. The effects are apt to be so 
much more prompt the more acute the symptoms, the higher the fever, 
the greater the number of joints affected, and the more marked the in- 
flammation in them. Wlien the pains have subsided— anS the swelling 
of the joints nsualiTdisappe.irBffith surprising rapidity at the same lime 
— the salicylic acid should be given every two hours for the next two 
days, then every three and four hours. If "the treatment is not continued 
for some time, relapses occur not infrequently. 

It may happen, however, that one or another joint remains swollen 
and painful. In sucli cases, I have obtained good effects from local 
warm hatha containing a ponnd of salt (thirty minutes' duration. 30" R.). 
The application of a plaster of Paris bandage may also cause rapid relief 
of the swelling and pain, but this is sometimes followed by rapid mus- 
cular atrophy, requiring the subsequent application of" the faradic 
current. 

If salicylic acid proves useless, we may warmly recommend flxation 
of the joints by splints or bandages, but this plan meets with practical 
difficulties, it many joints are attacked. 

We have often obtained good effects from Davies' plan of treatment. 
A fly blister (it the joint is large, two blisters) is placed upon the 
^^ec'ted joint, the blister opened, the surface covered with carbolized oil,jP 
id then inclosed in salicylated wadding. Poisoning with cautharidei 
iurs very rarely. 



Wo may mention the following other methods of treatment: a. Derivatives : 
leeclies, cups, moxa, aotual caulerj, alcoliolic iaunctionH, veratrine ointment, 
ichthyol aiiitment (!5 : 50), nitrate of ailfer, faradic current, b. AnCiphlogistJcs : 
ioe-baKB, ether apray, elnyl chloride, c. Narcotic iaunctions witli chloroforni, 
chloroform liniment, ointnentB of belladonna, opium, etc. d. Subouianeooij 
injections of morphine or carbolic acid (one to three per cent), e. Absorbenta J 
tincture of iodine, iodoform ointment. /. Antirheumatics: aconite, colchicumt^ 

Ktaasium iodide, g. Antipyretica: digitalis, tartar emetic, veratrine, quinins,^ 
nzoicncid, salicin, antipyrin, kairin, etc. h. Diaphoreiica: pilocarpine, lint-air 
chamber, i. Laxatives. It. Mercurials (internally and eiternally). /. Alkalies: 
pntaaslum nitrite, sodium nitrite, potassium carbonate, sodium bicarbonate. 
m. AstrinKents: acetate of lead, ergotin. n. Narcotics, opium, morphine, chloral 
hydrate, ammonium bromide, potassium cyanide, o. Speciflcs : propylat 
(□eelera in many at my coBea), tincture aynarne, tincture {{uaiac, permaagau 
of potash. 

Iodine and iron may be employed in persistent anemia. 



■ 158 ntFBcrnouB DieGASEB isvoi.yn»> the M0T9K AprABATca 

Complications must bo treated according to general principles. In 
^perpyrexift wo should use protracted lukewarrn baths (26* R., thirty 
minutea' duration) and large doses of antipyrin ( 3 i.-iss. by eoema). 



N 



2. Chronic Articular Rkeutnaiism. 
{Chronic Polyarthritis.) 

I. EtioloqT. — In many cases, this is a sequel of the acute form. 
But the disease may also be chronic from the start, and is then generally 
attributed to colds, to repeated wetting, and living ia damp rooms. As 
a rule, the patients are past the age of 40 years. Heredity is sometimes 
said to play its part in tlie etiology. 

II. Symptoms. — The chief symptom is pain in the joints, which 
develops apoutaneously, on pi-essure, or on movement. The joints are 
often, though not always, swollen, and at times the overlying skin is red 
and cedematous. The ankles, knees, shoulders, elbows, anu wrists are 
attacked moat frequently; but similar changes may also appear in the 
fingers aud toes. 

After the inflammation has lasted for some time, creaking of the 
joints may develop, motion becomes difficult, and even ankylosis may !» 
produced. The capsule, ends of the bonee, and the inserted fascise may 
be permanently thickened. 

Fever is absent. As a general thing, there are no complications oa 
the part of the heart or other orgaue. 

The disease lasts many weeks, months, years, or even a lifetime. 
Remissions and exacerbations are frequent; the latter occur particularly 
during changeable weather. 

Special morbid causes occasionally produce exacerbations of such a 
severe character that the symptomB of acute articular rheumatism ara 
produced. 

The complications and sequel® consist of the previously mentioned 
deformities of the joints and ankyloses. These are sometimes followed 
by very rapid muscular atrophy which cannot be attributed entirely to 
disuse. 

III. ANATOMICAL Chasges. — These consist of thickening of the 
synovial membrane, the villi and capsule of the joint, sometimes of ad- 
hesions within the joint cavity. The articular fluid is usually scanty- 
Erosion of the cartilages may occur as the result of fatty, fibrous, and 
mucoid degeneration of the cartilaginous tissue. 

IV". Diagnosis. — The diagnosis ia evident from the symptoms. 
The disease is distinguished from gout by the fact that it nma a more 
gradual course, and that the great toe is not attacked with special fre- 
quency or severity. The differential diagnosis from arthritis deformans 
ia more difficult; chronic rheumatism is often preceded by acute attacks, 
and iuflammatory changes prepare the way for deformities of the joints. 

V. Prognosis. — While there is no danger to life, the disease can 
only bo improved, not cured, by medical interference. 

VI. Tbeatment, — Trial may be made of salicylic acid or salicylate 
of soda, hut the effects are uncertain, and can only be looked for if large 
doses are continued for a sufficiently long timo {gr. xv. every hour BntU 
tinnitus aurium is produced repeatedly). Potassium iodide (gr. iv. 
t. i. d.) may be given; also tincture of aconite, colchicum, or other 
remedies employed in acute articular rheumatism. 



INFECnOUS DISEASES IMTOL^ISO THE BLOOD, ETC. 1 

^ Dnnng the aiimmer the patient mav be reoom mended to tuke a ood... 
of indifferent thermal baths, xodium chloride, or sulphur baths. Bene- 
fit may also be derived from mud baths, Russian or Turkisli baths, and 
cold-water cnrea. The poor must be satisfied with ordinary warm baths 

^^^(30° K. ), perhaps, with the addition of salt or sulphur. Trial may also 

^^Hm> made of sweat cures. 

^^^H The local measurea include leeches, cups, alcoholic and narcotic i: 

^^^Rictions, subcutaneous injections of morphine or carbolic acid, massag. 

^^^bd electricity. Seeligmueller recommends the faradic brush (stron| 

^^Hbrrent, the brush as tne negative pole). 

^^^P 3. Muscular Rheumatism. 

I. Etioloqt and Symptoms, — Muscular rheumatism is charac- 
terized by pain in the muscles, which appears spontaneously or is pro- 
duced by pressure. The pains may be confined to one muscle, or they 
jump to various muscles. As a rule, the disea.se is apyrexiaJ, ati4.H 
elevation of temperature only occurs when many muscles are attacket" 
The usefulness of the limbs maybe consitlerably impaired. Pain an 
difficulty in respiration, cyanosis and dyspnoea may bo produced by rliea-l 
matism of the chest muscles. In one of my coses the rheumatism of all 
the muscles of the back waa so violent aa to give rise to marked opis- 
thotonos. When the neck muscles are attacked, the head is held stiff; 
if the afl^ection is unilateral, rheumatic torticollis is produced. We must 
avoid mistaking rheumatism of the abdominal muscles for peritonitis. ~ 

The disease may be acute or chronic, the former lasting a few dayi 
the latter laetiug weeks and months, and often presenting remissions an< . 
exacerbations. Muscular contractures or fibrous thickenings sometimM 
develop. 

Endocarditis and myocarditis have been observed in a few c 
CO rnpli cations of muscular rheumatism. 

The disease generally develops beyond the age of thirty years, and !»■ 
attributed, as a rule, to colds, living in damp rooms, etc., sometimes to 
hereditary influeucea. 

n. Anatomical Chanqes are not disooverablo. The diagnosis is 
■B][, the prognosis favorable, escent in old cases. The treatment ia_] 

'lar to that of chronic articular rneumatism. 



3CTIOU8 DISEASES IN WHICH THE BLOOD AND HEMATO-J 
POIETIC ORGANS ABE CHIEFLY INVOLVED. 

1. Relapsing Fever. 

{Recurrent Typhus.) 

1. EnOLOOT.— The mode of infection and spread of relapsing feverl 

ftnilur to that of typhus fever. As a rule, the disease is contracted T 

_ direct personal contact, more rarely through the medium of inter- 1 

mediate persons, still more rarely by various utensils, clothing, or bed- 1 

ding. In hospitals, the nurses, lauudresses, and physicians are ofteal 

attacked, and tlie disease sometimes spreads to adjacent bods, wlieu tli6>l 

"""inta are placed in general wards. " 



^^AftCi«i 



160 INFECTIOUS DISEASES INVOLVING THE BLOOP, ETC. 

The disease occurs chieflj[ among poor people and tramps. An epi- 
demic often spreads from a single importea case, especially in miserable 
lodging-houses and prisons. In our opinion, its autochthonous develop- 
ment is impossible. 

In Ireland and Russian Poland the disease occurs endemically, and 
Jewish immigrants from the latter country have started a number of 
epidemics in Great Britain. Irish immigrants, in like manner, have 
imported the disease into England and America. 

Repeated importation into a city or State may finally convert the lat- 
ter into an endemic site of the disease. 

As in the case of typhus, the outbreak of epidemics of relapsing 
fever is favored by failure of crops, famine, and war, but is uninfluenced 
by the character of the soil, climate, temperature, drinking-water, etc. 

The majority of cases occur between the fifteenth and twenty-fifth 
years, although the disease is not rare in children, especially from the 
fifth to tenth years. As a rule, the disease does not occur during the 
first year of life, but Albrecht showed that it sometimes attacks the iGstus 
in utero. It is rare beyond the age of forty-five years. 

Sex, occupation, and constitution exercise no noteworthy infiuence 
on its frequency. Pregnant women have been attacked in a number of 
instances. Premature delivery is generally produced, the child being 
still-born or living onlv a few days. 

The virus is undouotedly contained in the blood, but inoculation is 
attended with successful results only when the blood is taken from the 
patient during a febrile seizure. The blood is not infectious during the 
period of incubation, and also loses this property ten weeks after the last 
attack of fever. 

In Motschutkoffsky's experiments, the blood remained infectious even after 
being kept for two dayB in capiUaxy tubes at 10** R., or diluted with an equal 
amount of a one-tenth per cent solution of hydrochlorate of quinia. The virus 
was not contained in the saliva, sweat, milk, urine, and excrement. 

Inoculations of animals were unsuccessful, except in monkeys. It ahnost 
seems as if the animal body possesses the power of modifying the poison. At 
least Carter states that in monkeys suffering from the disejQkSe the spirilli are 
shorter than in man and present fewer turns. 

The physical shape of the virus is unknown. Movable schizomycetes 
(spirochaete Obermeieri) are always found in the blood during a febrile 

Earoxysm, but they are not the carriers of the infectious matter. The 
itter must be sought in the spores of the spirochaetes. Motschutkoffsky 
found that the blood remained infectious even after the spirilli were 
killed by the addition of a solution of quinine (O.lj^). Hence it is 
inferred that the spores are more resistant than the spirilli. It has been 
supposed that the spores are those small shining granules which are found 
in the blood (?). Carter believes that the spores develop into spirilli in 
the walls of tne splenic veins. 

The corpse retains the infectious power for a short time. Perls was 
attacked with severe relapsing fever immediately after making an autopsy. 
Heydenreich found moving spirilli in the blood nine hours after death, 
the body having been kept at a temperature of 36.8° C. 

A single attack generally confers immunity in subsequent epidemics, 
although a few cases have been reported in which individuals were at- 
tacked several times. 

Epidemics of relapsing fever are sometimes associated with typhus. 



iHrscnnrs diseases jsvolvjso the blood, vro. 



161 



I rarely typhoid fever. The individnal is BOmetimes attacked by 

Helap-ting fever, and immediately afterwards by typhus, or vice Tersa. It; 
has also been foand on several occaaionB that when relapsing fever and 
typhus were prevalent at the same time, the former attaclced mainly the 
poor, the latter the well-to-do. It has also been observed repeatedly that 
patients suffering from intermittent fever were attacked by relapsing 
lever, or that the former developed immediately after the latter. 

II, AsATOMicAL Chanoes. — RigoF mortis develops early and IS Very 
prolonged. The akin often has a slightly yellowieb color, and may con- 
tain petechiie. In some cases there is intense icterus, and then the 
iotemal organs are also janndiced. The body is not emaciated to any 
noteworthy extent. As a mle, the mnscles are dry and have a deep-red 
color. Uemorrhagio inBammation and softening of the rectasabdominia 
are observed occaaionatiy, as in typhoid and typhus fever. Small hemor- 
rhages are often found in the muscles and viscera. 



The heart muscle is pale, brittle, and flaccid, and in some cases 
hardly a muscular fibre can be found which is not ina condition of cloudy 
swelling and fatty degeneration. The bronchial mucous membrane is 
almost always swollen, red, and covered with profuse secretion. The 
bronchial glands are often enlarged and congested. 

Atelectasis and hypostasis ai-e commonly found in the lungs. 

The spleen is sometimes enlarged to five or six times its normal di- 
mensions. Its capsule is tense, and not infrequently presents recent 
perisplenitio deposits. The splenic pulp is intensely red and difBuent. 
The Malpighian corpuscles are enlarged, and visible as gray or yellowish J 
nodules. Their centre is often necrotic or contains an abscess. Larger j 
abscesses also occur with reintive frei^aency, and generally develop from ' 
wed£e-abaped or simple hemorrhagic infarctions. 

Rupture of the spleen has also oeen described, either as the result of 
excessive swelling or of previous suppuration (in 5.9 per centof all cases, 
according to Petersen). The rupture is said to occur most frequently 
on the surface directed towards tne stomach. 

The enlargement of the spleen depends parti; on congestion, partljr on hyper- I 
pluia of the cellular elements. A striking phenomenon is the appearance of. 1 
l«rg« tattr celln, which pass from the spleen into the general circulation, and an 
aJbo touna in the blood of the splenic vein and portal vein. 

The chansea in the follicles atari from the central arteries, in which round 
cells accumulate and undergo rapid fatty degeneration; this results in the forma- j 
Clan at central cavities. Oranulo-fatty cells are found in the parenchyma of the 

Splenic follicles, and in the adveiititia and muscular coat of the arteries. The eu- 
otliplium ot the splenic veins also undergoes fatty degeneration and desquama- 
tion, so that apindle'Shaped cells are found in the circulation during life. 

It hw been suggested that the frequent infarctions may be the reHult ot occlu- 
sion of the vessela by masses of spinlli, but this has not l>een substantiated by 
mtoroecopic examination. Spirilli have been found in the necrotic splenic folli- 
«lea, and in the blood of the spli^nic vessels. 

As a mle, the liver is very large, and its cells in a condition of cloudy 
swelling and fatty degeneration. Infiltration with round cells is noticed 
along the branches of the portal vein. Recent perihepatitis has been 
described a number of times. The gall-bladder is often distended, 
generally with dark-green bile, which may be mixed with shreds of ma^ 
11 



163 



INFKt,TIOOa 1H8BA8B8 INTOLVTKO THE BLOOD, ETC. 



cua. The mncoas membrane of the ductus choledochns ia often swollen 
at its entrance into the duodenum, or is occluded by a ping of niucue. 

In the bilious typhoid variety of relapsing fever, the hepatic cbaoges 
are similar to those of acute yellow atrophy of the liver, 

Gastro-intestinal catarrh is frequent, and there may also be bloody 
suffusions and swelling of the follicular apparatus. The mesenteric 
glands are not infrequently enlarged. 

The kidneys are large and flaccid, and contain hemorrhftgea. Ac- 
cording to Ponfick, these are found particularly in the convoluted tubes 
and Uenle's loops. The epithelium of the tabes is in a condition of 
cloudy swelling and fatty degeneration. Small hemorrhages and slight 
inflammations are also noticeable on the mucous membrune of the uri- 



narr passages. 

Meningeal hemorrhages and cedema of the brain have often been 




Blood In relupaiug tevee vlUi splrocbKte 



Ponfick found changes in the medulla of the bones similar to those 
in the follicles of the spleen; they nro maujfesied macroscopicaliy by 
branchiug chalky white lines. As in the spleen, so spots of softening 
develop in the medulla of the bones, and may produce cysts, abscesses 
and carious changes in the bones ; the medulla also contains many 
granulo-fatty cells. 

III. Stmptoms — The duration of the stage of incubation is five to 
seven days. 

A prodromal stage is absent in many cases. In others, gener^ dis- 
turbances (malaise, anorexia, etc.) are felt for a few hours or days. 

The disease generallv begins with a violent chill or repeated chilly 
sensations. Very high feyer rapidly develops, the patients complain of 
violent throbbing in the temples, headache, and are often so dizzy that 
they stagger like a drunken person, and are unable to stand. They; com- 
plam of pain in the back, especially the loins, and shooting pains in the 
legs. True neuralgias mav also develop. ^ The feeling of prostration j- 
eepecially pronounced. Tne conjunctiva ia injected, the sclera s 



iiu> III iiue h 

tration is J 

Ji 



IKFEOnOCa DISEASKS IHTOLVmO THE BLOOD, ETC. 



168 



jHow, the face often very pale and almost cachectic in appearance. 
Jome patienta experience, at the onset of the disease, a dietressing feel- 
ing of oppression in the epiEastrium, with or without vomiting. 

In tlie further course or the aSection, the chief symptoms refer to 
the hlood, bodily temperature, spleen, and liver. 

The blood obtained by pricking the finger oEten has an intense black- 
ish-red color. Under the microscope it is found to contain corkscrew- 
like, rapidly moving structures (spirochffito Obermeieri, ride Fig. 34). 
These so-called spirHli are bo constant iu relapsing fever that the diag- 
nosis cannot he made if they are permanently absent, 

Hejrdenreich noticed that they are sometimes present a few houn before th« 
attack of fever, and wlieu the axillary temperature is btlow 88° C, Asa rule, 
they occur only with the beginniag of the fever, Boinetioies Bveii spverat hours 
Later. Towards the crisia their luovemente become slower, and they usually dis- 
appear before the crisis is over. In two oaaes. however, tliey were found Upon 

FlQ ffi, 




Ifemperature currp In rptapslnii fpwr with one relapae. 

the second and third days after the cesa^tion of the fever. With the next attack 
of fever they reappear in the blood. Theirntimber varies greatly. Motschulltoff- 
sky noticed that tliey are most abundant l>efore the crisis of a third attack of 

In examining a specimen of blood, we sliould look for any apparently eponta- 
neoua movement of red or white blood -globules, which is found not infrequently 
to be conveyed by spirilU. They often dart rapidly across the tield, finshinK 
asideever>-thing that oomes in their way. Sometimes they are arranged in coils 
or one above another. 

The spirilii form fine threads, 16-40;i (1/1=0.01 mm.) in length, and with 5-IS 
oorkscrew-like twists. Their forward movement is attended with rotation around 
the long axis, forward and backward movements in toto, tind undulations along 
their entire length. The more extensive the coagulation of the blood, the slower 
their movements become. Finally they are surrounded by fine granules into 
which they appear to dissolve. Their structure is homogeneous; rarely they con- 
tain flna granules. 

They maybe preserved alive for a long time outside of the body. Motschut- 

koffsky found them abve in the blond nt the end of thirty-seven days. Muellen- 

dorf preserved them for eiuht to ten day« in capillary lubes. They are very 

L^ansltivD to reagents, and are killed by everything which alters protoplasm, for 



ISrECTIOTTa DISKASES ISVOLTZVO THB BLflOD, FPC. 



n of sodium chloride acta like tbe serum ot Ih)^ blood. In human 
inilk their DioveineDte coniinuc<l eight hours, in perspiTHiioii two houiv, in saliva 
one to four hour;, Lncow'e milk oiib hour; urineanilliileexerciseiL very imfsror- 
nbleeSect. According to Heydenreiuli, a temperature of ia-ttl" produces death in 
one and three-qtiarters to three and a lialf hours. At & temperature of 0° they be- 
come rigid, but recover if the low temperature has not continued too long. Vapor 
of (jhlorofiirm, cai-bonic acid, oxytsen.land the electrical current also produce rapid 
death. Eoch found thnt, in cultures, the Hpirilli developed into long threads 



which 

The epirilli are found 



iuteriaced among one another, but always retained their twisted 
at the secretions and excretions of tlie body. 



The white blood-globulea are incTeased in nnmber during the febrile 
paroiysniB. The blood also contains large, granular, in part fatty cells 
— so-called protoplasm cells—which diaclose spveral nuclei on the addi- 
tion of acetic acid, and are capable of annBboid movements. These cells 
are also found in the spleen in which they probably originate. Spindle 
shaped fatty cells (endothelium of the splenic veins) arc also foaud. A 
few of the protoplasm cells may also contain one or more vacuoles or red 
blood-globnles. Finally, we may mention the granules— so-called proto- 
plasm granules — which are snpposed by some writers to be the germs of 
the spivilli. 

Tlie initial chill is followed by rapid rise of temperatare, which soon 
reaches 40, 41, or even 43° C. The fever generally runs a continued type 
for five to seven days. Then follows acritical fall of temperature, the pa- 
tient recovers very rapidly, and remains free from fever for five to seven 
'days. Then follows a relapse with same symtitoms a^ before, and even 
a third, fourth, or fifth rolapse may occur. But the later relapses are 
usually shorter and less typical. After the disease has run its coarse, 
the diagnosis can be made from the temperature curve alone. 

In rare cases, the disease terminates with a single paroxysm. If in- 
termittent fever is prevalent at the same time, an intermittent type of 
fever, with chill and sweat, is sometimes observed at the beginning of 
the diaeaao. More frequently relapsing fever terminates, as it were, in 
intermittent fever. 

The crisis is sometimes preceded by critical perturbation; in sneh 
cases, I have observed a severe chill with relative frequency. The crisis 
generally occurs at night, and the temperature often falls 5-7° C. in 
three hours. 

The spleen is generally very large, and the patients often complain 
of pain in the region of the organ. It is said that a systolic blowing 
murmur is sometimes heard over the spleen. Friedreicli noticed that 
the splenic enlargement appeal's before the onset of the first paroxysm 
of fever. After the paroxysm, the size of the organ diminishes consid- 



erably, and again enlarges . 
The liver also increases 



the next paroxysm. 
, size, and is tender on pressure. 
All other symptoms are the result, partly of the fever, partly of the 
infectious process. 

The pulse is accelerated (120 to 140 beats a minute) out of propor- 
tion to the rise of temperatare. It is generally hard and full, rarely 
dicrotic at the height or the fever, more frequently so after the crisis. 
Arhythm of the pulse may occur. After the crisis, the frequency of the 
pulse is sometimes subnormal. 



^ 




Al 



INFECTIOUS DISGASES INTOLnNO THE BLOOD, ETO. 

The senaorium is generally unaffected, and deliriam is decidedly 
rare. .Many ptitients complain of obstinate insoinaia. There is gen- 
erally ringing in the ears and difficulty in hearing, partly from tubal 
catarrh, partly Irom severe changes in the middle ear. The tongue is 
covered with a white, yellow, or brown coating, is thickened, and the 
impressions of the teeth are seen not iufreqnently upon its edges. 

There is often disagreeable fcetor ex ore. The patients complain of 
a bad taste in the mouth and increased thirst. The appetite is very 
little diminished in some cases despite the high fever. There is often 
a oomplaint of dryness and burning in the nose and throat, and diffi- ' 
onlty in deglutition. 1 

The skm often has a light grayish-yellow oolor. Koseola is oftffifl 
seen upon the abdomen and chest, occasionally herpes UbiaUs, mora 
rarely herpes nasalis or auricularis, Extensive erythema, or petechite 
and urticaria are observed at times. Litten described hlnish-red patches, 
which do not grow palo on pressure, upon the anterior surface of the 
trunk and thighs. The skin is almost always hot and dry; more rarely 
the disease begins with sweating. The crisis is always attended with 
profuse diaphoresis, which often gives rise to miliaria. Hyperalgesia, 
more rarely analgesia, has been repeatedly described. Desquamation of 
the skin usaally takes place during convalescence, sometimes in larger 
shreds. 

Dry bronchitis ia an almost constant symptom. The right side of 
the heart is not infrequently dilated, and the first sound is often very 
feeble and indistinct. I have observed vigorous puleationa of the carotid 
and temjjoral arteries in several casea. 

The abdomen is sometimes distended and tender on pressure. Some 
patients experience very violent pains in the region of the kidneys. 

The urine presents the characteristics of febrile urine: small quan- _ 
"ity, dark-red color, very acid reaction, and high specific gravity. Ati 1 
imos, there is a temporary increase in the amount of urine excreted. ■ 
After the febrile paroxysm, the urine again becomes normal. During 
convalescence, the amount excreted may again become very large (six 
thousand cubic centimetres). Albuminuria occurs very often during the 
fever, and the sediment may contain hyaline and granular casts and 
tabular epithelium; the formed elemente may also be present without 
albuminuria. 

So lonx as the boditf temperature ia elevated, tlie amount of urea ia in- 
creased; Ihis increase is not bo great in tlie subsequent utlackH. Auoording to 
Book and Wyss, the amount of uric iiciJ is diniinlalied duriug the paroxyxm; ao- 
cording toother writers, it ia increased. During the febrile period, there ia also 
increase of ammonia and F>ui|>htir)c acid in the urine. The chlorides diminish to 
a mere traoe, and gradually increase in amount during tlie inter missions. In a 
diabetic patient ttutleriug from relapsing fever, the sugar in the urine disap- 
peared, aooording to ^emrm and Traube. during the febrile period, and the ape- 
dflc gravity ot the urine diminislied at the same time. 

There are often several thin evacuations from the bowels every day, 
and these often contain a large amount of bile. 

Recovery generally takes place very rapidly, but it is so much slower I 
the greater the number of febrile paroxysms. Complications and 
seqnelee are not uncommon. 

In addition to delirium, nervous symptoms sometimea appear in the 
shape of epileptiform convulsions and trismus. In rare cases, conscious- 
""n^^mpaired to such an extent that urine and foBces are passed invol- 





^^^ mi 



mFEcnous diseasks isvolvisg the sluud, ktc, 

nntarily or the bladder beeomea distended to the level of the nmbilicus. 
All these aymptoma occur during the febrile period. There may be con- 
siderable rigidity of the back of the neck, which is not always due to 
meningitis, out to pain in the muaeles of the nape. Violent deliriam 
Bometimes appears immediately after the crisis (inanition deliriam). 
Temporary inaanity develops occasionally during convalescence. Para- 
lyses are sometimes left over, for example, atrophic paralysis of the arm 
and ocnlar paralyses. Griesinger mentions diabet«s mellitus as a sequel. 

The eye is often attacked by seonelfB, and it seems as if the fre- 
quency of such changes varies with the character of the epidemic. 
They are more frequent in men than in women, Flocculent opacities 
of ttie vitreous are observed not infrequently, and may be combined 
with iritis, irido-choroiditis, and irido-cvclitis. The posterior surface 
of the cornea sometimes contains fine light dots ( Descemetitis) and 
hypopion. Keratitis may also develop. Retinal hemorrhages, phlyc- 
tenular conjunctivitis, transitory amaurosis, and paresis of accommoda- 
tion have also been observed. 

Catarrhal and purulent inflammation of the middle ear has baen 
described in a number of cases. 

Stomatitis, pharyngitis, and swelling of the follicles of the toagne 
have been obsen'ed. Purulent parotitis and inflammations of the sub- 
maxillary gland sometimes develop as seoueliP. Croupons deposits have 
been found in the stomach. Bloody or dysenteriform stools may be the 
result of necrotic or diphtheritic changes in the large intestine. 

Similar changes have been found on the mucous membrane of the 
larynx and bronclii; ulcers like those of typhoid fever have been seen 
upon the posterior wall of the larynx. CEdema of the glottis also occurs. 
Bronchitis is sometimes complicated with atelectasis, hypostasis, catar- 
rhal or fibrinous pneumonia, rarely withabscess or gangrene of the iDoge. 
Huff observed hsemoptysia. Plenritis, pericarditis, and endocarditis 
occur rarely; inflammations of the serous membranes are sometimes 
hemorrhagic. 

Peritonitis is equally rare. Rnptnre of the spleen sometimes occurs, 
and is followed by rapidly fatal peritonitis. Abscess of the spleen is 
manifested by chills, renewed fever, and sweats; it may perforate into 
the peritoneum, pleura, lungs, pericardinm, muscles of the loins, stom- 
ach, or intestines. 

Hsematuria sometimes occurs, and in Leyden's cases the urine con- 
tained spirilli which were evidently derived from the blood. Chronic 
Bright's disease may develop as u sequel. 

Pseudo-menstrual discharges of blood from the genitals is observed at 
times. 

Abscesses or furuncles of the skin may occur as sequele. In rare 
cases erysipelas or bed-sores ^leveloj). Equally rare is gangrene of the 
skin, for example, the ears, nose, lips, or scrotum. Arterial thrombi 
may also give rise to gangrene of the limbs. Pustular, bulloue, or liche- 
noid eruptions, or inflammation and suppuration of the Ivmphatic glands 
may develop during convalescence. Desquamation of the skin has been 
observed in a number of cases. 

The patients are sometimes aufemic long after recovery from the dis- 
ease, and tedema of the skin may develop. 

During the febrile paroxysms, the joints sometimes present changes 
similar to those of acute articular rheumatism. Contractures of the 
muscles have been described, 



Hepatic complications include catarrhal jaundice with its well-known 
s^ptoms, In Home cases these terminate in the symptomatology of 
bilioQS typhoid, which is undoubtedly a variety of relapsing feyer, as has 
been shown by inoculations. In certain epidemics, this form of the dis- 
ease is frequent. The condition is a combination of relapsing fever and 
gmve jaundico, the latter being hematogenous in origin, and resulting 
from the severe infection. The jaundice becomes very intense, consciooa- 
neas is clouded, hemorrhages occur into the skin and mucous membranes, 
and many patients die from collapse in the first attack. 

In uncomplicated, moderately severe casea, the duration of relapsing 
fever varies from four to fire weeks. Death may occur in the first attack 
of fever from excesaive rise of temperature, paralysis of the heart, col- 
lapse, or choleemia; it may also be produced by the sequelie. 

IV. Diagnosis. — The diagnosis is rendered certain by the discovery 
of spirilli and by the characteristic temperature curve. 

V. pROOsodis. — In uncomplicated cases the prognosis is good, and 
the mortality often does not exceed two per cent. It ia rendered grave 
by complications, and is very serious in bilious tvphoid, in which the 
mortalitv may reach sisty per cent. 

VI. 'ruEATMENT. — Tho prophylactic measures are the same as those 
employed in typhus fever. This ia also true of treatment (vide page 124). 
In Dillons typhoid, Oriesinger obtained good effects from large doses of 
quinine {gr. xxx.), Kairin is said to be useful; otherwise antipyretic 
treatment produces very little effect. Bogourdow has stated recently 
that Fowler's solution causes disappearance of tlie spinlli from the blood 
and shortens the fever, but other writers have ueed this remedy without 
benefit. Oks claims that no relapses occur in 60^ of the cases, if calomel 
is administered. 



, Malar in. 



^^ isa 

^^H I. ETinLOGT. — Malarial diseases are also known as marsh fever, 

^^Bfere especially frequent in marshy regions. 

^^Bf Kndemic malaria ia often found near the banks of large streams and 

^^^\he shores of lakes. 

The sea shore, likewise, is often the site of endemic malaria, for ex- 
ample, the coasts of the North Sea. Those regions are especially dan- 
eeroua in which the waters of rivers and seas mingle, ana the waters 
become brackish. • 

Foci of malaria are sometimes formed in an accidental manner, 
for esampte, after inundations, or heavy rains followed by a period of 
dry heat, digging of ditches, draining of swamps, etc. It has also been 
observed after volcanic eruptions. It also develops whon previously 
oultivatcd districts are allowed to fall into disuse, or if barren distriota 
again are subjected to cultivation. Malaria has also been known to da- 
Telop iu vessels as the result of stagnation of bilge water. 

• The conditions necessary to the development of malaria always ob- 
Uun where decomposition of vegetable matter ia associated with a certain 
^Iwree of moisture in the soil. The richer the superficial strata of the 
nil in organic matter, and the more porous to moisture, the more favor- 
able are the conditions for the production of the malarial poison. Hence 
the disease ia sometimes found at high levels. 

Malarial poisoning is a prototype of miasmatic infection. Whoever 
^^^mters the malarial region is ia danger of infection; as a general thing. 



INFFOTIODS DIBEASK8 INVOLVING THE BLOOD, 

infection does not result from personal contact with diseased individuals. 
Whether infection occurs through the medium of drinking-water is atill 
an nnaettled queatiou. The poison seems to be propagated with greater 
£uilitr near the surface of tlie ground. 



According to some accounts, the disease may be produced bj personal contact. 
Sawyer states that he visited a district which w-.i» entirely fiee from malaria, 
was there attacked by malaria wliioh he had contracted iii his ovm home, and 
at the end of nine days infected his nurse irho lived in the non-malarial refcion. 
Buchner claims that the pnrspiratiou of the jiatieDta may convey the disease to 
those sleeping in the same bed. 

Malaria occurs endemically, epidemically, paademically, or eporadi- 
colly. lu regions in which the disease is endemic, the cases increase in 
such numbers at times aa to constitute an epidemic. The majority of 
epidemics begin in the spring and autumn. The temperature is also 
important. The higher ic rises, and the more the swamps are dried up, 
t. e. , the more the decomposition in them incroases, the greater Is the danger 
of its epidemic spread. In tropical regions, the spread of epidemics is 
furthered by the rainy season. A certain influence is also exerted by the 
winds. Geselle observed that the inhabitants of a village lying near a 
peat bog were attacked by malaria because the village was constantly ex- 
posed to the winds sweeping over tho bog, while the laborers in the bog 
itself were not attacked. It has also been found that a vail suffices oc- 
casionally to protect large numbers of people. 

Now and then the disease has assumed a pandemic character and 
travelled into regions which had previously escaped. 

Sporadic cases are generally imported from malarial districts. They 
aometimes recover spontaneously after a stay in a non-malarial region. 
The first sigfis sometimes appear after removing to a healthy region. 

Sleeping on tho damp ground and remaining near marshes early in 
the morning and late at night are said to be especially dangerous. 

The susceptibility to the disease is increased by excesses of all kinds 
and by colds. 

Age and sex exert no influence on the danger of infection . Even the 
new-born may be attacked with malaria, if the mothers suffered from the 
disease at the time of delivery. 

According to some writers, negroes suffer very little from the disease. 
Goth maintains that the puerperal condition increases the predisposition 
to malaria. Among forty-six cases, premature delivery occurred in forty- 
one per cent.; the children weighed, on the average, one-fourth pound 
less than normal. 

A single attack of malaria predisposes to relapses. If the individual 
is unable to leave a marshy district, the disease is obstinate aod not in- 
frequently continues for life. 

In the tropics dysentery and malaria are often prevalent at the same 
time. Epidemics of cholera have been repeatedly known to be preceded 
by intermittent fever. It has also been found that typhoid fever some- 
times precedes or follows malaria. During malarial epidemics, other 
diseases sometimes assume an intermittent character, for example, 
Porter reports intermittent hemorrhages from an amputation stump. 

At thn present tim^, the malarial poison ia sutiposed to consist of bacteria. 

Klebs and Tommafli-Crudeli have dwcribed rod-shaped structures — bacillus ma- 

lariee — which the v cultivated and succesBfully inoculated in rabbits. Oerltardt 

I recently eucoeedad in producing intermittent feveriu healthy individuals by sab- 

^ - - - 




UIFECnOUS DIBBA8ES ISVOLVISQ THE BLOOD, ETO. 

outaneoaa iDJections of btood which he had taken during tlie febrile parozTsm 
from patients suSeriiig from intermittent fever. Dochuann had obtained posi- 
tive reeulta b^ inoculation with the contents [of herpes veaiclee obtained from 
patieats Bu9ering from intermittent fever. 

II. Symptoms. — There are several forms of malarial disease which are 
knonrc aa intermitteut fever: latent intermittent, pernicious inter- 
mittent, remittent and continued fever, and malarial cachexia (pri- 
mary and Becondarj). 

The stage of incubation varies, as a general thing, from seven to 
twenty-one days. But it is said that the symptoms sometimes appear 
within a few hours after infection. Thus, several physicians have re- 
ported that, immediately' after reaching a malarial region, they were 
attacked by scratching in the throat and laryns, a feeling of drvneas 
and conatnction ; and_, soon after, by other manifest symptoms of malaria. 
On the other h^nd, it is said that -individuals are sometimes attacked 
more than three months after leaving the malarial region. 

The outbreak of the disease is sometimes preceded by prodromata: 
pallor, malaiae, chilliness, somnolence or disturbed sleep, gastro-intes- 
tiaal disturbances (anorexia, foul taste in the mouth, f(etor ex ore, enic- 
tatioDB, vomiting, diarrhcea, etc.). 

The form of malaria depends partly on the locality. In oar latitude, 
pure intermittent or latent intermittent fever predominates; in the tropics 
and endemic sites of malaria, remittent and continued fevers and cachec- 
tic conditions are prevalent. Pernicious and comatose intermittent 
fever is also most frequent in tropical regious. 

Intermitteut fever ia the most frequent form of malaria in our climate. 
It consists of febrile paroxysms, occurring at cedain definite periods, 
with apyrexial intervals. 

In many cases, the fever occurs at a certain time of the day, lasts a 
certain number of hours, and recurs in twenty-four, forty-eight, seventy- 
two hours, etc. In quotidian intermittent, the fever occurs every day; 
in tertian intermittent, every other day; in quartan intermittent, every 
two days. Binz recently described a case in which the fever returned 
once a week (intermittens ootava), and the interval is sometimes said to 
last thirty days ('■*). 

The miccesBive attacks of fever sometimes recur at s UtUe earlier period, bo that 
a t«rti&n mar be converted graduully into a quotidian, etc. The opposite condi- 
tion ia also observed at times. A second attack sometimes occurs before the first 
has entirely run its course. 

Double mtermittent fever is a special variety. In double quotidian, two at- 
tacks occur daily at certain definite times. In double tertisji. an attack occurs 
dailf , but the attacks vary in severity, tliose occurring on alternate days being 
alike. In double quartan, an attack occurs on two successive days, then follows a 
daj without tever, then two febrile days, etc. 

The temperature curves generally suiBce to permit apositive diagnos 
(Tide Pies. 26-28). 

The difterent types may undergo transformation, so that, for example, 
the disease begins as a quotidian and is then converted into a tertian. 

The paroxysm almost always consists of several stagee, viz,, the cold, 
bot, and sweating stage. 

In aome cases, the stages appear In an invert order; in others, intervals of 
l^oura elapee bi'twoen the dlnerent stages. In erratic intermittent fever, the 
kroxjBma follow no definite order with regard to time, 




INFSXTIOLS DI8EABE8 INTOLVISO THE BLOOD, BTC. 

A« a role, the cold stage begins gradually. The patients feel weak, 
grow pale, yawn (reqnently, and stretch themselves. A elight chilly 
•cnaation Ih noon felt along the back, and extends into the limos. This 
•enaation JH gradually intensified into a well -marked ohill. The teeth 
obatt«r, and the palicnts sometimes shake with such violence as to move 




the bed. The skiu is pale and feels icy-cold, and its temperature may 
be 5-7° C. cooler than that of the inside of the body. On pricking the 
finger, very little or no blood escapes of a deep blackisb-red color (con- 





In tertian lDt«rtDlctent. 




In qoftrtMi intennltMit. 



tnction of the cntaneoua vessels, and slowing of the circulation). The 
Bkin loses its turgor, the eves are surrounded by blue rings, the piipila are 
large, and their reaction slow. Manycomplainof dizzinessaudafeeling 
of eynoope, flashes of light before the eyes, and ringing in the cars. The 
loDgue is often coated. Eruotatious or obstinate romiting are occasion* 



ally obeerved. The piilae and respirations arc accelerated. The patients 
often, though not always, discharge alarge amount of pale, watery urine. 
The spleen increaaes m size the more the second stage approaches. 
There is not infrequently tenderness on pressure over the stomach and 
liver, or spontaneous pains in the region of the kidneys. The bodily tem- 
perature rises during the chill, and reaches its highest point towards the 
end of the cold stage {even as high as 44° C). 

The cold stage generally lasts one or two hours, not eery rarely much 
longer (six hours or more). 

The hot stage begins withagradually increasing sensation of internal 
heat which radiates into the periphery. Objectively likewise, the tem- 
perature of the skin rises and approaches that of the interior of the body. 
The latter generally remains tlie same us at the end of the cold stage, 
more rarely, h rises a little. The skin becomes titi'gid, feels dry and 
bnrning. The pulse and respirations are still more accelerated. The 
radial artery is unusually full, and the pulse vigorous. The face is con- 
gested, the conjunctiva injected. The dizziness, ringing in the eara, 
pain and throbbing in the head continue. The temporal arteries are 
nsually very sinuous and pulsate vigorously. The right ventricle is not 
infrequently dilated, and the first (Ivftolic) sound of the heart often has 
S blowing miality, A systolic murmur may be heard over the carotids, 
,nd a systolic arterial sound over tlu large periplieral arteries. The 
ihysical signs of bronchitis are sometimes present. The spleen in- 
in sine, and continued or systolic vascular murmurs are heard 
lally over the organ. There mayalsobepain and tenderness over 
ipleen. The stomach and liver remain sensitive, and the latter is 
tonally enlarged. The urine is acantvaud saturated (febrile urine). 

The amount of urea increases consid'rably during the chill, and 
reaches its maximum towards the close. Ringer noticed an increase of 
the urea even before the beginning of the chill. During the hot and 
sweating stages, the amount of urea gradually diminishes, l^nt A. 
Fraenkel has shown that a smaller amount is sometimes excreted in the 
febrile paroxysm than in the apvrexial period, although the production 
of urea is increased during the former period. If the occurrence of the 
febrile attack is prevented by the administration of quinine, the in- 
creased excretion of urea, nevertheless, occurs at the time when the 
paroxysm should have apiwared. 



it Riegel'o palients, in whom the pulse was not accelerated durins the 
TBDnio naroxyHm, the rndiitl piilne was very dicrotic at tliis period. Ziehl ob- 
served bacilli in the bliiod.' alxiut 4 >i in width, and varying in length from 
that of a red blood-globule to oiie-quarttr uf ite Itnsth. Hehlen also observed 
oocci ill the blood, partly free, partly in the red globulea. 

The hot stage lasts three or four hours, sometimes even ten hours or 
more. When the sweating stage begins, the subjective sensation of heat 
, gradually diminishes in intensity. The integument of the covered 
portions of the body (beginning jn the axillse) becomes moist, and very 
large, sour-smelling drojjs of sweat appear on the forehead and face, and 
Anally on the entire body. The temperature falls, and may even be 
subnormal ut the end of this stage. Thcjiulse becomes full, soft, and 
slow. The spleen diminishes in size. The urine often, though not 
oOTistantly, deposits a brick-red sediment of urates. Many patients fall 



usually vi 

infrequec 

^^^H s blowing 

^^knd a sys 

^^^■physical 

^^^Mocaaiona 
^^■gie spleei 

^^H The s 

I < reaches it 



^ 



^^L Ten 



ISFEOrlOCa DISEASES f^fVOLV^KO TIIK BLOOD, ETC. 173 

into a profonnd, refreahios Bleep from which they awaken with a feeling 
of relief. As a general tiling, the ptitieuta recover very rapidly, eape- 
ciallr daring the first period of the disease. 

As a rnle, the sweating stage lasts two to four honrs. The attacks 
generally begin between midnight and noon, althongh there are note- 
worthy erceptions to this rule. Da Gostu Alvareugn reports the case of 
« woman who was nnnsually pale, without any apparent cause. Exami- 
nations with the thermometer showed that paroxysms of intermittent 
teTor began towards midnight. 

Careful e]:aminfition shows that the rise of temperature during an 
attack is more rapid than the fall, and the course of both parts of the 
temperatnre curve is generally uninterrupted (vide Fig. 29). 

The weight of the body sometimes diminishes with striking rapidity. 
The patient whose temperature curve is shown in Fig. 26 had only two 
attacKs before entrance to the hospital. On admission, he weighed 
one hnndred andfifty pnnnds: aweek later (after five febrile attacks), he 
weighed only one hundred and forty pounds. Despite recovery, his 
weight increased very slowly, and, at the end of another week, amounted 
to one hundred and forty-two pounds. 

If the disease is acquired in an endemic site of malaria, it may be 
Tery protracted. If the patient parses from a malarial to a healthy 
.ngion, the disease sometimes recovers spontaneously in one or two 
Veeks. Belapses may be expected so long as the spleen is enlarged. 

The complications of simple intermittent fever are not numerous. 
In children, general convulsions may occur during the cold and hot 
stage. Gastro-enteric disturbances are al^ prominent in children. 
Curtmann mentions asa constant symptom, a leaden gray coating on the 
tongue from its tip to the circumvallate papillse. Rupture of the sjDleen 
waa observed in one case at the onset of the attack, perhaps from disten- 
tion of the organ with blood on account of the general arterial spasm. 
Albuminuria, hematuria, and hEematinuria have been noticed in a few 

es. Herpes often develops on the lips or other parts of the face; J 

icaria-ltke or erythematous eruptions are also frequent. ■ 

Among the sequels, malarial aniemia occupies a prominent part, m 
Hany patients grow pale very rapidlv. and the lips iiud mucous mem- ' 
branes assume a waxy, pale color. Kelsch found that the red and white 
blood-globules, particularly the latter, diminish considerably in number, 
especially at the beginning of the disease. Some of the red globules are 
unusually large. The amount of htemoglobin sinks to one-eighth the 
normal. The diminution in the number of red globules is so much 
greater the larger the size of the spleen. After the attack, the white 
globules increase in number, and numerous elementary granules are 
often found in the blood. Melantemia is one of the sequelie (vide 

Sage 11). and leuktemia may also bo associated with intermittent fever. 
Indocarditis, ulcerative endocarditis, and myocarditis are occasionally 
observed. Chronic interstitial changes sometimes develop gradually in 
the liver and kidneys, and there may be extensive waxy degeneration. 
Dropsy sometimes develops without albumiuuria. Glycosuria has also 
been observed, and terminates occasionally in diabetes meltitus. Paro- 
titis, noma, mnltiple hemorrhages, chronic d3'spepsia, and psychopathies 
must also be mentioned among the aequelte. 

Latent intermittent fever is characterized by functional disturbances 
of certain organs, which occur at regular intervals, and are often cured 
by quinine. They are often preceded by malaise, slight chilliness, and 



■»« 



ijif MjiKHJi msEjunn mroLvnis tbs bloch]^ mv. 



The epleen is often, thoagh 






le wmpei 
mA «lw«n, rnlargecL 

'I'lie dueftw oocura moat frequently as intermittent neuralgia, os^ 
4)Ull; of the rapraorbitaJ nerve. U also occurs as iutenrostaT, sciatic, 
linil mviipital neuralgia, claru^, ciliarv ncDralgia, mastodynia, and 
bDuralgia of the testicle. The pain uccasioDuIl; paeses from one nerve 
Ui another. 

InU^rmitteiit paraljsee, spasms, hypeneathesia, aneesthesia, hyeteria, 

Eycbupathv, dehriutn, aphakia, agrypnia, and contracturea have ' ~ 
UR dMCriued. 

Xlyilrops artionlornru intermittens and intermittent arthralgia (i 
daily coxalgia) are oocasioually observed. 

The skin may present local or ^neral intermittent cedema or isl 
mitt«iit eriiptions (erythema, ervsipetas, urticaria, pemphigus, bemor- 
rliagea, oven gangrenous changes). 

Among other symptoms may be mentioned intermittent deafness, 
biiiiiliiesa, paralysia of the vocal corda, or periodical attacks of sneezing, 
coughing, asthma, vomiting, eructations, gastric pain, meteorism, bem- 
orrliiiges from various organs, painful swelling of the breast and tesii- 
oles, uysurta, constipation, &nd uiarrhcua. 

In some cases these symptoms are preceded or followed by manifest 
evidences of malaria. 

Ill pernicious intermittent fever, otherwise mild symptoms of malaria 
are intensiHed to a dangerous degree, or certain unuaiml organic diseases 
develoj). The danger may simply be owing to the fact that the disease 
occurs in non-resistant children or old people, or it is owing to the se- 
verity of infection. Death occurs often if vigorous treatment is not 
Adopted. The symptoms are not infrequently mild at the atart, ' 
pernicious symptoms appear in the subsequent attucke. 

The following is a brief resnm6 of the more frequent varieties: 

Algid pernicoua intermittent. After a violent cbill, the hot stage _ 
mains absent, the patients graduallv grow colder, the pulse becomes 
email, and finally death occurs in collapse. 

Sweating pernicious intermittent. In the sweating stage, the dia- 
phoresis becomes so excessive that the patients become comatoee. and 
death occurs in collapse unless speedily relieved. 

Syncopal pernicious intermittent Deep and protracted syncope oc- 
curs, particularly during the cold stage, and in some cases the patients 
do not come to again. 

Comatoae jiernioious intermittent. The patients grow more and more 
oomnti.>so, espttcially dnriug the hot stage; sometimes remain in a stale of 
ooma for one or two days, and ma^v die in this condition. 

Ajioplcctic pernicious intermittent. Apoplectic attacks occur, fol- 
lowed by transitory or permanent paralysis. 

Kpileptio, tetanic, hvdrophohic, delirious, and eclamptic pemicioas in- 
lermittout arc euflioienily characterized by their namoe. A trance condi- 
liim onousiouallv develops, and Trousseau states that a patient in this 
Oniidition had been brought into the dissecting room where signs of 
lifn wurw uoticeil. 

In limni'hilic pernicious intermittent, there is violent bronchitis, as- 
aooiatod omiftHionally with dyspmea and asthma. 

Ihuiumonie ]Hiriuoii)ii3 intermittent gives rise to the intermittent d&- 
nlonmant of pnoumouiaduriogtfae febrile paroxyems; pleuritic and pat* 
lettrditjii pornioioiis intermittent has also been described. 



raFKCTIOUa DISEASES INVOLTtNO THE BLOOD, FTC. 



175 

Cardiac pernicions intermittent prodacea dangerous attacks of pal- 
pitation aua heart failure, often associated with violent pains in the I'e- 
gion of the heart. 

Finally, we may mention cardialgic perniciouB intermittent (severe in- 
termittent gastric pains), choleraic intermittent (diarrhcHa, rice-water 
stools, and collapse), dysenteric intermittent (bloody stools and tenesmus), 
icteric and peritomtic pernicious intermittent, hemorrhagic intermittent 
(hemorrhaees from the uoae, lungs, stomach, intestines, kidneys, gen- 
ital organ^, amaurotic, erysipelatous, and lymphaagitic pernicious in- 
termittent. 

' Remittent and continued fever occurs chiefly in the tropics, and only 
during very severe epidemics in temperate zones. Constantly increasing 
anticipation of the paroxysms occasionally converts an intermittent 
into a remittent or continued fever and vice versa. Gafltric symptoms 
are prominent, likewise enlargement of the spleen, and often of the liver. 
Icteric symptoms, bloody stools, and hsematemesis are sometimes so prom- 
ineat as to rouse the suspicion of yellow fever. In other cases dysen- 
teric symptoms develop, or the patients lie iu a typhoid state, and not in- 
frequeutly die in collapse. 

FiSvrebilieuse-li^maturique is the term applied to ca^ea in which severe jaun- 
dice and hsoiaturia occur. Remittent or coDtiiiued fever may laat from severai 
day e to a few weeks. 

Malarial cachexia derelops not uncommonly after all the various forms 
of the disease. It may also develop primarily, especially in the localities 
in which malaria is epidemic. The patients have a waxy complexion. 
Buffer from palpitation of the heart, shortness of breath; the heart is 
dilated, and systolic murmurs are heard over tbe heart and cervical 
veins. Coated tongue, anorexia, vomiting, and eructations are often no- 
ticed; the spleen and liver are often enlarged. 

Diarrhcea is frequent, and may even be dyscnteriform. Tremor, 
chorea, paralysis, spasms, contractures or grave psychopathic conditions 
are occaeiooally produced. Borelli described atrophy of the maio sexual 
organs and gradual approximation to the feminine type. 
I The aequeliB are similar to those of simple lutcrmittent fever, 
I III. Anatomical Changes. — The splenic enlargement is the resnit 
at first, of excessive hyperiemia. Hemorrhagic infarctions are sometimes 
obwrved, more rarely abscesses and perisplenitis. At a later period the 
spleen becomes hard, and hyperplastic cliangea develop. 

The liver may also present diffuse and miliary hyperplastic changes, 
in addition to melansmic processes. 

At the present time, most writers are inclined to believe tliat, wliile the splet 
perhiipn acta as a tiort ot reservoir for the malurial poiaon, tiie latter chiefly a 
tacka the nervous aystem, especially the heat-re ([ulatini? centrea. The perindio 
recurreooe of the attacks ana the genesis ot latent forms of the disease ar 



IV. DlAONOSia. — The chief diagnostic features are the periodical oc- 
CBireDce of the symptoms, the opportunity for malarial infection, and 
the usually prompt effects of quinine. 

Simple intermittent fever may be mistaken at limes for pviemia, ul- 
cerative endocarditis, and pulmonary phthisis, In doubtful cases we 



^ 



178 IWTBCTI0C3 DISEASES tSTTOLTWO TltK BIXWO, TTC. 

t search for wounda, or changea in the lungs and heart (vido Vol. 1., 
page 75). 

Romittent and continned fever may be mistaken for grave jaandice, 
yellow fever, and dyBentery, 

V. PaooNoais. — The prognosis depends partly on the ability of the 
patient to leave a malarial region. If this cannot be done, cachexia, ex- 
tensive waxy degeneration, and incurable marasmus often develop. The 
more marked the intermittent type the better ia the prognosis. Perni- 
cious, remittent, and continued fevers are especially dangerous when 
their nature ia unrecogniiBed, 

VI, Theatment. — The prophylactic meaanres are partlv general, 
partly individual in character. Marshy regions should he drained or 
brought under sufficient water to prevent decomposition at the bottom. 

' Malarial regions are often rendered innocuous by cultivation. 

Individuals should avoid a long stay in poisonous districts, especially 
after sunset, should avoid sleeping on the ground or drinking water. 
Colds and excesses of all kinds stiould be guarded against, and commend- 
able habits of the natives should be imitated. The bed-rooms should be 
on the upper floors of the house, on the sunny side; the windows should 
■be clnaea at night. 

The prophyftctic administration of quinine, arsenic, gentian, or strych- 
nine is not very serviceable, because the organism rapidly becomes accus- 
tomed to the remedy. 

During the cold stage, the patient should be well supplied with blan- 
kets; later, the covering should be li^ht. Pieces of ice or carbonated 
waters may be given in cases of vomiting. 

Quinine is tlie beet remedy in all forms of malaria; gr. it. to xxx. of 
the hydrochlorate may be given for two or three days about three honra 
before the expected attack. One-half or one-quarter the amount may 
then be continued until the enlargement of the spleen hoe subsided, and 
the danger of a relapse has piisaed. If the quinine is vomited, it may be 
given subcutaneously (quinia hydrochlorate, glycerin, puri, aq. destil., 
no. M. D. S., warmed, two syringetuls) or as an enema with some starch 
and lukewarm water. 

Fowler's solution (five to eight drops t. L d. after meals) is useful in 

After the febrile paroxysms have subsided, the existing anaamia may 
be treated with iron and arsenic (tinct. ferri chlorid., 3 v.; liq. potass. 
arsonit., 3 iss.; gtt. xxv, t. i. d. after meals). 

A large number of other remedies have been employed, but all are much less 
reliable tlian quinine, a. Cinchonia. cliinidiae, i:hmoidiiie, cinchotiidine: b, Tinct, 
eucal^pt. globuli; c, Carbolic acid, salicylic acid, resurcin; d. Rolicin, berberine. 
lupinin, apiiil. picric acid, Btiruhnine, HantoniDe, busine BUlpliute: e. I'ulosaiuiu 
bromirle, putaeaiuni iodide, sooiuoi chloiide, nttraie and acetate o( ]H)tasli ; /. Lic^, 
ferri xeAqitichlorid.. mercurinle; jj. Chloroform; h. Gelseinium Bemperrirens; i. 
Pilnrarpine; j. Facadication ot the Hplcen and galvanisation of the Hympathetic. 
Hearty eating ia considared an effective remedy in certain malarial regious. 



i 



3. ne Plague. 

I, BTIOLOOT.—Epidemicti of plague appeared long before the ChriMiaa era. 
In thQ gTva.\, epidemics »f the Uiddle Agee. Bometimes more than a fourth of the 
inhabitants fell victiiua to the djseaee. Europo haa escaped its ravages since the 
mirtdle of the fourteenth century, but in 1878-70 there was renewed danger of iti 
introduction from tiie ahores of the Volga. 



Deliri 



The dieefua has also become less prevalent in the Orient, India and Ajiterioi 
Asia are suppoBed to be its habitut. 

If t<ie pUigue breaks out in places in which it is not epidemic, it is Always in- 
trnduoed from without, so that strict quarantine is the best means of prevention. 
The disease acquires a so much firmer hold the poorer the siirruundini^ and liygi- 
enic condiliona of the inhabitants. A single attack does not prevent subsequent 
iDfection. although later attacks are apt to be less severe. Age and sex exert no 
influence ; the foetus in utero may be attacked. It has been lield tliat the plague 
may develop autouhthonousty. but this is not probable. The majority of writers 
do not believe thatsicnple contact with a patient will produce infection, but there 
is no Aoubt that it i* conveyed t-hiefly by utensils of all kinds. 

The nature of the virus is unknown, but it is said that in the recent epidemics 
in Astrachan, very small shining bodits were found in the blood, perhaps also \a 
the pus of the buboes. 

II. SyaPTOMS.^The plague is an acute infectious disease, in which the exter- 
nal and internal lymphatic glands undergo inflammation, with a tendency ta . 
BUppu ration. _ 

The stage of incubation lasts two to seven days, but longer and shorter periods I 
have also been mentioned. | 

Uirsch descrit)f8 tliree forms of the disease. 

In the mildest form, the patients sometimes feel well enough to walk about. 
Prodromata are absent. Tlie disease often begina with a chill. Then headache, 
vomiting, and constipation set in. At the same time the glands (inguinal, crural, 
axillary, submaxillary. c«rvica1) become painful and swullen. In three to six 
days, some of the glands discharge pus, profuse diaphoresis occurs, and tbea ■ 
convalescence. The scars of the buboes are always superficial. 

In the moderately severe cases, all the symptoms are more marked. The con- 

[unctiva is injected, and subconjunctival hemorrhages are occasionally found, 

d unoonsciousneas frequently occur, and the temperature of the body 

increased. Carbuncles and petf^^hice appear on the akin. Tongue thickly 
coate<l. Then acute buboes ; the escape of pua is often looked upon as a favora* 
ble sign. Death in tour to six days, or recovery in one ta three weeks. 

In the gravest form, the patients complain of violent (error, but sometimes 
retain consciouanees until death. The disease may run such a rapid course as to 
prove fatal before the glands enlarge. There is ubstinute vomiting with persist- 
ent constipation. The excretion of urine sometimes ceases entirely. Then fol- 
low symptoms of dissolution of the blood, especially hemorrhages from the skin, 
■tomach, intestines, kidneys, and lungs. Rapid death from collapse. 

Convaleeoonce is sometiinea protracted for a lona time ; relap*e« are not un- 
common. Furuncles of the skin and muscles, parotitis, pneumonia, paralyses, in- 
sanity, otitis, and dropsy have been mentioned aa sequelffl, 

UI. Akatouical Chanobs.— The lesirmx in the lymphatic glands (external 
and internal) consist of oongeEtion, inflammatory cedema, and hyperplasia of the 
parenchyma and periglanduliir connective tissue; hemorrhages Into the elands 
may also occur. I^ter. circumscribed necrosis and suppuration of the glande. 
Thespleen is always enlarged, the liver and kidneys swollen and in a condition 
of cloudy swelling. There are ntimeroua hemorrhages in the viscera. 

IV. DiAaNOsis, Peoonosis, TRKATaBST.— The diagnosis i 
The diae&sp may be mistaken for typhoid fever, malaria, 
syphilis. The prognosis is grave, and the mortality may exce< 

The spread of the disease can only be prevented by the si 
, Tba dieeaje itselT is treated symptomoiicuty. 



not always easy. 
ilenic fever, and 
90 per cent. 
'"' quarantine. 



This hooh is the pro 
COOPER MEDICAL L . 

SAN FRANCISCO. OAL. 
aw/ i.i not to he rpmorttl Jr-n 
JLiOrni-y Room htf auif jifr.'i. 
Under Uiiif ■//I'rtext whaUuH-r. 



178 INFfiOnOUS DiaSAfiSa UiyOLYUHQ the R£8PIRATQST qboans. 



PAET IV. 

INFECTIOUS DISEASES IN WHICH THE RESPIBATOEY ORGANS 

ARE CHIEFLY INVOLVED. 

1. Whooping-Cough, Tussis Convuhiva. 

(Pertussis.) 

I. Etiology. — Whooping-cough is an infectious and contagioas dis- 
ease. It generally appears m epidemics^ and in most cases it can be 
fihown to follow contact with previously attacked individuals. 

The disease is not alone conveyed by immediate contact, but also by 
intermediate persons (nurses, physicians, relatives, etc.), and by inani- 
mate objects. 

It is probably infectious in all stages, to the greatest extent in the 
convulsive stage. The virus is assumed to be contained in the exhala- 
tions from the lungs, since mere presence in a patient^s room, without di- 
rect contact, suffices for infection. The virus is also contained in the 
sputum which probably retains its infectious properties even in the 
dry and powdered condition. It is still doubtful whether the infection 
is purely local and emanates from the respiratory mucous membrane 
alone, or whether it is general and originates in the blood. The infection 
of the foetus by the mother cannot be explained except as the result of 
blood infection. 

In large cities, sporadic cases occur almost constantly. Hence the 
possibility for the outbreak of an epidemic at any time. (This can some- 
times be traced to an imported case. 

The majority of epidemics occur in the winter and spring. Their 
duration varies from less than two months to more than a vear. In some 
large cities, they are said to recur at different intervals, ^he epidemics 
are sometimes so mild that hardly any fatal cases occur; in otners, the 
mortality may exceed fifteen per cent. 

They sometimes occur at the same time as, immediately before or 
after, epidemics of other infectious diseases. This is true most fre- 
quently of measles, more rarely of scarlatina, small-pox, or varicella. 
Whooping-cou^h has also been observed in combination with intermit- 
tent fever, erysipelas, and herpes zoster. If the whooping-cough preceded 
the other infectious diseases, it disappears entirely in mild cases, but in 
severe cases it is merely rendered milder, and grows worse at a later 
period. It is said that vaccination sometimes exercises a favorable in- 
fluence on the course of whooping-cough. 

The disease is rare in the tropics. Its development is favored by 
cold, windy, and rapidly changing weather, because this induces catarrh 
of the air passages. 

Some writers maiiitain that whooping-cough may develop autochthonously 
as the result of bad sanitary conditions, dentition, helminthiasis, scrofula, rickets, 
and even imitation, but this opinion is opposed to all modem doctrines. 

The nature of the virus is unknown. Successful attempts at inoculation in 
anim^ have been reported by some, but denied by other writers. 



I 



DfPECTIOtra BIBEASSa mVOLTINO THE BESPnUTOBV OBOANS. 179 

The susceptibility to the disease depeods very materially upon the age 
«f the inilividual. It is a disease of childhood, and occurs rarely in 
jidalts, though even old people have been attacked in rare cases. It ia 
most frequent from the age of seTen months to seven years, and is rare 
in infants before the age of six months. A few cases have been reported 
in which mothers suSeriog from whooping-cough bore children who pre* 
eentod the symptoma of the disease at birth. 

a the mother during pregnancf 



The female sex is attacked more frequently than the male sex. This 
has been attributed to the greater susceptibility of the female sex to spas- 
modic alTections of all kinds, and to the fact that, among adults, females 
are more exposed to the danger of infection, because they are chiefly con- 
cerned in nursing. 

Feeble, anaemic, rachitic, and scrofulous children are more fre- 
quently attacked because they possess less powers of resistance, and be- 
cause they often suffer from catarrhs of the respiratory tract which 
&vor the deposit of the virus of pertussis. 

The children of the pooi-er classes are attacked more freauently than 
those of the well-to-do (overcrowded dwellings, imperfect isolation of the 
patients, insuQicieut care, and frequency of catarrhs of the air passages). 

Some individuals enjoy permanent immunity, others only temporary 
immunity. A single attack confora acquired immunity; individuals are 
rarely attacked several times. 

The susceptibility may be occasionally increased accidentally, for ex- 
ample, by catarrh of the air passages, pregnancy, and the puerperal con- 
dition. 

II. Symptoms. — The stage of incubation lasts about a week, during 
which time no aymptomsaru produced. Theduriition of this period may 
Tary according to the power of resistance of the patient and the virulence 
of the poison. 

The clinical history may be divided into the catarrhal, convulsive, and 
decreasing stages. The duration of the disease varies from four or six 
weeks to as many mouths or more. On the average, the catarrhal stage 
lasts two to four weeks, the convulsive stage four to sis weeks, and the 
decrecsing stage four to six weeks. 

The catarrhal stage not infrequently begins with mild general eymp- 
k'toms. The children lose appetite, grow pale, sleep is disturbed, and 
"■•tliere is slight fever. The conj'nnetivae are injected, there is slight pho- 
tophobia, and increased secretion of tears. The patients complain of 
burning and pricking in the nose, frequent sneezing, and increased se- 
cretion of nasal muous. At times, slight burning in the throat and 
difficulty in deglutition indicate mild pliaryngitis. Cough and slight 
hoarseness appear, associated with u tickling sensation in the larynx and 
beneath the sternum. The conjunctival and nasal catarrh diminish, 
while the cough becomes more frequent and severe, finally it beoomea 
spasmodic, ana the disease thus posses into the convulsive stage. 

Tba catarrhal stage 1)4 aometimea abaent, especially in narsUngs. 

The convulsive stage manifests itself in characteristic paroxysms e£' 



k: 



a 



ISO IXrBCTCJC^ OIBK^ES ISTOLTISQ TOE BSSFISATOBT OEOAJXS. 

ooudi'^J'Jj?- T!ii?7 beiria with a deep, whistling inppiration, followed by 
Ti'iiricur'-'iTKeiJ. ^lorc. tfxpir»:orv coaghs. Sometimes twenty to thirty 
oxjnrHCijrv '.MjuicMs fi)Uow one another before another long-drawn, whis- 
rli ri;; Tis|MrHruMi ruki»s place, to be again followed by expiratory coughing. 
\ <in:i\M !>an)xysm '.ii^cs fmm one-fourth to one minute, and a series of 
tiuMti iiuv *oitcitiue fn)m ten co fifteen minutes. At the end of the pa- 
n>\N*<4ii, (umh. j:iui^v mucus tills the mouth and pharynx, and is expec- 
Mu*HU'a tv h Miu'oitiucion ot coughing, strangling, and vomiting move- 
rm*ius« Itt tuaacs, tills m\x&t often be removed from the mouth with 
\\u? fcui u' 'iio 'iiitfei**. 

l*'K' •iin»\x5»tiis .kre -u'fcen provx)ked by fright, joy, laughter, crying, 
ou*. vii 'oi-v -u^ftuy pucieuca an attack may always be produccNd by de- 
;M'«i«i»ii(;k: :to iMtj^ie with a ^spatula, until gagging movements ensue. 
HtiiiKTv U5U 'ua\:<L au important part. If a paroxysm appears in one of 
.i tuituHu- <<i' . iuldrciu the rest very often are also attaclced in a short 
*tiiu\ Itt 'liter ^-atf^t^ the paroxysm is preceded by the rattling of mu- 
.'u^ •! tu) iiK'itva «ir larynx, and the irritation of the laryngo-tracheal 
*i4iu-i4<^ 'ii%:iii^itiuo MVhloucly provokes the attack. 

!*i,oilt;t;«uii !»ctiioiii2^ complain not infrequently, before the paroxysm 
's>|^tit%. •( iu\»Ioiiib(o lickliu^ in the larynx, trachea, or beneath the 
^kv.*».j.u, i'**^ Iceuiv Lu cou>{li can rarely be repressed by an effort of 
• iiv *% tii t*tu? luliii-tiii i{ruw more and more terrified, hola fast to a firm 
*;m»v*. '4 '^* '^^^ iuu'Hi^» and ask that their head be held between the 

!»M.iu^ :lio kitt4\)k. iho face presents evidences of increasing venous 
.i>4.vi< '(- V^otuvrf iiioi^ and more cyanotic, the eyeballs protrude, 
..», M-,. i •.! luvk,** )>cci>mo swollen, the jugulars appear as blue cords 
(, .K..V 4. lu) iiuKiir, iho face and limbs are bathed in perspiration, the 
. li^it ^wiii tlitlli'uliv. partly on account of the violent concussion 

I. '*.'.; ^, i»aiLl\ lK.vauW the heart's action intermits, and the pulse 
!., .u.k!ii-(. Ttioro is sometimes involuntary evacuation of urine, 

• it* • lit i 'UA'i'Oi 

I ».. .«.,, I lii^ i).\j>tmtt>rv coughing, the thorax is dull on percussion, on 

.. , I ill.) iiuitMiil c>>iu>)tv5Siou of the thorax. During the whis- 

i!..., .•> jMu^iion, Iho I >c IV usfiiiou sound becomes very loud. Therespira- 

1 ... ... ..iiiii I] iu»i. ,4iuliblc vluriug the long-drawn inspiration because 

it L li.iiiiti.i i;i i}KMtuoilically narrowed, so that the air enters the 

I ... |*,i...y.i^.i vny .\U»wIy« Foeble respiratory murmur is heard 

I,. 1 1... I It • > \ ()iial\u > cou^h, 

\ .. u«i,. i.> uui)Ui?au iW Muiwy» there is dulness over the manubrium stemi 

4..L .i i,«« Utitf^ oi iIh> ii-twh«x>-brouchial glands (?). 

1 ii . |. ii H iii.i lUiTiu' iiaolerable fear of suffocation during the attacks. 

II,, ■ : '» , 'iu It m I'voi \»iih surprising rapidity, and return to their oc- 

., ... .1 I. li" ii.iiliMiv; h.ul hiippotied. Others suffer from exhaustion, 

I t.. iM iik \u .111. .4iiil tli^^hl vertigo for some time. There is frequent 

. , I..:... .1 |. kiu (ti iho .kbJoiuiual walls on account of strain in cough- 



.1 



i,. ... I ... \x i» VI to vK4raK4. twoutv to twenty-five attacks occur daily; 

k. iiMitv i-i \>iko hundiwl may occur in a day. They are 

1., ,.i, tti. \[ uigM. kv^use mucus is then more apt to accn- 

I . ... tu ^^i |>.v..44cio.i. .Uwixtiug to Uanke, the attacks are more 



lyfPBOTIOFB DWBABEB ISVOLVISG THE BK8PIBAT0KT OB6AWB, 181 

frequent if the sir is polluted vith carbonic acid uod ammonia, wliile 
exercise in tlie open air acts favorably. 

The oonvnlsiTe stage gradually passes into the decreasing stage. The 
paroxysms of oougiiing become less frequent, and lose their fii)aeniodic 
character, so that the symptoms resemble an ordinary catarrh of the air 
passages. Exacerbations are apt to occur as the result of a cold, and the 
convulsife seizures again make their appearance. 

The laryngoscopio changes readCy pass into complications, although 
in my experience, as a rule, the laryngeal mucous membrane generally 
presents catarrhal changes. But as these changes are absent in many 
cases, I am inclined to attribute them to the violence of the coughing 
epells rather than to the specific influence of the pertussis Wrus. 

Aaarnle. there is diffuse redness of the pharyngo-nasal cavity, larynx, 
trachea, and origin of the bronchi. The true vocal cords escape ; the 
anterior portion of the laryngeal cavitv, as far as the true vocal cords, la 
sometimes not at all, always very little affected. The region between 
and beneath the arytienoid cartilages, and the anterior wall of the larynx 
and trachea below the true vocal cords, are inflamed with special in-sf 
tenaity. 



Bronchitis is a frequent complication, and is present in the majoritv 
of cases. The situation becomes serious when this is complicated nitn 
pneumonia, as shown by accelerated, short, groaning respirations, and 
j;reat rise of temperature. The alveoli sometimes rupture on account 
of the violent cough, and interstitial emphysema develops. If the pul- 
monary pleura ruptures, this may terminate in pneumothorax, or the air 
spreads along the peribronchial cellular tissue to the main bronchus, 
mediastinal connective tissue, aud subcutaneous cellular tisaueof the ju- 
gular fossa, where it appears as subcutaneous emphysema. The latter 
sometimes extends over a large part of the body. It is also possible ] 
that very extensive emphysema may produce danger of suffocation by | 
- compression of the air passages. 

I Struma, pleurisy, pericarditis, and endocarditis ore rare complications. 

There is often obstinate vomiting. The patients vomit after each 
epell nr coughing, and, on the other hand, the ingestion of food produces 
a coughing spell. This may give rise to a serious condition of inanition. 

Ulcers are sometimes found at theantarioredgeof thefrwrnimlingute, 
more rarely on the inferior surface of the tongue. These are the result 
«f mechanical injury by the teeth during the coughing fits. 

The excessive strain of the abdominal muscles may result in hernia 
and prolapsus ani. 



Charflcteristic cutaneous changes are often produced. On account 
of the pronounced venous stasis during the coughing fits, subcutaneous 
liemorrhages develop and occasionally attain considerable size. 



182 niFBCfnous diseases DnroLviNa the bespisa.toby oRaAKs. 

Cutaneous cedema has been obseired. but it is doubtful whether this is the re* 
suit of marasmus or complicating nephritis. Pierson explains it as the result of 
acute dilatation and insufficiency of the ri^ht heart, i. e., of staeis, and attributes 
to it a very unfavorable prognostic significance. 

HomorrhagOB of the mucous membranes are also observed frequently* 
Sitbronjunotival hemorrhages are very common; hemorrhages may also 
<MHnir from the nose, air passages, and gastro- intestinal tract. Hemor- 
rhagi^H from the external auditory cansd are sometimes obserred as the 
rvnult of rupture of the drum membrane. 

()tUU mvilla is present in rare cases; if bilateral, it may produce deaf -mutism 
III oliildivu undl^r four years of age. In one case, Landesberz noticed optic neuri* 
tin aiui b^HHiy inHltration of the lids; in another, ezophthaumus of one eye from 
r«4r^»(mUiar hVmorrhage; in a third, hemorrhages into the retina and optic nerve» 
aiivi U\ a tourlh. liislooation of the lens. 

l\\ a f^«w oaaes. there is marked change in the mental condition, 
miumutinu ovou to insanity. In rare instances, hemorrhages occur within 
ilu) Mk\ill iivm venous stasis. Barrier reports a fatal case of subdural 
luMMorrliugo. Convulsions sometimes occur during a coughing spell 
tw\\\ oxiH'fwivo venous stasis within the skull. 

Ill MiMiio otises, grave sequelae follow, and prove fatal at an early age. 
(Uiuuiul iiiamsmus is occasionally observed, and the children succumb 
af tui' u longer or shorter period. They grow pale, emaciate, and finally 
tlutof oxhauHtion. Signs of scrofula sometimes develop. Chronic di&- 
iti4^itt c»f the respiratory tract (chronic hoarseness, bronchitis, or tuber- 
iuilur proiHiSHoa in the lungs) are not infrequently left over. Tuberculous, 
i'.huudy, brdueliial glands may give rise to miliary tuberculosis, especially 
hi Uiimroulur meningitis. Pulmonary emphysema is sometimes produced 
by the ucuto distention of the lungs observed during the paroxysms, but 
us u gunoral thing it soon disappears. Epilepsy and chorea are rare 
bii(|uuhi). Certain complications (hernia, prolapsus ani, valvular lesions 
i»f the heart, auditory or visual disturbances) persist as sequelsB. 

III. Anatomical Changes. — Specific anatomical changes in per- 
tussin are unknown. 

The mucous membrane of the air passages is generally swollen and 
uongusted, and covered with abundant secretion. These changes may 
rapiilly ilisanpear in the dead body. 

Tile tracneo-bronchial glands are often enlarged and congested. The 
liongestion may also extend to the pneumogastric, which is embedded in 
the glands. 

rulmonary lesions are freouent and are often the cause of death. 
The upper lobes and median borders are pale and distended, the pos- 
terior and inferior portions contain congested and depressed non-aerated 
putehes which are the result partly of atelectasis, partly of catarrhal 
jineumoniu. Fibrinous pneumonia and fibrinous inflammation of the air 
jiubriiiges are observed in rare cases. 

The liver, spleen, and kidneys are congested and often slightly swollen. 
^)irnihir changes are found in the mesenteric glands, the solitary glands. 
mid I'eyer's putclies of the intestines, and the follicles of the stomach. 
intuH'ationri of the follicles of the intestines have also been mentioned. 

Miiiiingeal and ])arenchymatous hemorrhages maybe present in the 
limiii. 

In liur opinion, whooping-<x>ugh is the result of a general infeotion, i. e., 




cnat 

boai 
boli( 



rSTEtTtOrS DISEASES CsTOLVING THK KESPIKATOKY ORGANS. 

sterling from the blood. This gives rise to increased irritability of the vaso>mo-* 
tor and cough centres in tiie medulla oblongata. Tlie former causes lucreased 
secretion of the mucous membrane of the nir paseages, the latter increased excit- 
ability of the nerves of coughing, especially the superior laryngeal. 

The llieory that the disease ie an ordinary centmt or peripheral neurosis is con- 
tradicted by its infecliouH character. This also disproves the opinion that it ia 
an ordinary bronchitis with unusual irritability of the raucous membranea, 

IV, DiAoyosis. — During the convulsiye stage the diagnosis 13 easy; 
and the laity properly lay great etress on the prolongeii whistling in- 
spirations. Obstinate coughing spells, attended with frequent vomiting 
and Biibconjiinctival hemorrhages, or hemorrhages from other mucous 
membranes, must also arouse the suspicion of whooping-cough. This 
is also true of cough associated with ulceration of the fnenum linguie. 
In doubtful cases, it should be remembered that deglutition or depression 
of the tongue not infrequently produces an attar.k of coughing. 

In the firat and third stages of the disease, it ia often difficult to make 
a differential diagnosis from ordinary bronchitis. The opportunity for 
infection is an important factor in diagnosis. 

V. PROGNoais. — This is usually good; the average mortality is about 
three per cent. The younger the patient the greater ia the danger. 
The disease is also serious in aniemic, rachitic, and scrofuloua children. 
Aa a general thing, more girls die than boys. The disease is more serious 
among the poorer classes than among the well-to-do, on account of inauf- 
igoient nursing, overcrowding, and poor ventilation of the rooms. Spora- 
dic cases are more favorable than epidemic ones. Grave complications 

a the part of the respiratory organs are more frequent in cold weather. 
The proguoBiB also depends on the daily number of coughing spells. Ac- 
cording to Trousseau, the prognosis is serious if thirty to fifty attacks 
occurdaily, and unfavorable if they exceed sisty. In pregnant women 
there is a possibility of premature delivery from the violence of the cough- 
ing movements, bnt the frequency of this event is often greatly 0- 

ti mated. 

\'I. Treatment. — The sprea^l of the disease can be prevented only J 
by the strictest prophylaxis. The patients must be isolated, and tbft] 
healthy children in the family are safe only when sent to another house. J 
Ualf-way measures are useless. Isolation should be continued until ths 1 
cough and catarrh have disappeared. f 

The children should have their own tabb service, their bedding and 1 
clothing should be cleaneil separately, and they should be allowed to ex- i 

fiectorate only in vessels cootaining caibolic acid (5^) or corrosive sub- J 
imate(1 :1000), The physician suoiild visit these patients last, in order I 
that he may not convey the disease to other families. 

Specific remedies against whooping-cough are unknown. The pa- 
il's room should be large and sunny, and well ventilated. Every two 
,. iora the air should be sprayed with a three- per-cent solution of car- 
bolic acid. In winter, a vessel containing water and a half teaspoonful 
creasote should be place<l on the stove. The air is kept at a unifoi'm 
temperature of 15° R. If the weather is not windy, daily exercise should 
be taken in the opeti air. The diet consists of milk, eggs, soup, boiled 
' stewed fruit, and wine. Older children should be directe*! to 
the desire to cough as much as possible. In obstimito cases, re- 
Wral to another locality sometimes produces favorable results with sur- 
iun^ rapidity, but the danger of producing infection in the new sur- 
nndings must be kept in mind. 




164 tSTSxniOm DISEABES UtTOLTtSQ THE RBSPIKATOBr OBOAN8. 

Specially prominetit syraptoms must be treated according to general 
principles. If the number of coughing spells is very great, or tlioir du- 
ration protracted, we may order narcotics, Buch as ^ Aq, amygdal. 
amar., Siij- ; morphin. liydrochloric, gr. 88. M. D. S. 5 to 10 drops 
every three hours. 

It there are numerous sonorous and sibilant rales, we may cive 
expectorants, such as IJ Sol. Apomorphin. hydrocblorat. gr. ias. : $ Liisa. ; 
acid, hydrochloric, gtt. v.; syr. simp., 3v. M. D.S. 3i.-i]. every two 
hours; if there are numerous moist rales, we mav -order ipecac. 

A combination of different dry and moist rales may be treated with 
. ipecac and iodide of potassium, etc. 

"We may mention the followinK other reoiedieg which have been employed 
in thia disecMe. a. Nervines : vnkrian, musk, asafcetida, campbor, nitrate of eil- 
ver, biamuth, Bnieiiic, zinc and copper preparutioos. etc. b. NarcotiCB: (chloral hy- 
drate, chloroform, ether, croton chloral, veratrino, hyoscvamuB, nux vomica, 
conium, ergotin, pulaatilla, cocaine, etc. c. Expectorants of all kinda. d. Anti- 

E&rasitica : carbolic acid, salicylic acid, creasote, benzin. petroJcum, quinine, 
reathing tbe air of gas houaes. e. Balsatuics: turpentine, ol. petrsB italiuum. 
f. Emetics, in repeated tioees. g. Tonics : iron and quinine, h. Astringents : 
tannic acid, acetate of lead. i. Purgativee, k. Abaorbents : potassium iodide 
and tincture iodine, applied to tbe manubrium (to disperse enlarged glands), ' 




Constant current to medulla and pnpuniogaNtnc. m. Inspiration of cumpressed 
air, o. Derivatives to the chest, p. Specifics : canthMridea tincture, propyla- 
mia, pilocarpine, powdered vaccine pustules internally, etc. 

3, Iiifiuenza. 

I, Etiology. — Influenza almost always occurs epidemically or pan- 
demtcalty, more rarely sporadioally. The disease baa sometimes extended 
over almost the entire globe, at other times only certain countries were 
attacked, or only certain cities or localities, such as crowded barracks, 
prisons, etc. 

The majority of epidemics occur in winter, but very little influence 
is exerted by meteorological conditions. The epidemics often appear 
unexpectedly over large areas, and disappear in'a few weeks with equal 
rapidity. They generally last four to six weeks, sometimes much lese, 
but occasionally even eight to ten months. The disease sometimes 
spreads from one locality to a distant one, leaving the intervening dis- 
trict unaffected, or attacking the latter at a later date, or it appears at 
the same time in separate localities. Epidemics have been observed 
upon vessels at sea. 

The disease occurs most frequently in middle and advanced life, and 
is also said to attack with special frequency those who live a good deal 
in the open air. Several attacks are experienced not infrequently by 
the same individual. A number of cases have been reported, in whicu 
individuals travelling to localities in which influenza was epidemic es- 
caped the disease. 

Whether the disease is conveyed from one individual to another is 
etill an unsettled question. 

Epidemics of other infectious diseases (measles, whooping-cough, 
varicella, small-pox, malaria) may also be present at the same time. But 
it has also been noticed repeatedly that, during influenza epidemics, the 
other diseases mentioned become less frequent or disappear entirely, 
Bometimes reappearing towards the end of the influenza epidemic. 

The nature of the virus is unknown. Leteerich described influenoa-microcood 



^^ 



iKFBcmoiTa msBABsa intoltdio- the sEePiRATOBr oBOAita. IBJl 



II. Stsiptoms.— The symptonis generally begin snddenly, more rarely 
they are preceded for a few honrfi or days by prodromita {malaise, paiua 
in the limbs, aoniDolence or iasomaia, gostro -intestinal diatarbances, 
headache, etc.). 

It is often maintained that the disease has no stage of incubation, 
but tbia is an open question. 

The manifest syinptoms are catarrh of various mucoas membranes, 
(ever, severe impairment of the cerebral functions, and striking weakness. 
AW the mucous membranes maybe affected in like degree, or the inflam- 
mation of one or the other may be specially prominent. 

As a rule, the scene opens with a chill or repeated chilly sensations. 
The temperature rises, ana the rapidity of the pulse is increased. The 
patients often complain of severe |min in the forehead near the glabella, 
more rarely of occipital pain. This may be associated with conmsiou of 
mind, delirium, convulsions, cramps in the calves, subsultua tendinam, 
tremor of the limbs, and a striking degree of prostration. 

Hyperffimia of the conjunctivBe and epipnora set in, with photo- 
phobia. Then follow hoarseness, soreness in the trachea and beneath 
the sternum, cough (sometimes spasmodic)— in short, signs of catarrh 
which begins above and gradually descends. Finally, bronchitis also de- 
Telops. Attacks of nervous dyspnoea occur not infrequently. Coated 
tongue, a bad taste in the mouth, anorexia, vomiting, constipation, 
or more rarely diarrhcsa indicate gastro- intestinal catarrh. If meteor- 
ism ia also present, a suspicion of typhoid fever may be aroused. 

The disease sometimes terminates in two to six days, or it may last 
two weeks. The sudden occurrence of diaphoresis may indicate a crisis; 
in other cases, the patient sweats during the entire course of the disease. 
TJnnsual prostration is generally left over tor a considerable period. 

The following complications have been observed: broncho-pneumonia, 
more rarely fibrinous pneumonia, pleurisy, even pericarditis, exceptionally 
croup. Erythema, roseola, urticaria, miliaria, piBtechise, and aphthie of 
the mucous membrane have also been described. Ptyalism and parotitis 
have been obsened in exceptional cases. 

Phthisis, secondary to chronic broncho-pneumonia, may develop aa 
a sequel. 

III. Anatomical GHAyoES. — The lesions are similar to those of the 
I oorresponding disturbances when independent of influenza. 

I IV, DiAONOSts AND Prognosis. — lu view of the sudden and epi- 

f demic oconrrence of the disease, the diagnosis is easy. The prognosis is 

sood in middle life, bnt is serious in adults and when complications 

develop. It often aggravates previously existing diseases. Pregnant 

women are exposed to tne danger of premature delivery. 

V. Tbeatment is purely symptomatic. Many recommend (juinine 
slmoet as a specific. Narcotics may be given to relieve the cough, expec- 
torants to facilitate expectoration, emetics if gastric eymptomfi are 
prominent, etc. 

a. 11.11/ Fever. Summer Catarrh. 

I, Etiology. — This disease occurs as catarrh of the air passages, con- 
jaootiva and lachrymal canal, and as asthma (so-called hay asthma). 



J 



186 

It id mont froqnont betweon the ages of fifteen and thirty years, rarer 
in childhcHMl ; it tioTor develops after the age of forty years. Men are at- 
tnokiMl alHMit twioo as often as women. 

T\w (Mhioatint classes are almost always attacked, the laboring classes 
rAn»ly. A ili«tiiiot |)rt»disposition is necessary to the development of the 
di9^tiWl ihi<i tiiuv U) iH)iip;nital or acquired. The patients generally 
iHttiH) (if iMnin){)(ithio families, or have been rendered nervous by various 
(*im«iHi. T\wy priHKUit increased irritability of the vaso-motor system, in 
H*ti«^HHtotuMt of whirS ifli^ht irritation of the mucous membranes pro- 
(liHHiA h>|HM'tvMUH and iuftammatory changes. According to Hack and 
Mmm4 uttiiiiikMHl itw\>lUu^ of the mucous membrane over the inferior tnr- 
l*(MfiiiMl \h*\m\ ali«u uvvr the middle turbinated bone and the septum, 
(«t('^u ^ivp ri«i» tu ha,v fvver. 

\k\ im«u,y |H>m>n«k'. the symptoms occur periodically at definite times, 
H^t^tlv Mwwu May and September. As a rule, the cases are more 
h^Mi>ui' U^lwiHUi May and July. 

It h«^ tuax l>ocu recognized that the outbreak of the disease coincidea 
with ihp lluwuring of grasses, and individuals are often attacked imme- 
diutut V i4ftur ai4>i*oaching a mowed lawn, a field of grain, etc. It is now 
Uplil th^t thu disease is produced by the pollen of fiowering grasses. As 
liiu ^Hillou ih diffused far and wide, it is not astonishing that individuals 
dhiiuUl bu attacked^ although not exposed apparently to the exciting 

Thiti theory is confirmed by the fact that the symptoms coincide in 

fiuiut uf tiuiu with the first and second crops of hay; that the secre- 
iuu uf tho iutlamed mucous membranes has been found to contain grains 
(if pullou, ami that tho application of tho latter to the nasal mucous 
Uiumhraiio of proilisposed individuals will produce the disease. The de- 
voliipiiient of tho disease is favored by drought and winds, and pre- 
vuutod by steady rains. People living in the country generally escafje tho 
dibouse, but this is probably owing to the absence of the predisposition. 
I. S\ VI I' ro MS.— -The symptoms not infrequently begin immediately 
after a walk aeross a meadow, i, e,, tho cause is immediately followed 
by its eifeet. Prodromata (malaise, anorexia, slight fever, etc.) are ob- 
tiurved uceudionallY for several hours or days. 

1 u t ho eatarrhal form of hay fever, the first symptoms are those of acute 
cuvyzu: burning and pricking in the nose, frequent sneezing, increased 
uusiil seeretion; olfactory hy|)enesthesia is sometimes noticeable. Then 
folU»w aymptonis of conjunctival catarrh, "foreign body'' feeling in the 
ejca, iiuueaaed lachrymal secretion, photophobia, injection of the conjunc- 
tiva, iuileina of the lids. Then scratching and dryness of the throat, 
and slight dittlculty in deglutition. These symptoms may or may not be 
followed by catarrh of tho larynx, trachea, and bronchi. There is some-^ 
times blight fever, often mental depression, and severe pain in the fore- 
head or oc(*iput. Tho patients sometimes h&ve an annoying sensation of 
ciildiiDbb in the nose, especially its tip, which maybe cold to the feel. In. 
iine i)f luv lUiUeagues, the integument of tho nose always became red and 
tiMiliiinei) ililuteii vessi'ls. Kxtonsivo erythema and urticaria have also 
lii:ijii iibsi.rviMl. The symptoms often last three to eight weeks, rarely 
uiilv u fi'W hours or days. As a rule, relapses occur. 

rullrn of pniiuiiue lias l>een found in the nasal and lachrymal secre- 
liuii.i. (.'iihor iiitui't or swollen and ruptured. The contents are described 
as wry line, moving granules, often arranged in chains. 

Hay utothinaoonH^IKkudsiu its clinical history to a fall-developed asth* 



^ 
N 
^ 



niFSOTtOTia DISKASES INVOLTISJO THE DIGESmVE APPABATUB. 18T 

matic attack. lu the bronchial secretion, Schmidt found Leyden's asthma 
crystals, in addition to grains of pollen. Transitions may occur between 
the two varieties of hay fever. 

III. Anatomical Changes, Diagnosis, Prognosis. — The ana- 
tomical changes are visible on inspection in the living subject. They 
consist of marlced congestion, swelling, and hypersecretion of the af- 
fected mucoua membranes. The disease rarely terminates fatally, and 
onlyono fatal ciwe (in an old man) has come to my knowledge. 

The diagnosiaia easy, in view of the causation and regoiar recurrence 
of the symptoms. The prognosis is unfavorable so far as regards per- 
manent recovery. 

IV. Treatment, — The treatment should be chiefly prophylactic. If 
the individual suffers from excessive erectility of the nasal mucous mem- 
brane, the gal van o- cautery should be employed. Predisposed individuals 
should live duriug the summer at the sea-shore, or on high monntains. 
Existing nervonsness should be combated by a rational mode of life, 
cold rabbings, baths and douches; when exposed to infection, the nose 
■hould be douched every two hours with salt water, or a solution of car- 
bolic acid or quinine, in order to remove the inspired pollen as rapidly aa 
possible. 

Irrigation of the nasal cavity with a solution of quinine (1 : 740), car- 
bolic orsalicylic acid, and other disinfectants, may be performed when the 
disease is fully developed. 

In one of mvcases. good effects were obtained from the followingsnnff 
powder: IJ Hydrarg. chlorid. mite, alumin., iia gr. xlv.; morphin. 
nydrochlorat., gr, ivsa. M. D. S. A portion as large as a pea to be 
suuSed up t. i, d. 

Nervines (bromide of potassium, arsenic, strychnine, and camphor) and 
central galvanization have been employed in order to relieve the general 
nepTOUsnefls. Narcotics may bo administered internally and locally if 
the symptoms of irritation are violent. 



I me sympiioms oi irriLauon are vioieni. i 

^H FART ^^H 

^H INFECnOtTS DISEASES IN WHlCa THE DIGESTIVE APPARATUS IB^^| 

^H CHIEFLY INVOLVED. ^^H 

I 1. Epidemic Parotitis. Mumps. 



1. Epidemic Parotitis. JIumps. 

I. EnoLoaT. — Epidemic parotitis occurs particularly in the winter 
and autumn, and its spread seems to be furthered by unfavorable weather. 
It is sometimes a forerunner of epidemics of measles, whooping- 
cough, or diphtheria, or it follows these diseases. It ia sometimes preva- 
lent at the same time as epidemics of scarlatina. 



i 



The male sex is affected more freqaently than the female sex. Cer- 
tain epidemics attack children almost exclusively, in others adults are 
chiefly affected. The disease does not occur in infancy or old age. It 
most frequent between the second and twentieth years. 



i^M \nfrmnovii duuases involving thb diqebtpf^ afpasatub. 

It i1ovtilo|)M very often in crowded iiiBtitations. Among 131 pupils 
1(1 (tits i'uilot Academy at Ploen 118 (90^) were attacked. 

'l^liu i:(iiilupriouri character of the aisease has been demonstrated in a 
hUiiiUist iff catM^H. For example, an apparently healthy individual trayels 
tnnh a lM'.alily iii which parotitis is epidemic to another district. Here 
Un i« uiiaiiked by mumps at the end of a few days, and soon infects those 
living ill thti itamo house, and then those in neighboring houses. 

iij«i<lHriii(} parotitis is prol)ably a general infections disease, character* 
imi in the main by a local affection of the parotid gland. This opinion 
in liMpported by its epidemic character and contagiousness, and the fact 
that a single attack generally confers immunity in subsequent epidemics. 
The general symptoms are often yery sli^ht^ but cases occur^ on the 
iither liand, in which internal organs are seriously affected, while clouded 
cuasitioiuness, high fever, and great prostration produce the impression 
of a serious infectious disease. 

It is plausible to assume that the virus passes from the buccal cavity 
thruuKh the excretory duct of the parotid, and that the general symp- 
toms depend upon tlie unobstructed passage of the virus into the gen- 
isral einmlation. Soltmann believes that the narrowness of Steno's 
duct in infants, together with the slight development of the salivary 
glands, confers immunity upon infancy. 

Pasteur found in the blood rod^haped bacteria 1 m broad and 2 m long, but 
attempts at inooulation in animals proved fruitless. 

II. Anatomical Changes. — According to Virchow, the lobules of 
the parotid gland are hyperaemic, the excretory duct is filled with muco- 
pus, and the periglandular connective tissue is in a condition of inflam- 
matory (Bdema and infiltrated with round cells. 

III. Hymptoms. — The duration of the stage of incubation is variously 
estimated at nine to twenty-one days. The characteristic symptoms are 
sometimes preceded by prodromata for one to three days. The patients 
complain of fever, prostration, and anorexia. In children tne rise 
of temperature (sometimes to 39.5° C.) may cause eclamptic convul- 
sions. 

The first specific changes consist of pressure and tension in the re- 

Sion of the parotid gland. Violent pains sometimes occur, and may ra- 
iate into the auricular region, and between the shoulder blades. The 
movements of the jaw are interfered v/ith. The parotid region soon be- 
comes swollen, the swelling extending in all directions beyond the gland^ 
upwards to the eyelids, downwards to the clavicle, posteriorly to the 
spine, and anteriorly to the chin. As a rule, the swelling is pale, the 
overlying integument smooth, glossy, sometimes cedematous. In rare 
cases, it presents inflammatory redness. It is hot to the feel, of a 
dougliy hardness in consistence, and more or less tender on pressure. 

The changes begin on one side (generally the left), but later extend 
to the other side. 

The swelling abolishes the ability to perform mimetic movements, 
and gi voa to the ])ationts a peculiarly stupid appearance. If the disease 
is unilateral, the head is generally lield immovable towards the affected 
side, and attemj^ts at rotation prmluoe extremely violent pains. In bi- 
lateral mumps, the head is held peculiarly stiff, and is somewhat bent 
over forwards or baekwanls. The movements of the lower jaw are 
almost entirely abolished, and sometimes only a narrow fissure is left 



mFEOTIOUB DISEAflES IirVOLVIlTO THB DIOKSTTVE APPABATCS. 




I 



^_ ('r 



bebreen the rows of teeth, lleace the patients are restricted almost 
exoluaively to fluid food. Articulation is rouJereil indistinct, and faetor 
ex ore is often produced on acconnt of the inability to keep the mouth 
clean. 

The latter symptom is intonsifled when stomatitis and ptyalism 
develop. The secretion of ealiva is often diminished at the outset, and 
is only increased in the later coarse of the disease. Tonsillitis, pharyn- 
gitis, and follicular inflammations are also observed in some cases. 

The swelling is the result, not alone of changes in the parotid, but 
also of inflammatory cedema in the surrounding cellular tissue. The 
submaxillary and sublingual glands are also inflamed in some cases, and 
it ia said that these glands mav alone be swollen during on epidemic of 
mumps. The adjacent lympliatic glands generally take part in the 
Bwelbng. 

After [he swelling has formed, the fever generally falls sod remains 
belov 39° 0. Some cases run an apyrexial course. 

An uncomplicated ease lasts about two weeks. The swelling gradually 
diminishes, the movements of the jaws become freer, and finally recovery 
is complete. The skin often desquamates over the site of the tumor. 

The most important complications are affections of the sexual appa- 
ratus. Orchitis develops not infrequently in male adults. Qranier found 
that among 495 cases in an epidemic among sotdicrs, orchitis developed 
116 times. Ohildren and old men are not attacked in this way. 

The orchitis is generally unilateral, often upon the side on which the 
parotid is mainly or exclusively affected. In bilateral mumps, the right 
testicle is more frequently inflamed. Bilateral orchitis is rare, but some- 
times one testicle is attacked after the other. The first symptoms consist 
of paina in the loins, groins, and along the seminal cord. The tempera- 
ture of the body is generally increased, and vomiting occurs. After a 
time, the testicle is found to he enlarged and tender on pressure ; the 
scrotum is generally red and cedematous. The testicle itself, not the 
epididymis, is inflamed. 

The frequent complication with orchitis depends on the character of 
the epidemic. Blondeau reported a case m which, although mumps de- 
veloped while the patient was suffering from gonorrhoea, orchitis did not 
occur. Nor does orchitis depend upon the severity of the inflammatory 
changes in the parotid. Rizet described an epidemic in which the mild 
cases gave rise to orchitis. 

In a number of cases, the parotitis subsides on tlie appearance of or- 
chitis, or both lesions present repeated variations in severity. In some 
cases of parotitis, a gonorrhcea-liko discharge takes place from the 
Drcthra. 

Pains and even enlargement of the ovaries, swelling, and hiematoma 
of the vaginal mucous membrane and labia, and enlargement of the 
breasts have been observed in female patients. 

Suppuration of the inflamed parotid gland is an unpleasant compli- 
cation. The pus may perforate exteraally through several flstulie or into 
the mouth, pharynx, or external auditory canal; or it destrovs the facial 
nerveand produces permanent facial paralysis; or erodes the largo vessels 
in the neck and causes fatal hemorrhage; or ruptures into the air pas- 
sages, pleural or pericardial cavities, etc, ; or finally it produces pytemia 
or septicfemia. 

Among othercomplications we may mention : a. e re bral congestion 
(from pressure of the parotid on the jugular vein) and meningitis, b. 



« ixi'i*ma:> lusLjksiLi' 3tmti5:- the digestive appabatus. 

*: • T ^' . ni^-^-u iiru4:.-Cr. "ri-'ii ilTajs hare an unfavorable prog- 

^ ._- •_ • -Li. :_^ri.":uz.':»r5 (amblyopia and color blind- 

., . - - • •- - ::.z>i' L :;sie:! bv Falrv, who attributes 

_ -. ;i _.-. . .CL::2'::ivitis. eniphora, and photo- 

-a.-^-T'-j^ 'r-^n^sii. resulting from comjires- 

:.s -.•■•-. 11 -in-? -rpiiemics. e. Acute albumin- 

.-._ r-r ..-!-'r :ei :\v Colin. Haematuria and 

r— ■ ?^r-.^:. •". Gastro-intestinal disturb- 

'.-■ ? u**" rmeraiLj constipated. Obstinate 

.: ztK-r. ■- liiiisi claims to have observed 






Zi*r mriammatory swelling may 
'• •': iij TffPjijiina for many mouths or 
V :: i.'»:;uil fre*[uency in scrofulous 
.— .: . i ik-si} ioc to follow in them, and 
;i i .1 ditala. burrowing of pus, 
■ir .'lust [ noticed severe ptyalism 
■:.--•: y- irr-^pine. Burton observed 
■ ■-: -::e jonJition by the applica- 
.1. ^u^u-sjs T.a7 be produced by pres- 
- I'r >:?::•:> sometimes occurs in 

- 1. :i. In *Tniui»»r's 115 cases of 
. ::ir -y»ci«:Ie. Jaloux described a 

'. r'vi-!i- irrtrrrrophy. Deafness has 

:i»r r^-^ 4::«i vertigo. It seems to 

. ;:.:: u :2e labyrinth or on secondary 

- :«:!• nad-e from the presence of a 
—lu* iLi i.rory canal, and zygo- 
!..-:».:;.':■ :: :he affection. 

- . •?; uwavj favorable. It is only 
.. -*.r'-.iis sei[uela persist. 

^ . . \U' ipL'Iication of cotton bat- 

•.:i^ •!: :r»faLment. The bowels 

>.?. •■i;t»dy i?f fluid food. Lestor 

. ». ■.; 1 aboraiidi. If orchitis do- 

».. ii-i v'.'cn the testicle elevated. 

^iiaiiii bo p«HiIticeii and opened 

i-uua •)>' applications of iodine 

...i'.^., .lud iodide of potassium or 



r • 



#.N .'''^f'ffr. 



i.r r. 



. .. ■ »:t»v»aoiy meets cases in which a 

\ .V wu.pss often without any known 

..X . I'Uc ^'cne opens not infrequently 

V. .».!•. ill^ vmplaiu of repeated chillV 

. .. . . -tvi -fc reeling as if a severe illness is 

.. X , .L- ii.i. icvelopn The bodily temper- 

... , . I'Mc pulse and respirations arc 

\ \ uiinished. The tongue generally 



W s-»i ."» 






DTFEOTIOtTS D1SEA8BS INTOLTIHO THE DIOE8TITE AFPABATITS. 191 

presentB a thick, gray, yellow, or brownish coating, and there ia often a 
oisagrceable fcetor ex ore. Eructations and vomiting are not uncommon, 
Tliore is sumetimeff tenderness over the stomach, and meteorism. 

Herpes often develops very rapidly on the lips, rarely on the a!a nasi, 
cheek, lobe of the ear, or other parts of the body. In a few cases I found 
a few patches of roseola on the abdomen. Even slight impairment of 
oonsciouBuess and dolirium may set in. 

The disease often terminates iu the following night. Profuse dia- 
phoresis occurs, and the temperature becomes normal or even sub-normal, 
Ru abundant sediment appears in the arine, and the existing feebleness 
rapidly disappears. In rarer cases the disease lasts several days, very 
rarely more than a week, 

II. Etiology. — Many individuals exhibit a predisposition to such 
attacks, and may suffer from a large number in the course of their 
lives. They are most frequent in middle life. They ate {rcnerally 
attributed by the patients to a cold, hut, in the majority of oases, without 
justiQcatioQ. Others attribute the disease to excesses in eating ordritik- 
ing. mental or physical strain, or the action of excessive heat. Several 
individuals are sometimes attacked at the same time, or in succession, so 
that, in our opinion, we are justified in regarding the disease as an infec- 
tious fever of ephemeral duration. Flessing has recently reported a case 
in which several patients were attacked iu the same ward of a hospital. 

HI. DiAOKOSis, PE0OSO818, TKEiTMBNT. — The diaguosis is easy. 
Apart from the febrile and gaetro-enteric symptoms, affections of other 
organs are absent, and the rapid and almost always favorable course dif- 
ferentiates the disease from typhoid fever, central pneumonia, etc. 

The prognosis ia almost always favorable, 

The treatment is purely symptomatic. 

3. Typhoid Fever. ^ 

I. Etiology. — Sporadic cases of typhoid fever are found almost con- ' 
stantly in large cities. In certain countries and cities the disease is 
especially frequent. While it is very common in England, typhus fever 
predominates in Scotland and Ireland. Among Oerman cities, Munich 
was formerly notorious as the habitat of typhoid fever. 

At times the disease appears in epidemics. These sometimes appear 
in places which were previously free from the disease, resulting from an 
imported case, from the ingestion of infected food, or apparently spon- 
taneously. 

Epidemics often occur during wars, their spread being favored by 
deprivation, colds, etc. 

The majority of recent writers believe that the virus consistsof certain 
low organisms (vide Fig. 30). Gaffky found typhoid bacilli jn the intes- 
tinal ulcers, mesenteric glauds, spleen, and blood-vessels of the liver and 
kidneys. They were situated in groups, and were so much more numer- 
ous the more recent the disease. Pfeiffer recently succeeded in cultivat- 
ing them from the fceces. They have never been found iu the blood. 

The length oF typhoid bacilli is about one-third the dt&meter of a red bliK>d- 
Clobule, tht^ir width about one-third their own length. Tlie ends are rounded. 
They are readily stained with aniline, for example, methyl blue, gentian violet, 
Bismarck brown, and fuchsia. Tiiny oocuBionally contain spores, which do not 
Blain with aniline colore. The spore* are a^ broad as the bacilli, and are always 
"'**■"""' ""Tar one extremity of the bacillus. Each bacillus contains only one 



well-developed spor^. If two bacilli are adhereuC, the spores are found odIj at tba 
adjacent extremities. 

Uaffky cultivated the bacilli in meat extract, peptone-^latin, and slices of 
potato, but inoculations in animals did not produce positive results. Hence the 
results of his investigations maj only be regarded as probable, not aa certain. 

Clinical experience indicates that the virua iscoutained in the faeces, 

BO that the danger of infection arises only from contact with the iutestiDal 

coiiteate. The virus is not diffused in the exhalations of the patient, bo 

that it is not conveyed to those who como in contact with him. Hence 

[the patienta may saiely be kept in the general wards of a hospital, if care 

Ibe taken to disinfect the fiecea, bed-pan, and soiled articles of clothing. 




I na 



Trphoid 



The vims may enter the intestinal tract through the anas or mouth. 
If the infection occurs through the agency of water-cloBets or bed-pans 
which have been soiled by typhoid stools, infection takes place in the 
former method ; but aomctimes the vims is introduced in the ingesta, or 
it is diffused from the feeces into the air, enters the pharynx, and then ir 
swallowed. Some assume the possibility of infection through the n 
atory organs. Certain cases in which the disease begins with severe i^ 
fiammation of the lunss would seem to indicate that the vims may flnf 
produce its injurious effects at its site of entry_ (the lungs) before exewr"" 
ing its full deleterious inBueuce on the intestinal canal. 

Drinking-water undoubtedly plays a prominent part in infection. 
Epidemics often affect only thoBe bouses or streets whose inhabita nt! 



nTFEcnocs diseases mvoLvisa the digestive APPiEATire. 198 

R)1)t&in their drinking-Tater from a certain well. In a number of Buch 
cues, it hae been found that the water supply commanicated with water- 
closets, dung heaps, ditches, etc., which contained infected fseoes. 

A number of cases have been observed, particularly in England, in 
which the disease vae conSned to families who received their supply of 
milk from a certain milkman. In the majority of theae cases the milk 
had been diluted with infected water. 

In the canton of Zorich a number of epidemica have been observed, which 
bave been attributed to the ingeaiion of spoiled meat. These generally occurred 
at festiTnls, thespojledmeat lieingused in the preparation of special popular deli- 
cacies. In the Kloten epidemic (18T8), amon^ 700 singers 600 were attaclie<l b; 
typhoid fever. These epidemics Jiave given rise to much controversy, especially 
Dpon*Che follonring points: a. Was the clieeaae really typhoid fever? b. If so, was 
it produced by meat which waa simply spoiled? Ore. By infection with the meat 
of typhoid animals? My colleagues in Zurich are agreed aa regards the typhoid 
nature of the epidemics, and the statements of Wy ss will hardly admit of any 
doubt. Huguenm states that the Kloten epidemic was produced by eating the 
flesh of a caU which suffered from typhoid fever, but fails to prove the truth of 
this assertion. Poaldve evideuoe that typhoid fever occurs in animals haa not 
been furnished hitherto. But to assume that the disease was produced by the 
mere iugmtioD of spoiled meat contradicts the theory of the specific nature of the 
typhoid virus. Moreover, we know tliat the ingestion of spoiled meat produces 
symptoms (hemorrhagic gastro-enteri lis) which differ from those of typhoid fever. 
It must be remembered that the participants in the festivals in question not alone 
ate. but also drank, and it is not at all improbable that the infection occurred 
through the medium of the drinking-water. 

In eome casea infection is attributable to certain occupations, tatM 
example, that of washerwomen, who wash clothing which has been soiled 
by the excrement of typhoid fever patients, or scavengers who clean 
water-closets, etc. It must he kept in mind that the virus may retain 
its potency for many years, and thus it often becomes difficult to ascer- 
tain whetner typhoid stools have ever been emptied into the closets. 
I The outbreak of an epidemic is sometimes cansedbyan imported case, 
l^lnit in other cases the mode of infection cannot be discovered. In oar 
■ opinion, there are mild forms of the disease in which the patients walk 
about. The f»cea of such individuals may form the starting-point for 
severe cases. Indeed, cases have been reported in which fully developed 
lesions of typhoid fever were found upon autopsies on iudividnala who 
had been killed by accidents while apparently healthy. 

The majority of cases occur from August to November, the fewest 
from February to April. Exceptions to this rule are sometimes noticed. 
In Munich, for example, the largest number of cases occur in the 
month of February. 

As a general thing, cases are more numerous after a hot sammert 
while the spread of tne disease is antagonized by a very cold winter. 

According to Buhl and Pettenkofer, typhoid fever increases the lower the 
level of the subaoil water. Thev assume tliat the typhoid virus then proliferates 
■noreabimdantlyin the upper, dry strata of the soil, and are thus conveyed to the 
1 . — .^ f^f jjig atmosphere. This theory, however, is oppoeed by numerous 



^p 



To explai 
of years, the subsiiil 

prolifernting. Asa ^ _„ 

ponant. but only becaueu the higher its level the more apt it will be to contMOir 



f 

I 



iy4 cFEcnoua maEABBfrTSMjf 

Tyitlioid fever very often occars in house-epidemics (barracks, pria- 
ous. etc. ). In large cities, cortain bouses and streets are apt to be no- 
torious as the habitat of the disease. £xteuBive epidemics are sometimes 
found to consist of a number of house-epidemics. 

The disease is most fre<)uent from the fifteenth fco the thirtieth years 
(ibaximum from twenty to twenty-five years), altfaough it also occurs iu 
childhood and old age. 

Chwcelay claims to have observed it twic« in Ihe new-born. HasteltuB re- 
ported the case of a pregnant woniau suffering from tj-phoid fever, who had a 
premature ileHvery iu the eighth month. In the siill-Dorn child were found en- 
largement of the spleen and lymphoid infiltration of the intestinal follicles and 
mesenteric glands. Typhoid fever is rare in the first year uf life. During child- 
hood, it is especially frequent from the age of five to ten yeius. 

Sex exerts no special inflnence on the frequency of the disease, 
though, on the whole, more men are uttaciced than women. 

Ib)hust individuals are often attacked, and some physicians believe 
that weak {enasmic individuals, aud those suffering from cancer, heart- 
disease, syphilis, or phthisis, possess almost complete immanity. 

It was formerly believed that pregnancy and the puerperal condition confer 
immunity against typhoid fever, but this view is now discarded. Indeed Hecker 
believes that the susceptibility is increased in these conditions. According to 
Duguyot.prematuredelivery is produced in two-thirds of the cases which oocuiiu 
pregnant women. The child is generally still-born, or dies soon after birth. As 
a rule, pregnancy does not affect the course of typhoid (ever, snd complications 
often remain absent, even after premature delivery. Tlie latter may be the re- 
sult of the high tever, the severity of the infection, or disturbances of respira- 
tion. 

PfeilTer believes that typhoid fever is unusuaUy frequent in certain famUiea, 
and asHumee that this fact is owing to the diminished power of resistance of the 
intestinal follicles. 

The disease is moat frequent among the poor. A predisposition may 
also bo created by certain occupations. For example, the pnysicians or 
nurses in a hospital escape, while the washerwomen employed to wash 
the clothing of typhoid fever patients fall victims to the disease. 

Strangers are especially apt to be attacked when they enter an in- 
fected city or house, while the inhabitants gradually become acclimated. 

Ab a rule, only a single attack is ex})erieuced, although exceptions 
have been observed, and in a few cases individuals have auSered even 
three attacks, JH 

Typhoid fever is sometimes associated witli, or followed by otherJ|^| 
fectiouB diseases. ^^H 



During an epidemic, the individual cases often resemble one another 
very closely in their symptoms and general course. 

II- Anatomical Changes. — The specifio lesions of typhoid fever 
affect the lymph follicles of the intestinal mucous membrane, the mes- 
enteric glands, and the spleen. 

The intestinal changes ^nerally begin with catarrhal inflammation, 
not alone of the lymph follicles, but also of the mucous membrane, and 
the lattei' persiats iu greater or less degree during the entire course at 







■BCfriOCS DISEASES INVOLVTNQ TUE DIOESTIVB APPARil 

the disease. The catarrhal follicles at first project more etroiigly from 
the surface, and are generally surrounded by a zone of hyperiemic vea- 
■ela. The solitary follicles not infrequently look like fine pearls, which, 
if punctured, discharge a clear fluid. It is evident that the swelling is 
the result of inflammatory cedema. But soon the cellular elements pro- 
liferate, the follicle becomes more opaque and cloudy, and no longer col- 
lapses when punctured. This constitutes the acme of the catarrhal 
stage (second half of the first week of the disease). 

There is now a gradual transition into the stage of medullary infiltra- 
tion. The hypertrophy and hyperplasia of the cellular elements con- 
stantly increase, so that the solitary follicles may attain the size of a pea 
or more, while Peyer's patches form large plaques, whose thickness mi ly 
exceed five mm. The edges of the infiltration usually are steep, but oc- 
oasionally it sprouts up like a mushroom, the resemblance being increased 
still further by a slight depression in the centre. In Peyer's patches, the 
proliferation of the follicular substance proper not infreguently greatly 
exceeds that of the interfollicular connective tissue, ho that its surface 

S resents a latticed appearance. In some places the infiltration is con- 
ned to certaiu parts of the patch, while adjacent parts maintain the 
normal appearance. If the morbid process is very extensive, adjacent 
follicles may coalesce. In this way tumor-like masses may form upon 
the mucous membrane, and may narrow the lumen of the canal to acer- 
tain extent. This is observed with relative frequency on the ileo-ciecal 
valve and lower part of the ileum. 

The medullary infiltration often extends beyond the follicles to the 
adjacent mucous membrane, in places to the muscular coat, and even to 
the serous layer. In this way small medullary nodules may form beneath 
the peritoneal covering of the intestines. Even if these changes are not 
produced, the serous membrane over the typhoid changes is often con- 
gested. 

At first the infiltrated places are congested and succulent, but later 
the congestion disappears, the parts assume a grayish-rod, then a white 
color, and become firm, almost crumbly. 

Under specially favorable circumstances, the infiltration may undergo 
absorption. The cellular elements undergo fatty degeneration, and the 
&tty detritus enters the lymphatic channels. This is shown macroscop- 
icall^ by the yellow color of tbe parts. In Peyer's patches, it is found 
not infrequently that the cellular elements in the follicular substance 
undergo fatty aegoueration and absorption earlier than in the interfolli- 
oular connective tissue, so that the patch presents a furrowed appear- 
ance, the follicles being depressed, and the interfollicular hands of con- 
nective tissue forming prominent ridges. If the medullary infiltration 
has been attended with extravasations of blood, the coloring matter of 
the blood is gradually couverted into blackish pigment detritus. The 
Payer's {tatches may then present a black speckled appearance. These 
chunges geuerall^ persist for many years. Extravasations may also form 
In the hyperiemic zones which surround the follicles, and may be fol- 
lowed by pigmentation. 

As a rule, however, the stage of medullary infiltration passes into 
that of necrosis, or at \e^l this is true of the majority of the infiltrated 
lymph follicles. As a general thing, the necrosis takes place about the 
iddle of the second week of tbe disease. This is evidently owing to the 

t that tbe cellular elements increase in such numbers as to compress 

blood-voBsels, and thus deprive the cells of nutriment. A thin layer 



1 

] 



196 isrzcnova dissabas nrroLvoro the dioestttb affj 

of BCCroeiB flrflt forms on the surface of the follicle, and aasnmee a yel- 
lowish or brownish color from imbibition of bile pigment. But the ne- 
croBis may ertend 80 deeply as to lead to perforation of the serous layer- 
The raucous membrane adjacent to the lymph follicles occasionally un- 
dergoes necrosis, and large gangrenous shreds sometimes project into 
the lumen of the intestines. 

About the middle of the third week the stage, of ulceration begins. 
The necrotic masses are exfoliated, and leave a loss of substance, at the 
bottom of which the muscular coat is distinctly Tisible. tTlcers of the 
solitary follicles are usually round, those of Peyer's patches are oval in 
shape. Unlike tubercular ulcers, tbeir long diameter is parallel to that 
of tne intestines, and annular ulcerations are almost always absent. Ex- 
foliation generally occurs in very minute particles. More rarely large 
pieces, or the entire necrotic patch are exfoliated, and may then be found 
in the stools during life. Ulceration and exfoliation may be attended 
with danger, particularly with hemorrhage from large vessels. Ab a 
general thing, however, tnis ia prevented by thrombosis of the vessels. 

The stage of recovery begins about the middle of the fourth week. 
Granulations form upon the base of the ulcev (sometimes so actively as 
to almost constitute suppuration) and gradual cicatrization ensues. This 
rarely results in intestinal stenosis, although the adjacent mucous mem- 
brane takes part iu the process, as is evident from tue slightly radiating 
character of the cicatrix. For years the cicatrix forms an attenuated 
patch which appears with special distinctness when the intestine is 
held up to the light. Its centre or border is not infrequently pigmented. 
The cicatricial tissue b sometimes lined merely with a layer (S epithe- 
lium; in other cases, a new formation of villi with blood-vessels takes 
place ; the villi are generally scanty, and of unequal height and width. 

The mioroBcopical chaugea iu the follicles affect all their constituents. Hie 
veseelB are dilated, Iheir wallH in a condition of vitieoua swelling. In places they 
are plugged with white bli>od-Klobules. The parenchyma cells of the follicles 
present active fission and proliferation; giant cells are found containing ten to 
fifteen nuclei (so-called typhoid cells of Rindfleiach), In the connective-tiBBUe 
stroma are found swelling of the tissue, proliferation at the branching celia, and 
infiltration with round cells. Trphoid tiacilli probably form an integral part of 
the changes. HeschI observed that the changes extended far beyond the lymph 
follicles. In the CBpilkries of the intestinal walls he found swelhng and prolifer- 
alion of the nuclei, so that they projected in places into the lumen. Similar 
changes were found in the muscle nuclei of the longitudinal muscular layer ot 
the intestines, where they had produced, in places, nests of round oella. 

The typhoid changes in the follicles begin and are most marked iu 
the lower end of the ileum and upon the valve. They are no longer fonnd 
in the duodenum, although some authors claim to have fount! typhoid 
changes even upon the mucous membrane of the stomach. The vermi- 
form appendix is sometimes attacked with special severity, and iu one of 
my cases of perforation-peritonitis a typhoid ulcer was found only at the 
tip of the appendix. The large intestine may escape entirely; when 
attacked, the solitary follicles are affected, since it does not contain any 
Peyer's patches. At times, the disease may extend into the rectum, and 
large losses of substance may result from the coalescence of adjacent ulcers. 
The large intestine is sometimes the chief site of typhoid fever. The 
changes in the follicles are often found in various stages of develop- 
ment. 

The aSoctiou of the intestinal lymph follicles is attended with changei 



ISFECnOUB DIfi£AB£B INTOLVIBO THE DmEBTIVE AeeABi-TCB. 197 

!q the mesenteric glands. These appear earliest and are most marked 
near the lower part of the ileam. Some of the meaenteric glands may 
attain the size of a pigeon's egg or even a hen's egg. On section, they are 
found to be very red, more markedly in the cortical Bubstance. Ex- 
travasations of blood may occur in places. The cut surface is moist 
aad juicy, the constBteaoe soft. Later, the congestion diminishes, the 
Buccnlence partly disappears, and a condition of medullary infiltration 
develops, as in the lymph follicles of the intestines. In teamed prepara- 
tions, cells containing blood-corpuscles have been found not infrequently. 
Bacilli have also been found here. As the changes upon the mucous 
membrane subside, the swelling of the mesenteric glands diminishes; 
they undergo fatty degeneration and absorption. In some cases, spots of 
necrotic softening form in the glands, ana may give use to perforation 
with subsequent peritonitis. Or caseation and cafcificatiou may develop; 
this may terminate finally in infection with tubercle bacilli and in genem 
miliary tuberculosis. 

The spleen begins to enlarge about the middle of the first week, and 
reaches ite greatest dimensions about the end of the second week. This 
enlargement may not occur in old people or in cases in which the splenic 
capsule is thickened or firmly adherent to adjacent organs. At the 
height of the changes the capsule is tense; when diminution in size 
occurs, it ia often wrinkled. The consistence of the organ is soft, 
occasionally almost diffluent. It is distended with blood, of a dark 
cherry-red color, and the follicles sometimes appear upon tiie cut sur- 
face aa small gray infiltrations. In advanced cases, there is often an ua- 
naual amount of pigment in the spleen, the result of unusual destruction 
of red blood -globules within the organ. In addition to evidences of 
proliferation and fission of the splenic cells, the microscope also shows 
an unusual number of these cells which are filled with more or less 
cbansed red blood -globules or with their detritus. Typhoid bacilli have 
also been foaud in the spleen. Wedge-shaped and simple hemorrhagic 
infarctions, and even abscess of the spleen are not very rare compUr- 

tioDS. 

Jit would appear as If almoat the entire lymphatic gland sfstem ma; beaffeot«d 
in severe cases. Thus, medullary infiltration has been observed, not alone in the 
retroperitoneal, but also In the tracheo-bronchial and even the peripheral glands 
(c«rvicat and inguinal). Similar changes have been ohserved in the tonsils, the 
foliiclse of the tongue, and the thvroid gland, The medulla of the bo&es is often 
of a red color, its parenchyma cells increased in number ; it contains an UDUsua] 
number o( nucleated blood-globules and celts which contain btood- corpuscles, 

The specific lesions mentioned above are always associated with 
changes in other orjjans, partly as tho result of infection, partly owing; . 
to the increased bodily temperature. f 

If the patients have died at the height of the disease, rigor mortis is -' 
apt to develop very quickly and to be very marked. Livoros mortis are ■ 
QBually very abuntiunt upon the back and dependent portions of the 
body. 

ITie panniculuB adiposus is often well retained, even if the disease has 
Usted two or three weeks. The musclea are generally dry, and have a deep 
red color. Here and there they contain pale-gray or yellowish patches, 
which are moat frequent in the recti abdominis and adductors of the 
thigh, but are also found in other muscles (even tho heart, tongue, and 
diipbntgm). In such places the microscope shows that the contents of 



INFBOnODS DISEASES ISVOLVISO THE DiaESTIVB APPAKATDS. 

the mUBcnlar6bre8 haveadnll shining, fitreous, coagalated appearance, 
and are converted into Bbrillatod cUimpa (Zenker's degeueratiou). In 
other places the muaciilar fibres coutaia very Sne ^rauales, which partly 
disappear on the addition of acetic acid (albuminoid), bat partly persist 
and tnm black on the addition of hyiierosmic acid (fat granules). Pro- 
Uferulion of the muscle nuclei is obssrved not infreouently. 

The heart muaclo is often flaccid, brittle, and pale. On section, it la 
found to contain numerous pale-gray and light-yellow spots, which show 
ander the microscope cloudy swelling of the muscular fibrea, fatty and 
wax-like degeneration. The fibres often contain an unuaiial amount of 
brownish pigment. Nuclear proliferations within the fibres are also ob- 
served. 

The larynx may contain uli^erg, which are situated most frequently on 
the edges of the epiglottis or the posterior portion of the true vocal cords. 
These are, perhaps, the result of typhoid infiltration, at all events they 
often contain typhoid bacilli. They sometimes extend to the cartilages, 
producing necrosis and exfoliation, or they may give rise to fiital cedema 
of the glottis. Bronchitis is observed in almost every case. 

The salivary glands are often enlarged, et^pecially in the first stagm 
of the disease. The microscoue shows proliferation tind cloudy swell- 
ing of the cells within the aoini. The signs of pharyngitis, wliich arc 
usually present during life, disappear in great part after death. CaUu^ 
rhal gastritis is found not infrequently. The pancreas presents similar 
changes to the salivary glands. 

Tue liver is often euIargeJ, its cells in a condition of cloudy swellinz 
or fatty degeneration. Wagner observed lymphomata in thu liver ana 
kidneys. The gall-bladder is often flabby, and contains thin bile which 
is poor in coloring matter. 

The kidneys are often slightly swollen, not infrequently pale and 
flabby. The microscope reveals cloudy swelling and fatty degenerstioii 
of the tubular epithelium. There is sometimes slight catarrh of thv 
mucous membrane of the urinary passages. 

The brain may present meningeal hemorrhages and oidema of the pia 
mater. Meyuert found distention of the cortical capillaries, granular 
degeneration of the ganglion cells, increase of their nuclei, and fibrilla- 
tion of the protopliifim. Fopoff observed infiltration of the ganglion 
cells with round cells, and an accumulation of round cells in the peri- 
ganglionic lymph spaces, adventitious lymph spaceeof the blood-Tessels, 
and along the nerve fibres. This author also observed pigment infiltra- 
tion of the ganglion cells. In places the pigment granules are free, and 
are visible to the naked eye as yellow or brownish patches. 

Fatty degeneration of the blood-vessels is found in the brain and other 
organs. 

III. Stiiptomh. — The duration of the stage of incubation probably 
. varies from fourteen to twenty-one days, although, as in the case of 
other infectious diseases, it is sometimes longer, sometimes shorter 
than this period. 

The prodromal stage generally lasts several days, more rarely a few 
weeks or only a few hours. The patients complain of general malaise, 
anorexia, restless sleep, inability to work mentolly or physically. Not 
infrequently there are shooting pains in the musclee, generally in the 
lege, more rarely in the back. 

The disease proper generally begins with repeated chillv aenaations. 
more rarely with ;i single chill. As a rule, this is followed "by rapid ele- 




TNTKcnoCB DISEASES TNTOLVINO THE DI0E8TITE APPAHATU8, 199 



vation of temperature. The maTiifest eymptoms depend chiefly on the 
aaatomicnl changes in the inteetines. 

Typhoid fever is almost always associated with increased bodily tom- 
nerature. and tho curve is so characteristic as to enable ub to umke a 
diagnosis from it, in doubtful eases. In the first week (catarrhal swell- 
ing and beginning medullary infiltration of the intestinal lymph folli- 
cles) tho temperatnre rises gradually. Every night it is usually about 
1° 0. more tnan on the preceding night, but the next morning it is 
generally about 0.5° C. lower (vide Fig. 31). At the end of the first 
fveek tho fever has generally reached its height, and then remains ap- 
proximately continuons during the second week (completed medullary in- 
filtration and beginning nlceration of the follicles). In the third week 
greater variations of temperature occur, tlie type of fever becoming re- 




coi 
^^^L on 






miltent. (iradual defervescenceoccurs during the fourth week (comple- 
tion of ulceration, and cicatrization). The variations between the morn- 
ing and evening temperatures are often very considerable. The inverse 
type ia sometimes observed, (. e., exacerbations in the morning, remis- 
sious in tho evening. 

The elevation or tho bodily temperature is attended with other fe- 
brile symptoms, viz. acceleration of tho pulse, diminished appetite, in- 
creased thirst, and diminished diuresis. 

At the lieginniiig of the first week, the tongue is stickif. moist, 
and covered with a thick, gray, grayish-yellow, or grayish-browu 
coating (desquamated epithelium, debris of food, and scliizomyoeteB). 
In the second half of the first week, the dryness of tho tongue in- 
creases, und its edges, as far as the tip, become unusually clean, and 
•Imost brick red. As the second week approaches, the coating is 
{[rvdually exfoliated (beginning at the tip ana gradually passing back- 
\Td).' This often occurs in the shape of a triangle, the apex elf < 



^ 



i 



nTFxcnoUB DiSEAaBs arroLVTso the DioseiiTB appabatqb. 

which is situated at the tip of the tongue. The tongue ^ geaenlly 
entirely clean in the first part of the second week. It ia unasually 
dr; and red, often rough and papular from ewelling of the fuugiform 
papillse. 

Towards the end of the first week, a peculiar eruption often appears 
in the aliape of pale red, usually rounded patches which are slightly 
raised, and become entirely pale on pressure (typhoid roseola). As a 
rule, they appear first on the abdomen, but also upon the chest and 
back, where they are occasionally even more profuse than upon th© 
abdomen. They are rarely found on the limbs, and then generally on 
the arms or thighs ; they hardly ever occur on the face. The individual 
patches generaUy disappear iq three to five days, but occasionally persist 
for more than a week. In the latter event, I have sometimes fonnd 
that the paling of the patches ia followed by slight desquamation of the 
epidermis. New crops of roseola may continue to return into the fourth 
week, and even into the period of convalescence. Their number variea 
according to the epidemics, but they may be so numerous as to remind 
UB of meaales. I have never eeen typhoid fever without roseola, bub 
some authors state that this ooours in rare cases. Fine vesiolea some- 
times form at the apices of the patches. 

Tiio abdomen is generally prominent, especially in its lower half, 
and in the ileo-ciecal region. 

The iieo-oteoal region is almost always tender on pressure, and even 
nuconscious patients distort the features when this region is palpated. 
More rarely there is tenderness on pressure over the epigastrium, or 
other parts of the abdomen. At the same time, a gurgling murmur ia 
often felt in the ileo-csscal region. This merely indicates the presence 
of fluid mixed with bubbles of gas beneath the compressing fingers, and 
while it is unusually frequent m typhoid fever, it is by no means char- 
acteristic. Percussion over this region generally furnishes a dull or 
dull tympanitic percussion sound. 

In the second half of the first week, the spleen, as a rule, is found to 
be enlarged, and this increases considerably during the second week. 
It not infrequently attains two or three times the normal dimensions. 
If the patient is placed in the right diagonal position, and the fingers, 
without pressing in deeply, are placed between the anterior tips of the 
eleventh and twelfth ribs, the enlarged organ can almost always be felt. 
Sometimes its borders can only be felt indistinctly; in other cases, the 
tip and anterior portions can be distinctly felt. The organ ia smooth, 
of peculiarly soft consistence, and not very rarely tender on pressure. 
In the third and fourth weeks the enlargement gradually diminishes. 

Some authors believe that percussion of the spleen furnishes more important 
nMultB than palpation. In our opinion, however, the pogaibilitf ot feeliDg the 
spleen ia one ot the moat constant BjmptomB of typhoid fever, provided that the 
examination is made in the manner mentioned above. 

At the beginning of the disease the bowels are often constipated. 
PiarrhoBa gradually sets in, and two to six stools are passed daily. They 
often look like pea soup ; they are thin, of a light-yellow color, not in- 
frequently have a biting, ammoniacal odor, and an alkaline reaction. 
On standing, they deposit a crumbly, partly flocculent sediment. The 
speeifio gravitv is about 1.005, the proportion of solid constituents about 
4 per cent. The typhoid stool is very poor in albuminoids. As rr-"" 



lafBUH OUa DI8E&BE8 INYOLVUtQ TH£ DIOBBnYS APPAB/iTCB. JHlI 

ery progresscB, the BtooU become more eonsiatent and scanty, and finally 
normal. 

Uicroscopical examination of the stools shows intestinal epithelium, round 
calls, ilebris ot food, fat cells and crystals, necrotio tissue from the mucoua 
membrane, round and rod-shaped achizomycetas, and triple phosphates (vide Fig. 
82). PfeiSer reports that he has succeeded in cultlvatmg typhoid bacilli from i 
the stools. 



Typhoid fever rarely rans the simple course indicated above, and 

8 eymptoms are unusually manifold. i 

Among the different varieties we will Qret refer to those in which ttia J 




phoaphstes, Enlv^ed w 



detrttm, and crystal) of tHpl» I 



^»lAt 



affection of other organs is so prominent as to ^ive rise to the liabiiitr 
of overlooking the typhoid fever. We refer chiefly to pnenmotyphoid, 
renotyphoid, and meningotyphoid. 

Pnenmotyphoid often creates the impression of an ordinary but 
severe flbrinous pneumonia. But we will generally be struck by the 
unusual degree of impairment of consciousness, the unusually large 
aise of the spleen, and the presence of roseola on the integument. It i» 
sometimes found that, despite the occurrence of absorption, the critical 
defer vescencti of pneumonia remains absent and the hitherto concealed 
typhoid symptoms become more noticeable. Not infrequently, however, 
death occurs before the crisis can be expected. Some authors assume 
in this variety of the disease infection does not take place throngli 




INFStmODa DISEAflKS IHVOLVINO THE DIQETTITB AFPAKATTS. 



I 

N 



9 mtestiDal tract, but through t)ie respiratory organs, so that the first 
and most yiolent morbid phenomena arc noticeii iu the lungs. 

The termB broachotjphoid and larjngotyphoid are aomBtimes applied to 
cases which are characterized by violent H;iuptoma or bronchitis or inflamma- 
tion and uloeratioD of the laryngeal mucous membrane. We regard these terms 
as misnotners. 

Eenotyphoid is characterized by prominent urinary symptoms from 
the very beginning of the disease. The urine cuatains albumin, casta 
and blood. The kidneys show parenchymatouB or interstitial changeB, 
Aocasionallj merely a condition of cloudy swelling. In these cases, there 
is dan^r of OTerlooking the typhoid faver and regarding the disease as 
nephritis. 

In uienin^otyphoid (cerebral typhoid), the suspicion of meningitis is 
aroused by rigidity of the nape, marked impairment of conaciousneea, 
sometimes by temporary inequality of the pupils. I ha?e often observed 
such cases in conditions of high fever, and the meningitic symptoms 
often disappeared as soon as the temperature was towered. We suspect 
that these symptoms depend on hyperjemic and cederaatous conditions 
of the meninges. 

A second group of varieties of the disease may be designated, acconl- 
ing to the severity of the symptoms, as mild typhoid. All or at least 
the majority of the symptoms are very mild. The patients sometimes 
feel so well that they go about their usual business (walking typhoid). 
Some of these individuals may be suddenly attacked by severe complica- 
tions (perforation-peritonitis, intestinal hemorrhage). In other cases, 
the fever is very mild, and in rare cases entirely abBcnt. In such mild 
cases, we may he struck by the slight degree of enlargement of the 
spleen, scanty roseola, and mildness of the intestinal symptoms. 

A third variety of the disease is known as abortive typhoid. The 
disease sometimes lasts only a few days, sometimes it continues to the 
beginning of the third week. Such attacks often assume the character 
of an acute disease ; they begin with a chill, followed by continued high 
fever, and q^uite rapid defervescence, accompanied with profuse sweating. 
In very rapid cases, fully developed medullary infiltration does not seem 
to develop, at all events necrosis and ulceration of the intestinal lymph 
follicles do not occur. 

Bronchitis is one of the most freguent complications of typhoid 
fever, and some authors claim that it is merely a. symptom of the dis- 
ease, not a complication. In our opinion, this is not true, since we have 
treated a number of cases in which no signs of bronchitis were notice- 
able. Bronchitis is characterized objectively by rude vesicular breath- 
ing, sonorous and sibilant r&tes, more rarely by moist rdles. As a rule, 
the symptoms are most marked in the postenor and lower portions of 
the lungs. 



t 



Pulmonary complications are not infrequent. Patients who occupy 
the same position for a long time are apt to develop pulmonary hypo- 
Btasis, characterized by more or less dulness (occasionally by a tym- 
panitic note), feebleness, sometimes absence of vesicular hreatliing, and 
non-Donsonaut moist rdles. If the position of the patients is frequently 



■ IKFBOnOOS DISEASES INVOLnSO THE DIOEBTIVE APPABATUS. 30$fl 

l^anged, it is often found that the dull parts become resonant. If this 
is tiol done, hypostatic pneumonia is apt to develop. The dulness then 
becomeE more marked, bronchial breathing is heard and the rdles be- 
come consonant. These complications are so much more apt to develop 
Ibe liigher the fever, tlie more profound the unconsciousness, the greater, 
itfl impairment of the heart's action. Fibrinous pneumonia sometinuttl 
bvelops in quite alatent manner. Apparently spontaneous rise of teRMl 
braturo. accelerated respiration, cyanosis, and slight cjouiling of conal 
Koustiess slioiild always Ifnd to careful exiiminatioti of the lungs. Tbilal 
BmpUoatiou develops most frequently after the second week. " ^1 

L In snveTBl cases, I Imva obmrvad "foreign body" pneumonia; lobular ca^ 
Irrhal paeumooiu is not uncotamon. UetnorrbHgic iufarctioaB are sonietiines 
^(tu(?«a, secondary to thrombosis of tbe right auricle, or inarnnCic throinlnisie nf 
veins. This is sometimeB Tollowed iiy abiicess Pulmonary gangrene may 
ir, but ruilier aa a iiequel. EruboliBtn •>! iIik pulmonary artery rany give rise 
to Budden death. Pleuritia is a rare complicatii-iu. 

The bronchial glands aometimeB undergo sopimtat'on. Tills may be rntlowecl 
bymediBstinitiB, which Fraantzelalaoobserveil aftt;rinf1amniatiun i>r tliece^opba- 
gUB and peri-oesophageai connective tiBtiue ; the pus may rupture into the cssoph- 
gus. bronchi, pleural or pericardial cavities. 

Typhoid ulcers develop not infrequently in the larynx, sometimes Bmm 
early as the second week of the disease. They often give rise to Ii3l 
symptoms and are found only after iaryngoscopic examination. lul 
other cases, the patients are hoarse and complain of pain in swallowing I 
and oil pressure over the larynx. The ulcers are so deep at times as tdj 
"re rise to perichondritis and necrosis of the laryngeal cartilages, oveul 
perforation of the laryngeal walls and cutaneous emphysema, TIhI 
may alao be the starting-point for fatal cedcma of the glottis, ■! 

According to Diltricli, iHryngeal pc-ricliondritis may also develop in typhoid 
fever indepeniJentiy of BpeciHc ulceiaiicuB. Diphtheritic and croupous laryngo- 
tracheal inflammation baa been observed at times, usually associated with efmQar 
cbanKi'sin the pharynx. 

In Zurich I often observed purulent or liemorHiagic inflammation of t^itres ; 
in enm« caeeedenth fniro auBocation occurred, despite tmcheototiiy. aa tiie result I 
of laryngeal BtenoaiB. ■ 

Nasal catarrh is a vei^ frequent complication, accompanied by rod- % 
3, swelling, and hence impermeability of the nose. Repeated eptstaxu I 
letimOH occurs in the prodromal stage or the ilrst week of the diseae9j| I 
become dangerous from its profuseness. The patients ofteai I 
easier after the hemorrhage. Epistaxia occasionally does not develoM 1 
until a later pcnoi], associated at times with signs of blood dissolutioQ^ I 

(|>6lechiiB on the skin and mucous membranes, intestinal hei ' 

Uffioiatuna, etc.), and is then an unfavorable prognostic sign. 

The rea^ntory complicatious are sometimes nervous in clinracter, Heckjrlri 
nporta » oaae in which Cheyue-Stokes breathing and stuttering developea on 
the fourteenlh day nf the diseBse. In one of my cases, Budden hoarspnesa was 
limduivil in the third week by piiralyRis of the internal thyro-aryiienoid and 
nrylnnoiil ntuaclea. la another case, complete unilateral paralysiB of the recur- 
rent laryngeal set in. 

Pericarditis and endocarditis ai* rare complicutiona on the part of 
circulatory organs. There is often slight dilatation of the right side 



^^snre ri 



r 

I La. 




nrFBcnous diseases ikvolvinq the dioestitb appakattr 

of the heart, as In other febrile or exhaastine diseases. The first 
(systolic) heart-sound is not infrequently soft and blowing, usually moet 
markedly over the apex. Paralyaia of the heart-muscle may set in 



n 




gradaally or suddenly, at the height of the disease or during convalea- 
ceuce ; in the former event, it is the result of the high fever, the 
severity of the infection, or both. 



I 



le diBHitt. Temperatup 



narniag, 38.4' ; BTenln; , 30.6*. 



Cardiac thrombi may alst 
Bide ot the heart, will give ri 
ptUmonar? artery, 

Uarsntio thrombosis of the veins occurs rather as a seqnelof typhoid 
fever. It is most frequent in the saphenous vein at its entrance 



SterenUi day o( tb 



, TaiiipentDu«:iD(iniliiK. aSi>';aTe)UiWr'ai.B>. 



into the crural vein, and in the latter itself. It is more frequent on the 
left side than on the right, and in men than in women. It is chai-apter- 
ized by pain, numbness, coldness, and cedema of the limb ; the throm" 




IHVBOtlOCS DIBEASBS INTOLTIKO THE DIOESTITE APPABATITS. 305 ^ 

baa 18 sometimes felt as a bard cord below Poupart's ligament. Palpa- 
tion must be performed Tecr cautiously, since particles are apt to be J 
broken off and carried into tne circulation as emboli. The tnrombug 1 




sometimes extends into the inferior vena cava and then into the other 
craral Tein. 



Toeu (f -second day of dlsesau. TaiDperatum. moraine, ^.I'; Biening. SO.lt". 

thigh, unattended with cedema, but followed by ulceration and discharge of a 
purulent, bloodjr fluid; tenniaation in recovery. Cole described a thrombus of 
the Itmombiate vein. I have otMervi^ Beverail cases of periphlebitis in women 
auSeriug from varicose veins in the legs. 



4 



The pulse is accelerated, but often less than would be anticipated from 

the height of the fever. As a rnle, it varies from one hundred to ono 

^tandred and twenty beats a minute, A more rapid pulse iudicatea great 



I 



gnwity, Th« i>(>W i* M>mDliine£ nnusaally slow, vitliont any aacertaiQ- 
uv: It I> ;j:'-iiir'riill)' Tiill uuil Koft, ufteu dUtioclly dicrotic, or 
iiv iluring the stage of recoTery. If the hitherto 
ri-e^tiUr, Ismail, auil 01.-018100^17 intermitteDt, 
: ■ urriTice of heart failure. 

' iroigh the sphygmographic tracings ia a case of 

(jj/)i'/j'l ftvir, Uk-_ii oil those 'iaya in which a change in the pnlae was 

\ auu)if«tU^. It ii eri'lent that during the cooree of the disease the pulse 

tf^ntrmot more and more dicrotic, t. e.. the blood pressure gradually 

Ho atMOllIu ohKUgM have been found in the blood. OixaHionBllv there is a 
«|i|(lit iuenmati In ttw number of white bluod-globitlea. or an unusual abundance 
fiif aUmantary granulM, •ipeoially diiHng eonvalescence. In ona OMe, 1 found in 
Hi* blowl larca grannlAr calle wblch contained aa nuuiy as seven red blood- 
giobulM. 

'i'lin Dps arc generally dry ; rhagades are apt to form upon them, and 
till o|ijthuliul layers ura exfoliated in part in the shape of yellowish and 
hrowninh neales. Hemorrhages are not infrequent. The blood dries into 
browniHh-rud or black cnists, and the lips look as if covered with soot. 
They are Hnmotimcs inflamed, thickened, and painful. 

t'lUv Bums ure often swollen and red, and not infrequently covered 
wi'th wonJes. Abscess of the gums develops at times, and may "form the 
BturtiaK-I"''''* '*"■ extensive ulcerations. 

KissuroB, sordoa, and hemorrhages are often noticeable on tbetongao. 
And its edges often contain the impressions of the teeth. These mar giro 
rise to extensivo ulcerations. The tongue isoften moved slowly and with 
difficulty from one side to another, and its movements are often trem- 
bling and uncertain. This has been attributed to various causes, such as 
fLmeral weakness, dryness, and stickiness of the tongue, but it must not 
forgotten that cloudy swelling, fatty and waxy degeneration have been 
observed in the muscular fibres of the organ. 

Catarrhal angina is an almost constant symptom in typhoid fever. 
White patches, consisting of swollen epithelium and fungi sometimes 
form upon the inflamed parts. Folticularangina may also develop. The 
oondition becomes more serious when necrotic or diphtheritic cnanges 
appear in the pharynx, and extend, as they sometimes do, to the larynx 
and oesophagos. I have repeatedly observed that the uvula was almost 
entirely destroyed by necrosis, and that violent hemorrhages were thus 
produced. These lesions hardly ever develop before the end of the third 
week. They give rise to pain in the pharynx, and difficulty in swallow- 
ing. Some writers claim that there is occasionally a specific typhoid 
angina which causes extensive superficial losses of substance. 

Parotitis develops in a few cases, sometimes even inflammatory chan- 
ges in the other salivary glands. These may develop from the extension 
of catarrh of the moutn to Steuo's duct and occlusion of the latter, or 
from typhoid ohungea which occur not infrei^uently in the parotid glands. 
If suppuration ensues, death may occur from exhatistion or pycemis, 
or the pus burrows, erodes blood-vessels, destroys the facial nerve, rup- 
tured into the external auditorv canal, etc. Thesecbangea ai-e latecom- 
plieatiuns, and do not appear l>e tore the end of the third week of the 





OITBCnOITS DI8SASEB nrTOLTmS THE DIGEaTITS APf ABATD& 

In rare cases, epriie develops on the buccal mucoiiB membrane and 

V even extend into the oesopnagus. 

ThirHt is alwajs increased, thongh apathetic patients do not ask for 
drink. The appetite is poor, but boulimia may be observed daring con- 
valeBcence. The taste in the mouth is generally said to be pasty, some- 
times nanseons. Vomiting is not infrequent. Oriesinger states that 
vomiting may be so obstinate during the prevalence of cholera that a 
diagnosis of the latter disease is apt to be made rather than of typhoid 
fever. Other patients Buffer from an annoying feeling of nausea. 

Catarrhal ioflammation. necrosia. and ulceration, and sprue bave been observed 
in the (esophagus. The iuflanimation sometimes extends to the p«ri.«esophageal 
tissue, aiiii then to the mediastinum. In one case, Lindner observed uncontrol- 
lable aesopbageal s^niB as soon as an attempt was made to drink, during the 
third week of the disease. The autopsy revealed a gelatinous exudation on the 
surface of the brain, and trifling catarrh oF the pharynx and (Esophagus. 

Htematemesis has been described in a few cases, and is secondary to 
roand gastric ulcer or to excessive congestion of the gastric mucous 
membrane. 

Serious intestinal complications are not infrequent. Thus, the diar- 
rh(Biv may become very severe (more than twenty evacuations daily), and 
is often attended witn tenesmus. The fteces are often passed in bed. 
Such conditions may result in fatal prostration. Erythema of the anal 
and sacral region may develop in such cases, and may be the startiue- 
point of severe inflammations of the skin, gangrene, and bed-sores. In 
some cases, on the other hand, constipation continues during the entire 
coarse of the disease. It may then happen that the thick and dryfieces 
irritate the intestinal mucous membrane and give rise to intestinal hem- 
orrhage or perforation. 

Intestinal hemorrhage must be regarded as a serious complication, 
despite the fact tliat immediately afterwards we may find that the tem- 
perature falls temporarily and even becomes subnormal, consciousness 
becomes clearer, and the patients feel relieved. If the hemorrhage is 
very profuse, it may prove fatal at once, or it may be checked at first, bat 
soon reours> and terminates fatally. Soon after the beginning of the 
hemorrhage, the pulse often becomes very dicrotic, and I have also re- 
peatedly observed slight temporary (sdcma of the malleoli. In one case 
of relapsing intestinal hemorrhage, Traube observed extensive (edema and 
death from cedoma of the glottis, Bapid diminution in the size of the 
spleen occurs not infrequently after the hemorrhage. • 

The most frequent cause of the hemorrhages is the erosion of vessels 
following exfoliation of the necrotic scurf of the intestinal ulcers. The 
bleeding vessel is not always easily found at the autopsy. We should 
specially examine those ulcers which are situated nearest to the first part 
of the bloody intestinal contents. Or the mesenteric artery is injected 
bymeansof ncanula, and the point of escape of the injection mass sought 
for. 111 rare coses, the hemorrhage is the result of excessive congestion 
of the mucous membrane (so-called capillary hemorrhage). From a clin- 
ical standpoint, we distinguish latent and manifest intestinal hemorrhage. 
In the former, death may occur before any blood escapes from the anua. 
The occurrence of latent intestinal hemorrhage may be assumed if great 
nallor of the face and body suddenly sets in, the face looks ghastly, the 
limbs are cold and covered with clammy sweat, the pulse becomes small 
and imperceptible; at the same time the abdomen is distended, and '~ 



)at ^m 
he ^H 

i 



SOS IHFBtmOUS DUSABES UTTOLTINQ THE DIOEBTITE APPABATD8. 




^ 

N 
I 



certain parts, corresponding to the site of htimoirhage, there is a feeling 
of increased reaistance on palpation, and a dull tympanitic percnseion 
note. Blood which is passed in the stools is nsuallj dark-red. sometimes 
blackish-brown, nsuallv coagulated, more rarely flnid. Several litree 
may be discharged, and death has been known to occur in an hour. In- 
testinal hemorrh^e is unusually freqnent in certain epidemics. It gener- 
ally occurs spontaneously, in rare cases it is produced by constipation or 
incautious movements. 

Still greater dangers arise if perforation of the intestines takes place, 
followed by perforation-peritonitis. This may take place if the ulcers 
haTe extended deeply, so that the thin portion of the intestine is rnp- 
turod from straining at stool, coughing, vomiting, from the ingestion of 
indigestible articles, etc. Ascarides in the intestines may favor perfor- 
ation, although their presence in the peritoneal cavity may be owing 
simply to the tendency of the worms to pass through narrow openings. 

Perforation does not occur, as a rule, before the third week, occa- 
sionally as late as the ninth or tenth week. The patients often complain 
of intolerable abdominal pain at the time of perforation. They grow 
pale very rapidly, often feel as cold as ice, and the pulse is small and 
rapid ; the abdomeu is distended and tender on pressure ; hepatic and 
splenic dulnesa disappear when gns enters the peritoneal cavity and 
separates the organs from the abdominal walls. Dulness soon seta id, 
corresponding to peritonitic exudation. Vomiting of grass-green, 
watery, or porridge-like masses is not infrBijuent. In two cases I ob- 
served stercoraceous vomiting without intestinal occlusion. The tem- 
perature generally falls below the normal, and the sensorium often 
becomes clearer. In other cases, the bodily temperature rises. Death 
follows not infrequently in a few hours, usually in twenty-four to 
ninety-six hours. Becovery is exceptional. 

In one case, l^hudnowsky observed amphoric breathing over the abdomen, 
eynchronoualj with the movements of respiration. It appeared to be caused by 
escape of gas tlirough the site of perforatioii into the pentoneal cavity, owing to 
rhythmical compregaion of the loops of intcBtiaea. Intestioai perfoistion is 
more frequent in men than in women, generallj affects the small intestine, more 
rarely the vermiform procras or colon. There may be several perforations at the 

Hepatic and splenic dulneee does not disappear if the organs are fixed in their 
position by old peritouitic adhesions. 

The perforation is sometimes preceded by adhesions of the loops of 
intestines and inflammatory changes in the peritoneum. Free perfora- 
tion does not take place under such circumstances, the changes run a 
slower course, and are apt to he overlooked. 

Typhoid fever may also be complicated by simple peritonitis, either 
circumscribed or diffuse. These changes start from inflammation of the 
serous membrane overlying the intestinal ulcerations. 

In some cases, necrotic or diphtheritic changes develop upon the mu- 
cous membrane of the large intestine. In one case, Scott observed intes- 
tinal invagination which terminated m recovery after exfoliation of a 
piece of the gut six inches in length. 

Excessive tympanites sometimes induces great danger, inasmuch as 
the compression of the heart and lungs may cause suffocation. 

Excessive increase in the size of the spleen leads to rapture of that 
organ in very rare cases. Splenic infarctions develop much mora 



mFBTnoTTfi DisBA&sa mvotmro the dioestitb appabatus. 

jiiently ; they are often secondary to tlirombi of the loft heart, moni 
irely to recent endocarditic depoaita. These may induce peritonitifl* 
aymptoms, or lead to supptiratioD and the formation of u splenic ubecesB, 
which ruptures into the peritoneal cavity or other organs. 

The liver is very often swollen and slightly painful. AhECees or 
acute yellow atrophy of the liver develops in rare caaes. As in many 
other febrile diseases, slight jaundice of the sclera is not at all uncommon. 
Hsematogenous icterus, associated with hemoglobinuria, appears to hare 
.been present in a case reported by Immermann. 



f^. 



The urinary changes depend entirely on the fever. 

Its amount ia diminished, reaction very acid, specific gravity increased ; _ 
hrick-reJ sediment of utid urate of soda is found not intrequenlly. The urea !»■■ 
iiicreHHvd, especially during the flnt week, but diniinlBhes during convalescence. 
If the tetnperature is reduced by treatment, tlie amount of urea generally in- 
crea»s. Tlie quantity of kreatinin and ammonia in increased. Salkowsky 
showed that the amount of potasaium sinks very considerably upon the occu> 
renoe of convalescence. ~ 

Lencin and tyrosln have been found in the urine, occasionally bile piginenti 

although jaundice is not present. Heemoglobinuria has been reported a u """ 

of timaa, Oerhardl observed peptonuria. 

Albuminuria is not uncommon during the conrse of typhoid fever. 
It is generally pyresial and does not appear until the end of the first 
week. Acute parenchymatous nephritis develops occasionally ; the 
amount of albumin is then larger, and the sediment contains casts and « 
red blood -globules. Death from unemia may take place during tbM 
conrse of typhoid fever. Wedge-shaped infarctions are found occasionalln 
in the kidneys. 1 

The symptoms of mild cystitis or pyelitis soon become noticeabla.^ 
Tn unconscious patients, the bladder is often distended and may react 
to the umbilicus. 

Diphtheritic changes develop very rarely on the mucous membrane of the 
urinary [MUBages. 

Menstruation often becomes irregular, and amenorrbcea is almost always 
noticed for two or three motilhs alter recovery froio typhoid fever. 

Orchitis and epididymitis have been observed in men. Phlegmonous inflam- ■ 
inatinn nnd tcangrenc of the genitals may occur in both sexes, aud may be ibftJ 
cause of death. I 

The functions of the nervous system are always more or leas impaired * 
in this disease. Headache begins very early. 1*he pain is either diffuse 
or looalized in certain nerve tracts on one side of the head. In addition, 
there is often hyporiesthesia. In some cases, there is very early hyper- 
nathesia or autesthesia of the entire skin or certain parts; partial or 
general convulsions and trismus have also been observed. Conscioua- 
nesB ia soon impaired. The patients feel incapable of thinking, com- 
plain of dulnees in the head, they arc sleepless and restless at night, 
Horanolent during the day. At first delirium is apt to set in just before 
falling ajiloep. Oradually the patients become more and more apathetic, 
mutter to themselves, or move the lips and tongue in a trembling man- 
If they are still able to answer questions, the words are epokeD in 






i 



210 IHFECITIOUB DISSAJ9E8 XNYOLYINa THE DiaEBHYX AFPARATUB. 

a jactitatingy tremulous manner. The patients move the hands rest- 
lessly, pick at the bed clothes, and often suffer from involuntary muscu- 
lar twitchings; movements of the tendons of the forearms (subsultus 
tendinum) are especially frequent. Chorea has been observed at the 
height of the disease. When recoverv begins, consciousness slowly clears 
and the patients awake as if from a lon^ sleep. The memory of events 
which occurred shortly before and during tne illness is lost, that of 
events long past is unaffected. In some cases, the patients are apathetic 
but quiet, must be fed artifically, and do not seek to satisfy their natural 
wants. In other cases, the patients are delirious, boisterous, violent, 
and make attempts at flight or suicide. These are the patients who, in 
an unguarded moment, rush to the window to jump to the street, escape 
in their night-gown, throw themselves into the river, etc. Such condi- 
tions not infrequently assume a decidedly maniacal character. They 
may develop even during the prodromal period. In some cases, delusions 
develop during the course of typhoid fever, and may persist for a long 
time during convalescence. 

In one of my cases, I observed, during the fourth week of the dis- 
ease, the sudden onset of apoplexy with right hemiplegia and aphasia, 
but these symptoms gradually diminished, and disappeared at the end of 
two weeks. Tne tendon reflexes may be increased,, unchanged, or dimin- 
ished. 

Among the organs of special sense, the ear is often affected, the 
majority of patients complaining of impairment of hearing and ringing 
in the ears. These symptoms depend in great part on tubal catarrh 
which has extended from the pharynx. In several cases, Hoffmann 
found purulent otitis media, with and without perforation of the drum 
membrane. The pus may extend along the Fallopian canal to the 
cranial cavity and there produce secondary purulent meningitis, or it 
gives rise to compression and paralysis of tne facial nerve. 

The following ocular complications have been described: ulcers of the cornea, 
mydriasis, paresis of accommodation, transitory and permanent amaurosis (optio 
atrophy). Qalezowsky mentions optic neuritis and perineuritis. 

In the beginning of the disease and during the stage of continued 
fever, the skin is usually dry. Sweats occur when the fever becomes 
remittent and miliaria are often observed at the same time. In some 
cases, sweats are observed from the beginning. Petechi® sometimes 
develop upon roseolsB or independently of them ; their significance is 
grave if there are other evidences of blood dissolution or a hemorrhagic 
diathesis (hemorrhages from the gums, nose, genitals, intestines, etc.). 
Indistinct, bluish-red patches which do not disappear on pressure 
(pelioma typhosum) are found occasionally on the trunk and limbs, but 
possess no special significance. Herpes labialis is extremely rare, and 
its presence is, to a certain extent, opposed to the diagnosis of typhoid 
fever. Diffuse erythema is occasionally observed, most frequently upon 
the chest and abdomen, more rarely on the limbs, and then particularly 
on the extensor surfaces. We must be on our guard against mistaking 
this for scarlatina. Decubitus is a very important complication. It is 
■een most frequently upon the sacrum, next upon the trochanters, mal- 
leoli, elbows, occiput, etc. It mav cause erosion of the sacrum and 
extend to the meninges, or spread from the trochanter into the hip-joint. 
In many cases, it is the result of bad nursing. Constant rest in one 



nTFBcnous diseases nrvoLvmo the diqebttvk apfabatub. 91 1 

iition and folds in the beddi.ig will produce it. But in some caaea it 
Torme deepite the best of care, and is then the reaalt of trophic Jistiirb- 
ani^cs of toe skin, partly from the accnmulation of abnormat prodiicti 
uf lisiUisimtlation in the blood, partlj" from the enfeebled circiilation in 
the cutaneous vessels. Erysipelas occasionally develops without apparent 
cnuBe; it generally begins near the nose, but not infrequently e-Tteuds 
to the neck and cheat. 

Muscular pains are a frequont complication and are attribnted by 
many to the anatomical lesions fonnd in the muscles. Hemorrhages, 
abaceas. and rupture of the muscles are occasionally produced. The 
rectus abdominis is affected most frequently, especially in certain epi- 
demics. 

The weight of the body diminishes to a not inconsiderable extent, 
less in children than in adults. During convalescence, the weight of the 
body is sometimes restored very rapidly, in other patients this takes 
place very slowly. 

The complications of typhoid fever often pass imperceptibly into the 
eeqnelffi. Furuncles and abscesses may develop in the skiu, are often 
of pj'ffimic origin, and sometimes cause a fatal termination by the loss 
of vitality entailed. Petechite or (edema of the lower limba, pains or 
cramps in the muscles sometimes appear after the Brst attempts at 
standing. The lymphatic glands may also be affected and give rise to 
slow processes of suppuration. 

In one cuae, Litten observed extensive pigmentation of the skio in the ahape of 
blackish patches which he attributed to uii affection of the ayiupathetic ; in an- 
other case, he observed an eruption libe erj-thenia. 

NecroBiB and spontaneous gangrene sometimes develop in peripheral 
portions of the body, such aa the noae, genitalia, toes, etc. Arterial 
thromhosia hna been found in a number of these cases. In a case of 
gangrene of the female genitals. Eppinger found the finer vessels filled 
with thrombi of micrococci. Noma may also occur. 

Inflammatory changes may also occur in the bones. Mensel reports 
eitenaive necrosis of the skull from thrombosis of a branch of the 
middle meniugeal artery. According to Paget, p oat-typhoid perioatitis 
occurs most frequently upon the tibia, next upon the femur, ulna, and 
parietal bone. In exceptional cases, the affection is unilateral. 

Suppuration of the joints followed by anklyosis haa been described 
in a number of cases. In a few cases, I have observed temporary pain- 
ful swelling of the joints at the height of the disease. 

Defluvium capillitii is an almost constant sequel of typhoid fever, 
and maybe so extensive as to produce almost complete balduess. This 
condition disappears after a while. 

Valvular lesions of the heart and Basedow's disease have been ob- 
served as aequelfB, Nothnagel mentions neurosis vasomotoria. 

Pulmonary abscess and gangrene may also be iucluded among the 
eequelte. Chronic pulmonary phthisis and miliary tuberculosis develop 
occasionally. 

Necrosis of the laryngeal cartilage may be left over. There may also 
be functional paralyaia of certain muscles of the vocal cords, the dilators 
of the glottis being attacked with relative frequency. 

The stomach and intestines sometimes remain sensitive for life, or 
evacuations from the bowels remain thin and frequent for Ufe. 

>paration of the perirectal cellular tissue (periproctitis) occurs in rare 



I uu e' 



212 iNFSonous disbasbs nnroLviNa the digestive, appabatus. 



e 



cases. Slight enlargement of the spleen persists permanently in som 
cases. 

Chronic Bright's disease is rare as a seqnel of typhoid fe^er. Polyuria 
often sets in daring convalescence. 

Nervous disturbances are often left over. Many patients exhibit^ for 
a long time, lack of desire for mental activity, indinerence, and feeble- 
ness of memory. Such individuals may never recover their previous 
mental vigor. Insanity develops more rarely and, according to Nasse, 
previous insanity sometimes disappears after typhoid fever. Meningitis, 
thrombosis of the sinuses or middle cerebral artery, hemorrhages into the 
meninges or cerebral parenchyma, and purely functional nervous disturb- 
ances are occasionally observed. Typhoid fever, like other infectious 
diseases, may also be followed by paralysis of individual nerves and mus- 
cles, which, in some cases at least, are the result of neuritis. Ataxia, 
chorea, tremor, paraplegia, and sensory disturbances have also been ob- 
served. 

In favorable cases, the duration of typhoid fever, including conva- 
lescence, may be given as eight weeks, though the disease often lasts 
much longer. 

Relapses occur occasionally, and their freouency appears to depend 
on the cnaracter of the epidemic. Among other causes mentioned are: 
too early ingestion of solid food, excitement, and getting out of bed too 
early, but the importance of these factors has been overestimated. 
There is no doubt that relapses may occur despite every precaution, and 
it is a question whether it depends upon a new infection, or whether 
previously present typhoid virus had been permitted to unfold its per- 
nicious properties. The latter view seems to us more plausible, since 
Oerhardt has shown that there is danger of a relapse if, after the 
disappearance of the fever, the enlargement of the spleen does not 
diminish; moreover, tyuhoid fever is one of those infectious diseases in 
which infection generally occurs only once. 

According to Ebstein, relapses are liable to occur in feeble constitutions. 
Immermann thinks that their frequency is increased by the antipyretic method 
of treatment. A relapse is less apt to occur the more severe the course of 
the disease has been. It generally runs a shorter and milder course than the 
first attack and is more rarely followed by sequels. The spleen again 
enlarges ; roseola is almost always present, sometimes more abundantly than dur- 
ing the first attack. The relapse may begin with a sudden chill and elevation of 
temperature, or the bodily temperature rises slowly, after it has been apyrexial 
for days. It generally terminates in recovery, in Leipzig, the frequency of 
relapses varied in different epidemics from 2.4 to tl.8 per cent. 

True relapses must be distinguished from the exacerbations which 
may occur before the disease has run its course, and from the so-called 
after-fever, i, e*, brief rises of temperature during the period of conva- 
lescence. 

IV. DiAGKOSis. — The diagnosis of typhoid fever is usually easy, but 
it is sometimes mistaken for typhus, measles, scarlatina, variola, pneu- 
monia, meningitis, nephritis, miliary tuberculosis, septic endocarditis, 
florid syphilis, and febrile gastro-enteritis. 

In the differential diagnosis l)etween typhus and typhoid fever, chief stress 
niU8t l)e laid on the abundance and character of the eruption, the more sudden 
onset and critical terminntioii in typhus, and the shorter duration of the latter 
disease. 



IKFEOTIOUB DISEASES ISVOLTISO THE DIOESTiyE APPAHATPS, 213 



Typboid fever may be misULken for variola ia the prodromaJ stage, but in the 
latter paint in the loins predominate. 

In doubtful cases, the dia^noais □( piieumonia is favored, apart from the 
pneumonic sputum, by the preaeuce of herpes labtalia. 

Iq meniugitis, there are rigidity of the nape, paralytic and irritative symptoms 
in the liinbs, and changes in the fundus of the eye. | 

In miliary tuberculosis, special attention should be paid to the fundus of tii* 
eye (choroideal tubercles). i 

Septic endocarditis requires careful examination of the heart for murmurs, 
and Bearch for embolic processes. J 

Florid syphilis isassociuted with changes on the genitals. I 

Acute gastro-enteritis runs a shorter course than typhoid fever, and ths 
febrile movement is generally less. I 

V. Pboonosis. — The prognosis ia always serious, but the mortality 
varies remarkably in different epidemics. The disease runs a mors , 
/adorable course in children than iu adults, because true ulceration of 
the intestines rarely occurs in the former, and complications are much 
leaa frequent. The danger is so much greater the higher and the more 
protracted the fever. 

Severe clinical symptoms do not always correepond to extensive 
intestinal changes and vice versa, and the severity of the general 
infection ia an essential feature in progiioais. | 

VI. Teeatment. — Prophylaxis is an important element in treat- 
ment. The stools and clothing of typhoid fever patients must be 
thoroughly disinfected. When water-closets are cleaned, care should be 
taken that their contents be not allowed to cuter adjacent streams, etc. 
Care must be taken to secure good drinking water and to clean the soil 
of excrementitious matters as much as poBsible by suitable canalization. 

When typhoid fever breaks out iu a house, we should endeavor to 
ascertain its cause in order to nrotect the other inhabitants.' The safest 
plan is romoval from the iuiected house. The treatment of typhoid 
fever itself is purely symptomatic. 

The patient's room should be large, airy, and kept constantly at a j 
temperature of 15° R. It should be aired several times a day. Too J 
. bii^t light should be avoided. J 

^ The bedding must be carefully smoothed, and this must be seen to I 
^reral times a day. The position of the body, especially if the patient I 
I apathetic, should be changed every hour, in order to avoid excessive ' 
^ pressure on certain parts of the body and the development of hypostasis 
in the lungs. The back may bo rubbed every morning and evening with 
Inkewarm water, to which alcohol, vinegar, or eau dc cologne has been 
added. If possible the patient should nave a separate bed for day and 
night use. lie may drink water, to each glass of which a teaspooniul of 
brandy or two or three tablespoonfulsofwhiteor red wine may be added. 

So long as fever is present, fluid diet alone should be given ; milk, 
soup, oatmeal or barley water, a soft-boiled egg, wine, beer, coffee ao lait, 
etc. When the fever subsides, we may gradually return to solid food, 
beginning with a few spoonfuls of farina or mashed potato, then adding 
beef-tea or a pigeon which has been thoroughly toiled and strained 
through a cloth, then scraped raw meat, etc. 

The bladder should be emptied at regular intervals, and an evacua- 
tion from the bowels secured at least every other day; the bed-pan must 
be used and straining avoided. If necessary, a mild laxative maybe 
"Ten (calomel, gr. vij. at one dose). 



314 INFBOnOUS DI8SA8B8 VXYOhYUXa THB DiaXSmTB APPABATTTS. 

Finally, the patient should receive two lukewarm baths ( 26° B.) daily, 
one at 9 a.m., toe other at 4 p.m. They must be kept uuder constant 
supervision, especially if they arc delirious. 

These measures are entirely sufficient in many cases, though we are 
often forc(}d to prescribe a placebo. 

In not a few cases, antipvreties are indicated on account of the severity 
of the fever. Such remedies are only indicated when the temperature 
remains constantly or for a lou^ time at an unusual height (above 40.5^ 
C); or if the patient is old, feeble, or a drunkard, or m pregnant wo- 
men, in whom the fever may produce abortion. Opinions differ as to 
whether the antipyretic should be administered in tne evening, during 
the night, or in the morning (9-11 a.m.). We prefer the latter method. 

In some casra, antipyretics produce iDcrease of the bodily temperature. Dif- 
ferent patients react ditferently to this or that plan of treatment. 

The antipyretics include cold baths, antipyrin, quinine, salicylic acid, 
benzoic acid, Ikairin, thaliin, digitalis, and veratrine. 

The cold-water treatment, when carried out strictly, consists of the 
hourly administration of a bath whenever the axillary temperature ex- 
ceeds 39.5" C. The temperature of the bath should be 16^ R.; its 
average duration ten minutes. Cold frictions, cold pack, and the ice- 
bag have also been recommended, but their antipyretic action is much 
less vigorous than that of cold baths. 

Biess recommends protracted (twelve to twenty-four hours) lukewarm 
baths (28-30^ C). 

The treatment with antipyrin is certain and more convenient than 
the use of cold baths, but it does not exert such an invigorating effect 
upon the patient. We give, by enema, a single dose of 3 i.-iss. dissolved 
in ? ii. of lukewarm water. The remedy may be continued, despite the 
production of antipyrin eruption. During tL action of the drug, wine 
should be given in large quantities to prevent the occurrence of collapse. 

Treatment with quinine is less certain. In adults, a complete anti- 
pyretic effect will not be attained with less than gr. xxx. of hydrochlorate 
of quinia. We give gr. vij. in a wafer every half -hour until gr. xxx. have 
been taken. When mixed with starch and lukewarm water, it may be 
given by eniema, but sometimes causes disagreeable tenesmus. If the 
stomach and rectum are very irritable, it may be given subcutaneously 
(ft QuinisB hydrochlor., glycerin., aq. destil., aa. 3i. M. D. S. One 
syringeful, warmed). 

Salicylic acid or salic^ylate of soda, gr. vij., may be given in wafer or 
mixed with succus liquirit. in a tablespoonful of claret, every fifteen 
minutes, until six doses have been taken. If necessary, twice this amount 
may be given. Benzoate of soda, which is much less effective, may be 
given in the same way. 

Kairin lowers the temperature, but produces very disagreeable inci- 
dental effects. The patients often become cyanotic, ice-cold, are covered 
with cold, clammy sweat, the pulse becomes small and hardly percep- 
tible, and there may be difficulty in respiration; in addition, violent 
chills occur when the temperature again rises; in addition, it is an in- 
convenient remedy, inasmuch as it necessitates hourly measurements of 
temperature. It is given in doses of gr. vij.-Xv. everv hour until the 
temperature has become apyrexial, and is again administered when the 
temperature reaches 38.0° C. 






niFECTIOCB DISEASES mVOLTUlO THB moBSTITE A.PPASATUS, 31S 

Thallln is also a certain antipyretic, but produces similar, though 
lesa severe, disagreeable iucideutal etfecta. In one of my caaes, its admin- 
istration was followed by marlted albuminuria. Q-r. iv. are given every 
hour until the temperature becomes normal. 

Digitalis and vpratrine have very little antipyretic action. 

Profound unconsciousness and delirium disappear not infretjiiently 
under antipyretic treatment; in addition, an ice-bag may be applied to 
the head, and large amounts of stimulauta given if the patient is very 
feeble. 

If the mouth is very drv. it should be wiped every two hours with » 
iece of wet linen; dry, fissured lips are anointed with cold cream or 

In conditions of cardiac weakness, large doses of alcohol must be 
given from the start. If necessary, coffee, tea, champagne, camphor 
(snhcutaneoualy), etc., must be resorted to. Under such circumstances) 
the patient must not be allowed to sit up in bed. 

Expectorants are indicated in extensive bronchitis; in pulmonary 
hypostasis, the position of the patient should be frequently changed. 

If there is frequent and exhausting diarrhcea, we may order Dover's 
powder j[gr. iij. every two hours) or B Bismuth, snbnitrat., gr. vij.; 
pulv. opii, gr. J, every two bonrs. 

In severe tympanites, the abdomen should be rubbed every three ' 
hours with turpentine, then covered with lukewarm compresses, and an 
enema of lukewarm water administered. In ouropinion, puncture of 
the intestines with a fine trocar is dangerous, because the intestinal 
contents may escape through the opening and set up perforation- peri to> 
Qttis. 

In intestinal hemorrhage, an ice-bag is applied to the ileo-ceecal region 
or to the part in which tne origin of the hemorrhage is suspected, an 
injection of ergotin made in this region, and bismuth and opium given 
internally. Liquor ferri sesquichlorat. (gtt. v.-x. every two hours) has 
been strongly recommended by many wntera. 

If the formation of bed-sores threatens, the patient should be placed 
on an air cushion or water-bed, and the skin covered with smoothly 
applied adhesive plaster. When the bed-sores are very extensive) the 
ttieut should be placed iu a permanent water-bath. 



, Dysentery. 



If 

^^B I. Etioloot. — Dysentery is an inflammatory affection of the mnoona 
^^Bnembraue of the large intestine, which is generally epidemic and depends 
^^^%& a specific infection. The inflammation may be catarrhal, purulent, or, 
^"' in an anatomical sense, diphtheritic. 

It is endemic in many tropical countries, for example. East India. 
Ceylon, Java, etc., and also in the Balkan Peninsula aud in Spain and 
Portugal. 

In the temperate zones, epidemics may develop from imported cases, 
crowded institutions being especially apt to suffer. 

Like typhoid and typhus fever, dysent^ery is one of the most danger- 
ous diseases during wars, and also puts an end to many an exploring 
«xj>edition in the tropics. 

The outbreak of epidemics is favored by certain circumatances, fop 

example, climate. The spread of the disease is favored by hot seasons, 

1 wiat«r epidemics occur much less frequently than those in the soio- 



K 



216 INF£0nOU8 DI8SA8E8 INYOLYINO THB DIGBailVB APPASAXUfl. 

mer. Hot da^stfoUowed by very cold nights are regarded as especially 
dangerous. This is also true of protracted rains aYid absence of winds. 
The spread of the disease also seems to be favored by marahy lowlands. 
Dysentery in armies sometimes disappears suddenly upon breaking camp. 
Or one army suffers extremely from the disease, while another, encamped 
in close proximity to the former, escapes entirely. Malaria and dysen- 
tery are often active at the same time, especially in the tropics. In not 
a few cases, the patient is attacked at tne same time by intermittent 
fever and dysentery, although it is erroneous to assume that the germs 
of the one disease may be converted into those of the other. In the Weimar 
epidemic of 1868, Pfeifer noticed that the first cases occurred in those 
houses in which the first cases of typhoid fever and cholera had also 
been obseryed. It has also been found that in successive epidemics the 
disease always started in certain houses. Overcrowding, bad air, dirty 
streets and houses favor the development of the disease. This is also 
true of excesses of all kinds, errors of diet and colds. Psychical condi- 
tions also appear to be significant. At least, Seitz states that, during 
the Franco-Prussian war, the disease appeared particularly among the 
desjpondent French prisoners. 

The disease never develops autochthonously. It is always the result 
of the introduction of a specific dysentery germ> although this cannot 
be demonstrated in all cases. Certain cases may run such a mild course 
that their real character is unrecognized, and such cases are especially 
dangerous as regards the spread of the disease. 

The virus is contained in the stools. It probably proliferates there, 
so that the infective power of the stool increases when the fsec^ stagnate. 
Bed pans, syringes, and water closets which have been used by patients 
suffering from dysentery and have not been thoroughly disinfected, may 
serve to convey the contagion. This is also true of articles of clothing, 
sources of water supply wnich communicate with water closets, and food. 
It is said that the virus sometimes retains its power of infection for ten 
years. 

The nurses and other patients are very often attacked in hospitals, if 
the dysentery patients are placed in general wards. These patienta 
should, therefore, always be isolated. 

In several of my cases, the patients were attacked a number of times. 

Nothing is known concerning the nature of the virus of dysentery, 
and even enthusiastic adherents of the germ theory are extremely re- 
served with regard to the mycotic character of the disease. The unknown 
virus is probably absorbed through the anus, mouth, or naso-pharyngeal 
cavity. 

li. Symptoms. — The duration of the period of incubation varies 
from three to eight days. 

Prodromata are absent in man^r cases, but some patients complain of 
anorexia, coated tongue, pressure in the epigastric region, colicky pains 
in the abdomen, and irregular evacuations. These symptoms may last 
more than a week. 

I n a few cases, the disease begins suddenly with a chill or repeated 
chilly sensations. Ini^estinal disturbances are often present irom the be- 
ginning. The specific symptoms consist of frequent' evacuations of 
peculiar composition, tenesmus, tormina, and borborygmi, tenderness on 
pressure, and pain in the left iliac region. 

Twenty to thirty evacuations from the bowels are not infrequently 
passed daily, sometimes as many as sixty, one hundred, or even more» 



k 



JVFKCTIOCS DISEASES DiTOLVINO THE DIGESTIVE APPAIUTDB. 

The daily amount of the stoole geoerally varies from 3 xxv.-ixxv. Some- 
timas only three or four drachms are passed at a time. 

The evacaations consist of fceces, mucus, pus. aiid blood in varying 
proportions. At first the intestinal contents are passed in a fluid condi- 
tion. MasBes of mucus then apt>ear, partly adherent to faiees, partly 
separate. They often contain small, vitreous clumps, looking like 
swollen sago. These are not always composed of mucus. Virchoir 
found that swollen starch granules may assume a similar appearance. 
After the faecal contents of the bowels have been discharged, purely 
mucous masses may be evacuated. 

It ia BuppOBed that the 
mucous membrane on oci 
shape, and ia excreted. 

In advanced cases, more and more pus is evacuated, and is readily 
recognized from its color and opacity. It appears not infrequently in 
the shape of small Docculi or larger shreds. Thestool sometimes contains 
hardly anything but pure pus, especially if abscesses have formod in the 
Bubmucoua tissue of the intestines. 

In many cases, the stools present a bloody appearance, and even 
almost purely mucous stools generally contain dots and streaks of blood. 
The blood is often present in anch amounts, and ia so intimately mingled 
with the other constituents, that the stool has a uniform bloody color, 
in which the mucous and purulent flucculi are easily recognized. The 
intimate mixture of mucus and blood often gives to the stool the ap- 
pearance of the rustv sputum of tibrinous pneumonia, 

The stool fiometi'mos consists entirely of blood. This occurs when 
the congestion of the mucous membrane is unusually active at the be- 
ginning of the disease, or in the later stages if ulcers have formed and 
eroded the ressels. 

The stool sometimes has a cadaverous odor and a blackish color, 
and contains exfoliated shreds of mucous membrane. Such cases are 
known OS putrid or gangrenous dysentery, and generally run a fatal 
oonrBe. 

The evacuation sometimes loses the fscal odor and occasionally 
■mells somewhat like semen. Its reaction is generally alkaline or 
neutral, rarely acid. It contains a largo amount of albumin, and this 
explains the fact that the patients rapidly grow pale and often assume a 
cachectic appearance. 

Under the microscope the passagea art Found tocontain round cells, red Ulooil- 
globule«, more or less altered epithelium, drops of fat, cryslala of triplt^ phos- 
phates, bile pigment, d^bria of food, and innumerable schizomjroetea of vnrioua 
■hapea. 

The majority of {patients complain, before the eracnations, of bor- 
borygmuB, colicky pains (tormina), and very soon of violent, almost nn- 
oontrollable tenesmus. The pain becomes especially severe when the 
stool passes the anal opening, and may be so intense that syncope occurs, 
or the patients grow pale and cold, the skin becomes clammy, and the 

a^,,!.... ..»«,....^n»4:vi^ 'PL.K „„..« :, „<!„_ _„* *.~j — J : i.;^^. 



I^^ingu 



pulse imperceptible. The anus ia often retracted, and inspection 
reveals spasmodic twitchings of the sphincter. In men, the cremaster ia 
often strongly contracted, and the left testicle drawn upwards against the 
inguinal ring. After dysentery has laeted for some, the anas and sur* 



1 



218 INFBOnOUS OI8BA9E8 INyOL>1NG THB DIOB9TIVE AFPABATUS. 

rounding parts become red, and erythema is apt to develop. Prolapsus 
ani may be produced by the violent tenesmus. After a time, a paralytic 
condition of the sphincter sets in, the anus remains open, and the con- 
tents of the rectum trickle out in a constant stream. 

In the beginning, the abdomen is occasionally somewhat distended, 
in advanced stages it is sunken. The left iliac fossa is generally tender 
on pressure, and often somewhat resistant. If the dysenteric process is 
very extensive, tenderness may be felt along the entire colon and even 
over a part of the small intestine. Gurgling is often felt on gentle 
pressure over the affected parts, while a dull or dull tympanitic sound 
IS heard on percussion. 

The urine is generally scanty and saturated, and often contains 
albumin. Tenesmus of tne bladder is often noticeable. Slight ten- 
derness on pressure over the stomach, vomiting, and singultus are occa- 
sionaJly observed. The tongue presents a gray or yelTowish coating. 
Thirst is generally increased, the appetite lost. 

Uffelman investigated the digestive secretions in a dysentery patient who 
also suffered from a biliarv fistula. He arrived at the following results : the 
saliva diminishes considerably in amount in severe cases and its reaction often 
becomes acid. At the same time it loses its sugar-producing property more or 
less completely, and does not contain rhodankalium. It is poor in salivaij cor- 
puscles, but contains numerous epithelium cells, granular detritus, and fungL 
The gastric juice becomes more acid, and, in mild casen, will convert albumin 
into peptones. In severe cases, it becomes alkaline and loses its peptonizing 
property. The biliary secretion ceases in severe cases, and the biie produred 
m toe TOginning of convalescence does not acquire the normal color for four or 
five days. 

The bodily temperature is sometimes unchanged ; in other cases 
irregular; usually remittent febrile movement sets in. Putrid dysentery 
is not infrequently associated with typhoid symptoms : fever, clouded 
sensorium, delirium, dry fuliginous tongue and lips, acceleration of pulse 
out of proportion to the bodily temperature. The patients are rapidly 
prostrated and die in collapse (adynamic dysentery). 

The dysenteric symptoms often last one to four weeks before gradual 
improvement takes place. The tenesmus and tormina gradually grow 
less, the stools assume more and more of a faecal character. But the 
mere evacuation of fsecal masses, if unattended with other signs of im- 
provement, should not induce us to prophesy recovery, since scybala are 
sometimes retained (probably on account of circumscribed spasm of the 
intestinal muscular coat]) and are suddenly expelled after the lumen of 
the gut has become pervious. 

Dysentery may aisorun a chronic course. The patients have purulent 
evacuations for months, and finally die of marasmus. Chronic ulcers 
and submucous abscesses or fistulsB of the intestines are generally found 
in such cases. Death from collapse is not rare, even in acute and sub- 
acute cases. 

Complications and sequelae are not uncommon in dysentry. Roseola 
has been noticed, but possesses no significance. Valentiner observed 
extensive dilatation of tne cutaneous vessels and atrophy of the skin 
after dysentery. The intestinal changes sometimes extend to the peri- 
toneum, and produce circumscribed or diffuse peritonitis. Even perfor- 
ation-peritonitis may occur. The perirectal cellular tissue sometimes 
undergoes inflammation and suppuration, and after perforation of the 
pus gives rise to complete or incomplete rectal fistulse. Cicatrices of the 



intestinal mucous membraoe sometimes give rise to atenosis and Bvmp- 
tomB of ileus. A teodency to diarrhcea persists for life in some ind^ivid- 
nals. Dysentery may bo associa.ted with hepatic abscess, especially in 
tropical countries. The hepatio changes sometimea appear so early that 
we are inclined to believe that the dysentery and abscess of the Liver are 
the result of the same agent. In other oases, the abscess is due to em- 
bolic processes in the mesenteric veins and portal vein. Gluck states 
that hepatic abscess is especially apt to develop after dysentery, if the 
liver is cirrhotic or waxy, aa the result of previous malaria, Pylephlebitis 
has also been observed. Chronic Brigbt's disease is a raro complication, 
but cacliectic mdema is occasionally observed. Burkart and Niemeyer 
found infarctions in the lungs and spleen, but only after the disease 
had lasted ten to fourteen days. Necrosis and diphtheria of the pharynx 
and larynx are rare. A fatal pyEemlc or septicfflmic condition occa- 
eionally develops, after having given rise to decubitus, pleurisy, pericar- 
ditis, parotitis, noma, or pseudo-erysipelas. Chronic dysentery may lead 
to waxy degeneration of the large abdominal glands. Multiple swellings 
of the joints, attended with pain and sweating, have been observed, 
sometimes followed by secondary disease of the heart. This is rarely 
noticed before the second week of the disease ; it may result in anky- 
losis. From analogy with similar conditions in other infectious diseases, 
this must bo regarded as a metastasis of the dysentery virus. Among 
the sequolftJ must be mentioned paralyses, generally of a spinal charac- 
ter, and which were shown by Leyden to be the result of an ascending 
nenritis starting from the intestines. During violent diarrh(sa, cramps 
sometimes appear in the calves or other group of muscles. The voice 
may become hoarse and high-pitched, as in cholera. Even the face may 
be sunken, the eyes sun-oundod by rings, and the skin clammv, 
while the internal temperature of the body is elevated. Signs of bloo^- 
disBolution (cutaneous hemorrhages, swollen gums) sometimes make their 
appearance. 

III. Anatomical Chanoes, — The intestinal lesions of dysentery are 
generally confined to the large intestine, in rare cases they extend to the 
email intestines (usually the ileum). The lesions are most pronounced 
in the rectum, and gradually diminish upwards. The points of fleilon 
of the largo intestine are usually attacked with special intensity. This 
is attributed by Vlrchow to the fact that masses of ffeces are apt to re- 
main (or a longer time in these localities, and thus exercise greater me- 
chanical irritation upon the mucous membrane. 

Upon opening the abdomen, the large intestine is generally found 
contracted and narrowed. Its serous layer is not infrequenrly very hy- 
persmic, and in places small subserous hemorrhages are visible. Its sur- 
face often looks opaque, and may be covered by a thin, veil-Iiko mem- 
brane (beginning |)eritonitis). 

The changes in the mucous membraoe ore sometimes catarrhal, somet J 
times diphtheritic. I 

In the catarrhal stage of dysentery, the mncous membrane of the 
large intestine is very congested, partly in a uniform manner, partly in 
the shape of individual dilated vessels. The congestion is most marked 
on all projecting )>arts of the mucous membrane, especially at the top of 
the folds and villi, and the three longitudinal columns of the colon. 
.Subepithelial hemorrhages are found in many places, and may be merely 
punctiiM or cover a large surface. The muoons membrane is also swollen 
.mi ite secretion increased ; the surface is covered with an aQaaoftlly 



I 
I 



□TFSCTnOIIS DISEASES IKVOLTIKO THE DIQESTIVE AFPA.RA.TV8. 

large amount of glassy macua, often dotted or streaked with blood. The 
enbmuGouH tissue is aUo very succulent, congested, and swollen. 

In the further course of the disease, the swelling of the mucons and 
sabmucous layers increases, while the hypersmia diminishes. The secre- 
tion of the mucous membrane becomes opaque, and aeaumes a more 
purulent character. In some casee, the solitary lymph follicles take part 
m the swelling. They are enlarged, surroanded by a hyper^mic zone of 
veascla. and often undergo disinl^gration, at first in the centre, later at 
the periphery. The caTities of the follioies often contain mucoid, sago- 
like masses, such as are observed in the stools during life. 

The microscope at Brat Bhow? marked dilatation and congestion of the reaseis 
o( the miii^ous niemtiraae and aubuiuoous tissue, with uedematous infiltrstioi). 
The epithelium of the muoous membrane ia intact, and the interstices between 
the individual Lieberkuehaglanda appear broader than normal. At a later period. 
there is active emigration of white blood-globules, which accumulate in ereat 
numbers on the walls of the veasels. Thev are so den.'iely aggregated in places 
between the glands of the mucous membrane, that the lower ends appear to be 
constricted. The more the oedema and emigration of white blood-globules increase 
the more the bloud-feasela are narrowed and the bypenemia diminishes. Whit« 
blood globules are also found on the walls of the vessels in the muscular coat 

At first the enlargement of the follicles depends chieilj on congest ion. and 
cedema, later upon hyperplasia of the cellular el^neutsi if the latter becomes ex- 
cessive, necroais takes place. 

If the dysenteric process advances, superficial epithelial necrosis and 
deposits are observed. The surface is covered with fine greenish -yellow 
or greenish patches, which cannot be readily removed. If forcibly re- 
moved, losses of substance are left over. In the most advanced cases. 
extensive necrosis occurs. The mncosa and especially the submucoaa are 
very much thickened. The surface of the mucous membrane forma a 
nodular, greenish or blackish mass, the cUanges being especially marked 
along the longitudinal columns, and the projecting transverse folds. 
The microscope shows infiltration of the mucosa and submucosa with 
masses of fibrinous exudation. Destruction of the mucous membrane 
may give rise to dangerous hemorrhages, or gangrenous shreds hang into 
the lumen of the intestines, and deep-spreading suppuration of the sub- 
mucosa and fistiilffi develop. The extension of the inflammation may 
lead to peritonitis and [)erf oration-peritonitis. Suppuration may also 
take place in the perirectal cellular tissue and terminate in rectal fistulte. 

After the acute inflammation has subsided, transverse ulcers of the 
mucous membrane are sometimes left over. These heal with difficulty. 
and give rise to chronic dysentery. Firm, callous cicatrices are a not 
infrequent sequel; they narrow the canal, and finally cause death from 
stenosis of the intestines. 

The lymphatic glands of the mesocolon are generally swollen and o 
gested; tney sometimes undergo necroais or caseation. 

The other organs present no characteristic changes. 

IV. Diagnosis, — A diagnosis is easily made, especially during Wl 
epidemic, from the character of the stools, the tenesmus, tormina,l>or- 
borygmi, the tenderness on pres^u re and dulness in the left ileo-c»cal re- 
gion. Thediseaaemayj'ossiblybemistakenfor: a. Rectal syphilis; syphi- 
litic changesare found lu other partaof the body, b. Rectal polypi; they 
are generally found in children and are recognized by digital examina- 
tion, c. Hemorrhoids; the stools generally contain masses of pure blood; 
in addition, the dilated hemorrhoidal veins can generally be seen or faU> 




nrFEOTIOFS DiaSASEB IBTOI.VtWG THE maEffTtTE APPABATD8. 

d. Paramcecium, distomum,-or anchylDstomiim; the ova at the parasites 
or the vorma themselves are found in the stools. 

V, Phookosis. — The average mortalitj is seven to ten per cent, but in 
«oine opidemica it may reach sixty or seventy per cent. Cases of putrid 
and scorbutic dysentery have an unfavorable prognosia. Many patients 
die, after recovery from the dysentery, from marasmus or other oompli- 
cationa. 

VI. Treatment. — The prophylaitia issimilarto thatof typhoid fever. 
The patients must bo kept in bed and, apart from ivine (especially 

astringent red wine), may take only soft-boiled eggs, meat broths, milk, 
and glutinons sonps. A large cataplasm (not too heavy) is placed over 
tbe abdomen. So long as solid particles of fieces arc fon nd in the stools, 
mild laxatives (castor oil, calomel, etc.) should be given, and in mild 
coses these will pruduce recovery. In severe cases, they should be fol- 
lowed by an astringent. We prefer the following: B Pulv. ipecac, 
comp., gr. v.; hydrarg. chlorid. mite, gr. ss. ; saccb. alb., gr. v. One 
powder every three hours). 

In addition, one to two litres ice- water, to which aalicylate of soda has 
been added {two to four per cent), should be injected two or three times 
a (lay by means of Hegar's funnel. Carbolic acid should not be employed, 
inasmnch as poisoning with this remedy has been reported. Severe 
tvnesmtis may bo treated with suppositories of opium or morphine; per- 
haps better still with cocaine. 

Cures in Carlsbad, Marienbad, Kisslngeo, or Tarasp may be very 
useful in chronic dysentery. 

Otherwise symptomatic treatment. 

Tlie following remediee have also been recommended; a. The various astrin- 
gents (internally or by enema) : (i. iiarcoticB: opium, Htrjchnine. chloral hydral*, 
ergotm: <:. laxativeB; d. emeticai c. antiseptics (carbolic and salicjlic acids, etc.); 
/. bKlaams: oil of turpentine ; g. acids ; n. potassium nitrate, potassium chlo- 

1 '). Asiatic Cholera. 

P I. Etiology. — In 1830, Asiatic cholera first appeared in Europe. 
Originally endemic on the banks of the Ganges and Brahmaputra, it has 
several times left its habitat, and spread over almost the whole earth. 

It is extremely probable, from Kocb's celebrated investigations, that 
the cholera virus consists of the so-called comma bacilli. These are 
found ooDstanLly in the intestinal contents and walls. 

They never appear in other organs or in the blood, urine, pei'spi ration, 
laolirymal fluid, or inspired air. In one case, Nicati and Pictacb found 
tliem in the ductus choledoohus, in five cases in the gall-bladder, Ilonoe 
oholera seems to be the result of a local infection of the intestines. 

The comma bacilli appear to be the virus of cholera, from the fact 
that they are constantly found in the disease, and also because inocula- 
tion in animals baa produced cholora-Uke conditions. It almost seems 
OS if the bacilli, in their growth, produce toxic substances. At least 
Micati and Pietsch state that oholera stools and bacilli cultures emit, 
after a time, an ethereal odor, and that chemical substances are produced 
which cause symptoms of poisoning in dogs. 

Comma bacilli are one-half to ttro-thirda aa long as tubercle bacilli, but thiokar 
•nd Bli^htl; curved. Asa rule, the turve is not greater Chan that ot acomnia, more 
^— 1y It is almost semi-circular. The baolUiare Bometimee in justapo«itioD, and 



K 



3 



392 nnFBonoua DisEiBES intoltimo the dumbhtb appabatdb. 

DMT then foiTD S-abaped fignm. Tbt^ often groir into lone thraada, wfaieb an 
delicfttely convoluted like epirilli, so that Eoch believe* that they are not tnie 
iMcilli. but constitute a transitional stage between epirilli and bacilli. 

In dry preparations, thej stain easily in a watery Bolntion of fnchsin or metbyl- 
blue. 

In tbe moist condition, they proliferate very rapidly (vide Fig. 89), but soon 
die on drying. Cultures are readily made in meat infusion, peptone-Kelatin.uron 
M&r-aKar, aJso in meat broth and milk. But the nutrient fluid shoola not be add, 
smce the bacilli are very Gensitive to the majority of aoids. Their proliferatioa 
ceases al meet entirely below 16° C, but they remain alive eren at 10 C. Accotd- 
Ing to Raber, they die at 80° C. They also perish in media which contain nunm- 
ous 1»ct«ria of putrefaction. Klebe suspecte that the level of the barometer ex- 
erdaes an influence on their proliferation. Spores have not been discovered. 

Curved bacilli are also found in diarrhcsal rIooIb, cholera morbos, tartar of tbe 
teeth, and cheese. Certain biological properties must also be present to permit 
the recognition of Koch's comma bacilli. Especially oharacterislio is their be- 
havior In culture* in meat infusion and peptone-gelatin. At the start, the culture 

Fio. s», Fio. M. 




WM'' 




EnlMgad MO (liuM. AfWr 



Puanel-Bluped rMnetloti kt Uie polDt of Id 
ocitlaUan ol the BeUUn Id tbet«rttuba. Afur 

Kaeb. 



appears insularly circumscribed, and has a granular appearance. Later the 
gelatin becomes fluid in the immediate viduity of the colony, the latter sinks 
more and more in the gelatin, and finally foruu a funnel-shaped depreaaiCHi, in 
the middle of which the colony is reoognized as a amall white spot (vide Fig. 40). 

Cases have been reported, eflpecially during the first epidemica, 
in which animals are said to have been attaoked by cholera, bat 
these statements cannot be regarded as reliable. The attempt has also 
been made to produce cholera in animals by feeding them with the vomit, 
stool, blood, urine of cholera patients, or injecting them into the blood- 
vessels or BUbcutaneously. Someeiperimenters obtained nesative, others 
positive results; but it must be remembered that most of the anbstancea 
employed were putrid, and that all tbe symptoms, accordingly], were 
proDably the result of putrid infection. Koch found that the acid gas- 
trJcjuioe ol aujnmls will destroy the comma bacillL 



^^^r mwanan dibe&sks nfvoLviiro tub: DioKerrvE AppABAirs. »« 

^^^^Even human beiogs have mode the disgusting experiments of swal-rl 

^^TRiring the Tomit unl gtool of cholera, and some suffered for their fool- 1 

hardioeBS. That, some escaped evil effects is not astonishiDg', if we hear 1 

in mind that the susceptibility to Lnfectiou varies greatly la different in- | 

dividuals. 

The viroB of cholera is andoubtedly contained in the stools. In two 
cases Koch also found the bacilli in the vomited matters. The fiecea 
are infectious in the fresh condition, and their virulent properties are 
intensified when they stagnate in a moigt place, [f they enter a water- 
closet, the germs are sometimes destroyed by excessive proliferation of J 
putrefaction germs, but sometimes they meet with conditions favorable ] 
to their further development. ^ 

The rink of infection is run by every one who cornea in contact with 
the stools (occasionally with the vomit^. The germs first adhere to the 
body of the patient. Hence, cholera is a disease of human intercourse, 
and foilowa the paths of commerce and of armies. The more active the 
commercial intercourse between two countries the greater the danger 
that the disease will be conveyed from one to the other. During wars it 
has been found that the disease spreads along the track of the army, if 
this is suffering from cholera. In Asia, the disease has often been spread 
by pilgrims to various shrines. 

Many cases are contagious, although the symptoms consist merely of 1 
alight diarrhceu. Such patients may spread the disease, and in this way I 
an epidemic may apparently develop spontaneously. | 

Simple contact with a patient is not contagious, but the disease oftea I 
attacks those engaged in cleaning the clothing or bodies of cholera I 
patients. A house which contains the undisinfected stool of a cholera 1 
patient may become a source of infection for all its inhabitants. Hence, 1 
the rapid transfer of the patient to a hospital is not so important as the 1 
immediate removal of the healthy inmates of the house. 1 

If tiie water-closets leak, their contents may contaminate the subsoil 
and drinking water. In East India, Koch found comma bacilli in a tank 
of water in which the clothing of a cholera patient had been washed. 
Kicati and Pietsch kept th» comma bacilli alive for eighty-one days in 
the water of Marseilles harbor. 

The germs of cholera may also be conveyed in the air, though this 
mode of infection is rare. This can result only from the mixture of in- I 
factious fiuida with the air, inasmuch as the bacilli rapidly perish when I 
in a dried condition. I 

Inanimate objects which are soiled with cholera stools or vomit are 1 
also capable of infection. Koch found unusually active proliferation of I 
the bacilli upon wet articles of clothing. I 

Vegetables and fruit which are not thoroughly cleaned may also con- I 
Tey the germs. Koch stated that insects may act as carriers of comma I 
bacilli, and Qrossi found them upon the wings and belly of flies which I 
aliffht upon cholera dejections. 

In all probability, ttio infection is at first purely local from the gastro- 
intestinal tract. The general symptoms of cholera are probably the re- 
mit in part of the enormous losses of water in the stools, and perhaps of 
the production of toxic substances by the bacilli. 

It 18 assumed that the virus is generally inlialed into the naso-pharyn- 
geal space, and then is swallowed with the food. It may also enter the I 
stomach direotly in infected drinking water or food. I 

^^^-fiome individuals possess permauent or temporary immunity ftam.t.^'^ I 

m _^ i 



224 iNFBGrnons diseases intolyino tub dioestiyb afpajultxjb. 

disease. Sex exerts yery little influence, although women are attacked 
somewhat more frequently. The majority of cases occur between the 
ages of 20 and 40 years, out the disease may also attack the new-bom, 
children, and old people. In children, the disease is less frequent dur- 
the first fiye years than during the next five years of life. It is more 
frequent among the lower classes, chiefly on account of their poorer hy- 
gienic surroundings. It is said that negroes are especiaUy apt to oe 
attacked. 

A predisposition may be created by excesses of all kinds, the adminis- 
tration of laxatiyes, or the ingestion of food which is apt to produce 
slight diarrhoea. A specially injurious influence is ascribed to mental 
excitement, particularly to the fear of contracting the disease. Gases 
haye been reported in which the patients were attacked three times, and 
Stoufftet reports a case in whicn the individual experienced four at- 
tacks. 

Cholera almost always occurs as an epidemic, or indeed as a pandemic 
which ravages the entire globe. The connection between the epidemics 
in different countries cannot always be readily traced, and they have been 
observed under very divergent external conditions. 

Nevertheless, certain circumstances are known to act as auxiliary 
causes to the spread of the disease. In some towns the epidemic often 
starts from certain streets and houses, or rages with special violence in 
these localities. As a rule, those parts of a town suffer most which are 
situated on low, damp soil, and, moreover, those who live in cellars are 
attacked more frequently than others. 

New, damp houses and overcrowded apartments offer favorable soil for 
the spread of the disease. 

Tne majority of epidemics occur from June to August, the smallest 
number from January to March. High temperature, especially if pro- 
tracted and followed by rains, favors the spread of the disease; cold 
weather and protracted rains oppose its extension. As a general thing, 
the more porous the soil, the more suitable it seems for the reception and 
proliferation of cholera germs (Pettenkofer). 

In our opinion, this writer attaches too much importance to the level 
of the subsoil water. He claims that a high level is associated with in- 
crease, a low level with diminution of cholera. But good observers have 
shown that this does not always hold good. 

Oholera sometimes attacks individuals who are suffering from other 
infectious diseases (measles, variola, pneumonia, intermittent fever, ery- 
sipelas, articular rheumatism). 

The epidemics generally begin with a few imported cases. Many 
days, or even several weeks, often elapse between the introduction of the 
imported cases and the outbreak of the disease in others. The isolated 
cases rapidly multiply, and the epidemic reaches its height in four to six 
weeks. 

At the beginning of the epidemic, the cases are generally more dan- 
gerous, and run a more rapid course than at the end. There are not in- 
frequently numerous variations in the number of new cases, and in the 
mortality. The epidemic terminates gradually, and sometimes extends 
over many months. 

If the cholera germs do not find a suitable soil, the single imported 
case, or a few cases of infection alone may be observed. 

II. SYMrroMS.— The duration of the period of incubation is generally 




^t». 



DTFBCnOCS DISEASES tin'OLVIIlG THE DIOEeiTVB APPABATCfl. 326 

''flstimated at two or three days. According to some writers, it occasion- 
ally lasts only two or three hours, in other cases four or five weeks (?(. 

We distiugtiish three difierent forma, aceordiug to the severity of the 
disease, riz.: cholera diHrrhcea, cholerine, and cholera asphyctica. The 
disease often begins in the mildest form, and gradually passes into the 
severest form. Transitional forms are also observed. In asphyctic cholera, 
and in cholerine (though not so frequently in the latter) recovery occurs 
srudually (stage of reaction). If, after the speoiflo cholera symptoraa 
nave ceased, the patient is apathetic, and a condition develops resembling 
uphold fever, we call the condition cholera typhoid. 

It is not impossible that the cholera virus may produce milder 
symptoms than those of cholera diarrhisa. The psychical depreaaion, 
[wlpitation, feehnff of oppression, borborygmus, and cramps in the 
calves, which are observetl in many individuals dnring cholera epidem- 
ics, have been attributed to cholera infection. 

In many cases, cholera diarrhoaa cannot be distinguished from 
diarrhcea due to ordinary cuuscs. Its occurrence during an epidemic, 
and its infectious properties, especially the possibility that tlie fieces 
may give rise to severe cholera, are its ohiei characteristics. Its real 
nature is often doubtful, so that it is well to treat every case of dian'hcea, 
during the prevalence of au epidemic of cholera, as cholera diarrhcea. 
The discovery of the comma bacilli in the stools or successful cultivations 
will render the diagnosis positive. 

In many patients, the symptoms appear during perfect health ; in 
others, the; are preceded by a cold, wetting, mental exeitement, error in 
diet, etc. 

The patients not infrequently go to bed well, and are awakened from 
sleep by the first symptoms shortly before midnight or in the early 
morning. In others, the disease begins in the daytime. 

The patients complain of rumbling in the belly, soon followed by a 
desire to go to stool. If they yield to this desire, they discharge at once 
an unusually large amount of fluid masses. These contain bile and, 
under the microiicope, are also found to contain crystals of the triple phos- 
phates, desquamated epithelium of the intestinal mucous membrane, 
dfibris of food, and innumerable round and rod-shaped schizomjcetea. 
In the majority of cases, no pain is felt during the evacuation. Many 
become prostrated after the first discharge ; in others, this is not felt until 
several stools have been passed. As a rule, five to ten evacuations occur 
daily, and sometimes they follow one another so rapidly that the patients, 
at times, do not dare to leave ,the bed-pan. The more profuse the 
diarrhoea the less the excretion of urine. Finally, only a few drops of 
urine are voided after atrainitie and severe burning In tde posterior ]iart 
of the urethra. Albumin is almost always present in the urine. 

Some patients complain at the start or soon afterwards of nausea, 
singultus, and even vomiting. The mouth is sticky and hot, the tongue 
is tnickly coated, there is often fcetor ex ore. Thirst is increased, while 
the appetite is lost. The patients not infrequently experience a sensa- 
tion ol oppression and extinction, complain of palpitation and spasms in 
the cardiac region, the skin becomes cold and pale, the face pinched, 
the pulse small, and there may ho cramp>Uke pains in tbe muscles, es- 
pocially the calves. 

If aid is rapidly brought, the disease may terminate In a few hours. 
Id other cases. It lasts several days to a week and then terminates spon- 
taneoaaly, or it passes into the severe forms of cholera. Ohildreii] old 



226 INFS0TIO17S DISEASES ISYOhYlSQ TOE DiaBSTlTS APPARATUS. 

and exhausted individaals sometimes die from cholera diarrhoea alone, 
with symptoms of increasing collapse. 

But the symptoms are not infrequently so mild that the patients go 
about their ousmess and even travel long distmces, depositing foci of 
infection wherever they have an evacuation from the bowels. Even 
the mildest cases, however, may suddenly become severe. 

The symptoms of cholerine often develop from those of cholera 
diarrhoea. The numerous fluid stools likewise constitute the chief 
symptom in this form. But the more frequent and copious the evacu- 
ations the more the^ lose their biliarv character ana finally form a 
colorless or cray fluid, mixed with yellow or gray flakes (rice-water 
stools). At the same time the fsBcal odor is lost, and the stool acquires 
a sickish odor. The urinary secretion diminishes and ceases earlier than 
in cholera diarrhoea. Vomiting is a constant symptom, at first of the 
contents of the stomach, later of rice-water masses, similar to those dis- 
charged per rectum. The other symptoms are similar to, bat more 
^vere than, those of cholera diarrhoBa. 

The symptoms may cease within twenty-four hours, after ten or 
fifteen evacuations. Recovery sometimes takes place with surprising 
rapidity, at other times it is slow and attended with symptoms which 
remind us of the sta^e of reaction of asphyctic cholera. So long as the 
^ools contain bile, the prognosis is not very grave. But if rice-water 
stools appear and persist for some time, aspnyctic cholera often devel- 
ops, ana a fatal termination is then the rule, rather than the exception. 

In asphyctic cholera, the chief symptoms are the rice-w^ter stools and 
vomit. The other symptoms are m ^reat part the result of the great 
losses of water. Hence the blood is thickened, and thus gives rise to a 
series of circulatorv disturbances (imperceptible pulse, deep cyanosis, 
associated with pallor, cold skin, loss of turgor in the various tissues, 
anuria, painful muscular cramps, etc.). 

The number of evacuations varies; there may be more than twenty 
or thirty in the twenty-four hours. The diarrhoea is often especially 
frequent in the beginning of the disease. Cessation of diarrhoea 
is not always a favorable sign, since this is observed in very feeble 
individuals shortly before death, when the muscular coat of the 
intestines is paralyzed. At the autopsy, the int^tines are found filled, 
in such cases, with large amounts of fiuid. Involuntary evacuations 
are also observed in patients who are in a condition of collapse. 

The amount of the stools is often larger than that of the food in- 
gested, positive evidence that the excess is derived from the blood. The 
daily amount may vary from 500 to 5,000 ccm. 

The reaction of the rice-water stools is nsuallv alkaline or nentnd; 
their specific gravity varies from 1.006 to 1.013. Il'hey have a gray coloi 
and contain the characteristic flocculi. The stools often assume a red- 
dish color on the addition of nitric acid. 

Microscopical examination of the cholera stools reveals detritns of 
food, a few triple phosphates, a few round cells, still fewer red blood- 
globules, round and rod-shaped schizomvcetes, punctate masses and 
drops of fat. Intestinal epithelium cells are often almost entirely 
abc>eat, in other cases we find a few shreds, often coherent cells. 
The litter form part of the flooeiili. The latter contain nothing else 
beyond a punctate miss, and are then composed of mucin and a trace of 
albumin. 

The comma bacilli are obtained by spreading one of the floccoli upoD 



ISFECT10C8 DISEASES ISVOLVTMO TUE DIGESTIVE APPAKATCS. 227"! 

i oTer glass, drying it by drawing it several times through the flame of a I 
■pirit lamp, and then coveving it witli an aijueous sohition of fachaia j 
or methyl bine. The cover glass is then rapidly washed in water, again 
dried, and imbedded in Canada balsam (vide Fig. 41). 

Despite every precaution, no bacilli maj' be foundj and it then be- 
comes necessary to make cultures with the flakes of mucus. 

The rice-water stools contain a large percentage of water, and ft I 
small amount of solid constituents, especially of organic matters. Al- I 
bumin is present, if at all, in mere traces. Urea and carbonate of ] 
ammonia are also present. Sodium chloride is the chief inorganic con- 
stitnent, the phosphates and potassium 
salts are present in very small amounts. 
Euebne foand a eugar-prodncing ferment r^o "■ 

in all cases, and this led Cohnheim to as- 
flume that the stools are not a simple 
transudation from the vessels, bnt intes- 
tinal secretion. According to this theory, 
the virus of cholera gives rise to hyper- 
secretion of the glands of the intestinal 
mucous membrane. The excessive seore- 
tioti stimulates peristalsis and thus caubcs 
frequent evacuations ; this probably gives 
rise, by reSex action, to increased excit- 
ability of the muscular coat of the stomach 
and thus causes the frequent vomiting. 

Tlie older writers applied the term cbolera 
ejectt to esses in which, while the patients had 
other cholerirctm Bymptcinn, they rarely or 
never had an evacuation from the bowels, but 
the autopsy showed tliat the intestines con- 
tained a large amount of fluid. In an epidemic 
in Koeiiigsberg, in which I treated nearly on« 
hundred cases of cholera, 1 obeerved one rase 
ittthis kind. In the G»noa epidemic of 1883, 
a comparatively large number of such cases 
appear to have been ob»erved, 

Vomiting occurs in almost every case 
of asphyctic cholera, sometimes more than 
twenty times a day. Emesis is generally 
very easy, and the fluid often bursts in 
streams from the mouth. As a general 
thing, it is so much more profuse the 
more the iiatients yield to the feeling of thirst. When the patients are 

S rostrated, the vomiting may be replaced by singultus which often pro- 
uces violent epigastric pains. Singultus and vomiting sometimes aUer- 
Dut<i with one another. 

The vomited masses consist at first of debris of food, later they are 
stsiued with bile, and then present the characteristics of the rice-water 
Htools. Thoy may amount to 35,000 ccm. in twenty-four hours, 
Ooldbanm calculated that one of his patients drank 10,200 ccm. of 
fluid and vomited 31,250 ccm. The amount discharged with each act 
of vomiting varies from 30 to 500 ccm. 

It is evident that some of the fluid is derived from the blood and 
probably enters the stomach from the inteatinuV ta-mV. \'t9, Tfca.t'Cvi'tt.'^a i 




Comma tutllU 



^ 



238 INFECTIOUS DIBEASE8 ISVOLVINO THE DIOKSTIY£ APPABATrB. 

nsually alkaline or neutral, ite specific gravity varies from 1.002—1.005, 

and contains only a small amount of soUd matter. 

The inicroacope generally shows drops of Cat. even If (at lias notbeeainiceated. 
epitlielium cells from Che (Esophagus and buccal cavitf, a few round ceLu, and 
various achizomycetes. mrelj coiunui bacilli. 

Tbe abdomen, as a rule, is eligbtly sunken; the lower part is more 
prominent than the upj>er. There is generally no tenderness on pres- 
sure. Below the umbilicus we often feel a peculiar shaky feeling of 
resistance and gurgiiog, and find dulnesa on percussion. 

The appetite ia lost, but the patients are tortured by thirst. If too 
much is drunk, Tomiting is produced. The majority of patients com- 
plain of burning in the mouth and internal neat, especially in the 
gastric region. Ihe tongue may be clean and unusually red, or it is cot- 
ered with a gray coating; it is usually dry and sticky. 

The loss of water, as a matter of course, gives rise to gradual drving 
of the various tissues, Not alone is the amount of blood diminished, 
but it becomes thicker and offers greater resistance to the propelling 
power of the heart. The friction in the peripheral vessels also increases. 
The circulation becomes slower, the blood cools at the periphery of the 
body, and this again slows the circulation. At the same time tbe 
nutrition of the tissues suffers. 

The skin is extremely pale and, at the same time, intensely cyanotic, 
particularly the lips, cheeks, tip of the nose, conjunctiva, and finger 
nails. The tongue also is often cyanotic. 

The features are extremely sunken. The malar bones and nose are 
prominent, the eyeballs are deeply sunken and surrounded by bluish 
gray rings. This, together with the diminished power of the musclea, 
interefres with closure of tbe lids. At first the patients can close the lids 
when so directed, but they soon open again. But in a little while they 
lie constantly with half-closed lids, and the eyeball rolled up until the 
cornea is entirely covered by the upper lid. According to Oraefe, the 
rolling upwards of the eye is only apparent, and produced by tbe im- 
perfect closure of the lids. The patient acquires such a peculiar ex- 
pression as to justify the use of tbe term facies cbolerica. 

Tbe exposed portions of the conjunctiva are often dry and devoid of gloos. 
Along tbe lower edita of the cornea we not infrequently find intense congestion 
of the subcoDJunctivul vessels. Joseph observed Bubconjunctiv&l hemorrhages 
in some caaea. The absorption of substances which are dropped into the con- 
junctival sac takes place very slowly. Joseph states that the patienta are un- 
able to weep. 

The sclera eometimes oonCains irregular bluish and blackish patches, arranged 
concentrically around the lower edge ot the cornea (partial desiccation and tniD- 
ning of tbe sclera). They are said to occur only in fatal cases. 

The lowermodC portions of the cornea sometimes contain dry brownish 
patches, wliich leave opacities if recovery takes place. In unfavorable cases, 
softening and destruction mayo 

The pupils are usually contra< 

Choroidal hemorrhages have I 

The ophthalmoscope ehows that the retinal arteries are uimauallv narrow, but 
Intensely red. Slight pressure on the globe sulfices to produce pulsation in the 
retinal arteries, and if the pressure is increased, complete anwmia develops. The 
retinal veins are very wide and bluish-red in color ; in places they are sometimes 
The optic disk often has a ^le lilac color, its centre is somewhat paler. 
- a generally unaffected. The obsotttatton of the field of vision, whicb 



"(&., 



INTBOTIOUB DISEASES IKTOLTIHO THIS DISEBTIYE APPABATHS. 



The Bkin, mi<ticularlj on the forearms and backs of the hands, is 
wrinkled and naliby. If it is cut, the edges of the wound do not gape; 
if they are separated, they do not exhibit any tendency to approacli one 
another. Vesiclea can no longer be produced by the application of blis- 
ters or the actual cantery. Not inlrequeutly the skin fcela elammy, 
moist, and ice cold (cholera algida). 

The panaiciilus adiposus is flabby and diminished in size. The ' 
absorptive properties of the subcutaneous tissue are impaired, but i 
aboliBbed. 

For example, Goldbaiiin producad ililatation of the pupils bj aubcutaueouB 
injection at atropine. Sodium salts, whicli were injectei'l subcutaneously, ni<re 
found in the evacuations, potasaium salts were found in the saliva, but not la 
the Stools, 

■ Painful muBcular epasniR are an extremely annoying symptom of 
f Solera. They are most frequent in the calves, neit in the thighs, 
iorearms, and fingers, rare in the muaclea of the abdomen and chest. 
most rare in the face. When they occur in the calves, the thighs and 
legs are iovoluntArily flext^d spasmodically, and in lean individuals the 
hard muscles can be readily seen and felt through the skin. The pains 
are so severe that many patients cry out aloud, and the spasms may 
recur at intervals of less than ten minutes, The more profuse the stools 
and vomiting the more violent are the cramps, though the latter some- 
times precede the former. They are supposed to be due to dryness of 
the muscular aubstauce, but, in our opiuou, aerroua causes cannot b» 
excluded. m 

Some authors mention increased meohanical and electrical exoitability of the i 
i muscles. Jodus hasfound thai, insevere cases, the tendon reflexes were increased 
L jk ihe height of the disease, and became normal during oonvoletcence. 

" Cousoiouaness is generally retained to the last moment; in rare cases, 
delirium occurs towards tlie end of life. The majority of patients 
manifest, at a very early period, a sort of fatalistic mood and feeling of 
indifference. Many complain of precordial terror, dizziness and ringing 
in the ears, and suffer from syncopal attacks. 

The weight of the body diminishes very rapidly, chiefly on account 
of the abundance of tho evacuations from the bowels. If the disease 
nins a very rapid course, there may be a loss of oue-half to one per cent 
of the weight of the body within an hour. 

The bodily temperature always appears subnormal to tlie hand, and 
the thermometer in the asilln also, as a rule, shows subnormal tempera- 
ture. Tho thermometer rises so slowly that it should he left at least 
half an hour in the axilla. The mouth and tongue generally feel cool. 
Tho vaginal and rectal temperature, however, is rarely subnormal, some- 
iVfaat more frequently normal, and, aa a rule, increased to 40" C. (there 
ky be a difference o'f 3.?° C. between the rectal and axillary tempera- 
res). Shortly before death, tho temperature sometimes increases rapidly 
43.4° 0, 

The pulse is accelerated and not infrequently irregular. Tho more 
ifuse the vomiting and evacuation^ the more i; diminishes in luj^ _ 




280 iKFBonous disbasbb iNYOLviNa THE DiaEfirmns appabatub. 

ness, until finally it becomes imperceptible. The pulse disappears earli- 
est in the radial artery^ later in the more central arteries^ latest in the 
carotids. 

The blood is generally of a deep black-red color, tarry, and growa 
red to only a slight extent or not at all when shaken in the air. It 
is often acid before death. 

The number of white blood-globules is generally increased, and they are often 
collected in masses. On account of tlie concentration of the blood, the red 
blood-globules are unusually close toj^ther, and exhibit but little tendency to 
form rouleaux. In a few cases, free drops of fat have been found in the blooa. 

TbespNecific gravity varies from 1.036-1.058 (normally 1.026-1.029). Theamonnt 
of albuminoids and potassium salts in the blood is unchanged, that of sodium 
chloride is diminished. 

C. Schmidt furnishes the following analyses : 

Woman, »t. 96 yean, sa- 
Healthy woman, hoars after the hef^rinnlni^ 
SBt. W years. of an attack of ehoteim. 

Water 824.55 760.85 

Solid matters 175.45 280.15 

Haemoglobin 1 1 6.48 154.80 

Fibrin 1.91 8.50 

Other organic substances 48.49 74.85 

Inorganic salts 8.62 7.00 

Sodium chloride 2.845 1.958 

If the arteries are laid bare, they appear narrow and transparent* 
Upon opening them, a thin stream of dark blood escapes, and in severe 
cases none escapes, unless the vessel is stroked towards the periphery. 
This manipulation is then followed by the escape of a few thick drop? 
of blood. Dieffenbach found in one case that no blood followed after 
opening an artery in the arm, although he introduced a catheter into the 
vessel K>r a considerable distance. 

The veins are distended with blood, but venesection is not followed by 
a vigorous stream. On the other hand, it can often be removed only by 
stroking the limb. 

On account of the impaired nutrition, there is diminished sensibility 
of the mucous membranes. This is noticeable upon the conjunctiva and 
the mucous membrane of the nose and air passages. 

The voice becomes muffled and peculiarly high (vox cholerica). Thig 
is the result of dryness of the larynx and weakness of its muscles* 
Matterstock found that the processus vocales were unusually prominent, 
and that the glottis opened widely in attempts at phonation. These 
symptoms were sometimes found only on the left side. 

The respirations are not infrequently accelerated, deep and irregular,, 
owing to the disturbances in the pulmonary circulation. The expira- 
tory current of air is often unusually cold. 

The heart's action is not infrequently accelerated and irregular; it 
grows feebler the greater the general prostration. The first sound be- 
comes indistinct, and the diastolic sounds disappear entirely. In a few 
cases, pericardial friction sounds are heard. These are generally at- 
tributed to excessive dryness of the pericardium, but result in some cases^ 
perhaps, from subepicardial hemorrhages. 

The excretion of urine generally ceases entirely in a short time; if 
small amounts continue to be passed, thoy generallv contain albumin. 

The complications of asphyctic cholera generally appear during the 
stage of reaction. We may mention bloody stools (usually an nnfavora- 



cho 
null 

t 



raFECnOCS diseases involving the DIGESXrVE APPARATUS. 

ble sign) aod bcematemesis. Tlie latter is commonly small in amonnt 
and produced by violent vomiting. 

Cutaneous emph;rsf'na is a rare complication which is secondary to interetilial 
pulmonaiy emphysema, produced by tue violent respiratory moTementB. 

The majority of oases of fully developed asphyctic cholera terminate 
fatally. Death may occur before the end of the first day. or life may be 
prolonged for forty-eight to eeventv-two hours. Life gradually becomes 
extinct from excessive weakness oi the heart and general prostration. 
The danger Is not always ended when the symptoms improve, inasmuch 
as relapses are apt to occur, and severe sequelte develop in not a few cases. 

Tho period between the cholera attack proper and pronounced recov- 
ery is known as the stage of reaction. 

It is not often that this runs its course without serious disturbances. 
The stools then become less frequent, firmer, and stained with bile; vom- 
iting ceases, diuresis is re-established, and the temperature, pulse, and 
respirations again become normal. But the patients must keep a strict 
diet for a long time, in order to prevent grave relapses. 

In a second group of cases, the reaction is accompanied hy slight fever 
and congestive symptoms. The conjunctivie are injected, the face 
flashed, many patients complain of rush of blood to the head, and de- 
lirium sometimes sets in. In a few days, these symptoms subside and 
recovery becomes complete. 

In a third series of cases, the condition, in its gross features, resembles 

Sphoid fever (cholera typhoid). The temperature rises considerably, 
e pulse is accelerated, full and tense, the tongue is dry and covered 
with sonles, the ab<lomen is tympanitic, and not infrequently roseolar 
patches appear on the trunk; in addition, diarrhoea and clouded con- 
sciousness. 

Grave dangers arise in the stage of reaction if the renal secretion is 
not re-established and anemic symptoms appear. This will occur if the 
renal circulation has been interrupted, or almost interruptod, for 
such a long time that the endothelium of the Mulpighian bodies and 
the tubular epithelium are rendered incapable of function. In some 
oaaes, no moro urine is secreted; in other cases, the urine is abnormal. 
Hence, urea accumulates in the blood and tissues. Crystals of uiva have 
even been observed upon the skin (urhidrosis). The unemicforraof iho 
stage of reaction not infreriuenlly presents a typhoid character, although 
QOt all cases of cholera typhoid are nrremio in character. 

The anuria occurring in cholera is the result of the low blood pres- 
luro and the slowness of the circulation. It may continue after 
the attack of cholera, and sometimes lasts six days. The longer its 
duration the mom certain is the fatal termiuation. According to Uold- 
baum, recovery never takes place if anuria persists for more than seven- 
ty-two hours. 

The quantity of urino passed on the first day after an attack of 
cholera varies from 30 to 600 ccm. (about 200 com. on the average). It grad- 
ually increases and may terminate finally in polyuria. The amount does 
not become normal until the second week. The urine generally has a 
~ ddish or reddish-brown color, and is ordinarily cloudy. Its reaction 
almost always acid; sometimes so intensely that Htohvis suspects the 
ireoence of an unknown free acid. In one case, this observer found a 
ratml reaction. The specific gravity varies from 1009 to 1025.5 (1015 



232 iNFEonous diseases myoLviNa the Diassmrs AFPAaAxuB. 

• 

on the ayerskge). The sediment contains round cells, a few red blood« 
globules, often very numerous and, in part, fatty epithelium cells from 
the renal tubules, vesical epithelium, and casts. The latter are partly 
hyaline, partly granular, and are covered with drops of fat and epithe- 
lium cells. Their diameter varies, and they are often unusually long. 
According to Wyss, the prognosis is so mucn more favorable the more 
numerous the casts, because in this way the tubules are rendered per- 
vious. The sediment often contains crystals of uric acid. Kedwetzky 
found spermatozoa. 

The urine which is first voided almost always contains albumin. In 
the subsequent portions the albumm diminishes, and disappears before 
the amount of urine has returned to the normal. Stokvis noticed that 
the higher the specific ^vity of the urine the smaller the amount of 
albumin. It generally disappears between the fifth and eighth days, but 
Wyss has found it as late as tne thirteenth day. 

Often, though not constantly, the urine contains a substance which 
reduces an alkaline solution of copper sulphate. This is generally be- 
lieved to be sugar, but Wyss thinks that it may be glucose, and be pro- 
duced by decomposition of the indican which is present in large quanti- 
ties in cholera urine. Olycosuria may occur after, or coincidently with, 
albuminuria. In some cases, Wyss found that the glycosuria was most 
marked from the fifth to eighth days, and lasfced a week. 

The amount of urea is very slight (2.5^ on the average) in the first 
cholera urine. If recovery occurs, it graduallv increases and may become 
excessive by the beginning of convalescence (two and a half to two and 
three-quarter ounces). Stokvis thinks that the amount of kreatinin is 
increased. Only a trace of sodium chloride is present, but the quantity 
gradually increases. According to Panchet, the urine contains an abun- 
dance of the salts of the biliary acids. The urine also contains a large 
amount of indican. 

The stage of reaction may be associated with a large number of 
complications, which sometimes begin during the cnolera attack 
proper. 

Various exanthemata are observed upon the skin. Herpes labialis is 
one of the rarer symptoms. Eruptions resembling urticaria, scarlatina, 
or measles occur frequently, and are sometimes followed by desquama- 
tion. Scattered roseolar patches appear occasionally. In some cases, 
pemphigoid or impetiginous eruptions are observed. Multiple cuta- 
neous abscesses sometimes develop and may last for weeks after tne attack 
of cholera. Miliaria and erysipelas have also been described. 

Oangrene of the skin or certain parts of the extremities develops in 
some cases. It sometimes follows wounds of the skin, for example, after 
blistering or leeching. In some cases, cutaneous changes are followed 
by thrombosis of the vessels. Gangrene of parts of the limbs has also 
been described, as the result of arterial embolism, which has taken its 
origin in cardiac thrombi or in recent endocarditic deposits. Marantic 
thrombosis of the veins may also occur. 

The skin is sometimes more or less ansBsthetic or hypersBsthetic. 
Muscular contractures, of central or peripheral origin, have also been 
observed. In a few cases, the joints undergo painful swelling. 

Some authors describe violent delirium during convalescence, and 
even maniacal attacks occasionally develop. On the other hand, im- 
provement and even complete recovery of previous psychopathies have 
veen reported in other cases of cholera. Among other nervous compli- 




TNTECnODS DISEASES ISVOLYXSQ THE DISESTrTE APPABA.TITB. 

lona may be mentionod: gBneral convulsions, trismua, tonic nnd clonic 
monoplegia, paraplegia, and hemiplegia, rarely meuingitis, 
and cliorea (in children). 

Catarrhal or diphtheritic changes are observed on the buccal mucous 
membrane, and salivation has been reported in a few cases. Purulent 
narotitis (more rarely inflammation of the Hubmaxillary gland) has also 
oeen mentioned, and, according to Queterbock, is always secondary to 
catarrli of tlie excretory ducts of the glands. The lesion is sometimes 
bilateral, and may terminate fatally on account of burroiving of pus. 
erosion of vessels, or cedema of the glottis. Paralysis of the tongue and 
palate has been observed in one case. 

Uipiitheritic changes may also develop npon the mncons membrane 
of the pharynx, iBsopbagus and stomach, doodennm and large intestine 
(tenesmus and bloody stools). 

Bronchitis is not uncommon; less frequently there is necrosis or 
(edema of the laryngeal tissues. Pneumonia, abscess, hemorrhagic in- 
farctions, gangrene cf the lungs, and pleurisy are observed occasionally. 

Icterus and peritonitis are rare complications. Women often suffer 
irom pseudo-menstrual bloody dischargee. Gangrene of the genitals 
may develop in both seses, 

Preuiianey does not protect aKainat cholera. When pregnant women aie 
Attacki^l, premature delivery i» often produced. The fcetus sometimos dies in 
Utei-o; iu other cases, it ii born alive, but ia attacked bj cholura immediately at ter 
birth, or a short time afterwards. 

In nursing women, the Isc teal secretion is not affected by an attack of cholera, 
and the milk does not appear to be infectious. 

The seqnelffi include chronic Bright'a disease and diabetes mellitns. 
In some instances, it is said that diabetics recovered temporarily or even 1 
permanently after an attack of cholera. i 

III. Anatomical CuANQBS. — When death occurs during the cholera j 
attack proper, the corpse often presents a peculiar appearance. I 

The body is pale, but deep cyanosis is exhibited m the lipa, tip of 1 
the nose, and finger nails. Trie features are sunken nud peakea. Rigor j 
mortis isunuBuaily pronounced. The arms, legs, and fingers are flexed, ' 
and the contoura of the muscles are distinctly visible under the skin. 
The corpse cools very slowly, and there is sometimes a post-mortem rise I 
ol temperature. Decomposition sets in very slowly. 

Post-mortem twitchings of the muscles constitute a noticeable fea- 
ture. Tlrey generally begin immediately after death, sometimes not 
until fifteen minutes later. Thoy appear first in the lower limbs, and 
then extend to the arms, truuk, and face. The calves are usually unaf- 
fected. The twitchings are so much more active the more rapid and 
violent the course of the disease has been. In many cases, they are capa- 
ble of changing the position of the body, and they may continue for two 
and a half hours. Drasche states that the skin over the contracting 
mosolefl is reddened uniformly or in patches, and that its temperature 
may ri« 0.7° C. Contractions oould be brought about by pouring chloro- 
form on the skin and allowing it to evaporate. The cause of t^s phe- 
DOmenon is naknown. 

Similar phenomena nppear to occur in the involuntarv muscles. Draacbe ob. J 
served cutis nnserjoa above tlie contractm^; muscles, and stales that la o 
a dlsobargo of semen took place one and a half hours after death. 



234 n^FHCTions dmeasm arrovrrso ths digestive appabatus. 

The snhcntaneooa cellular tissue and muscles are generally Terr dry, 
and the muscles are uiinsnally dark and red. Tlie medulla of the boneg 
is also extremely red. 

The serous membraDes have a sticky, soapy feel, aud their cavities 
do not contain the ordinary post-mortem transudation. 

More or leas e.ttensive hemorrhages are found not infrequently 
beneath the epicardium and also in the heart muscle. The right heart 
and main venous triiuks are filled with blood, the left heart is empty. 
Patty and waxy degeneration is observed in the muscular fibres of the 
heart, 

The blood has a tarry color and consistence, and is very alightly or 
not at all coagulated. 

The lungs are strongly retracted and pale; on section, a few thick 
drops of blood can be soneezed out of the larger vessels. The consists 
enoe of the lungs is leathery and tough. 

The loops of the small intestine are filled with rioe-water masses, and 
agonal invaginations are often present. The serous layer is injected and 
often cyanotic. The mucous raembrane is swollen. The ton of the 
folds and villi is often congested, and sometimes infiltrated witn blood. 
The solitary follicles and Peyer's patches are swollen aud may be sur- 
rouuded by a halo of distended vessels. In the beginning of the disease, 
the swollen follicles, if punctured, discharge a clear fluid aud then 
collapse, but later the swelling is produced by hyperplasia of the lymph 
cells and is not diminished by puncture of the follicles. 

The intestinal epithelium is elevated in places by serous finid, or is 
exfoliated in more or less extensive shreds. This may occur during life, 
but is also, in part, a post-mortem change. These changes are most 
marked in the lower part of the ileum, but in very rapid cases hare been 
traced to the pylorus. 

Kelsch and Renault found marked infiltration of round oellB in the subepithe- 
lial and subserous connective tissue, considerable dilatation at the submuuous 
veuseU, and occlusion of the lyiuphatic vessel n. partly wiili round cells, parlly 
with desquamated and swotlen epithelium. Lieberkuebn's glands were diktat! 
in part with mucus, and the epitbeiium of the upper portions often absent (prob- 
ably a post-mortem change}, Kocb found comma bacilli in these glands, partly 
in their lumen, partly between the epitbelium and basement membrane. Other 
bacteria are slso found, but appear to have entered after the death of the tissues. 

' ----- - i^tly- ■■ - ■ 



I, especially in very rapid cases, the intestinal contents form 
almtwt n pure culture of comma bacilli. 

Small losses of substance are sometimes produced in the central portions of 
the swollen lymph follicles by hemorrhagic iu&ltration and softening. 

The large intestine may appear intact. In other caaea, there is con- 
gestion of tne serous and mucous membranes, with swelling of the latter. 
The microBCoptcal changes are similar to those found in the small intes- 
tines. This is also true of the stomach. 

Ooldbaum describes swelling of the circumvallate papillse of the 
tongue as a constant appearance. 

The mesenteric glands are often congested and slightly swollen. 

The spleen may be slightly enlarged. 

The liver is slightly aneemic, the gall-bladder occasionally distended 
with watery bile or with a serous fluid. According to Nicati and Eiotach, 
the month of the ductus choledochus is often occluded by epithelial and 
mucous masses: the functions of the liver are soon abolisned, aud its 
weight diminishes considerably. They believe that acholia plays a part 




nrFECnOlTS DtSEASBS INTDLTIKO THE atOKSmB APPABATQS. 335 

ftk producing the fatal terminatiou. In one case, Goldbaum ilesoribed 
^diplitheria of the gall-bladder. 

Tho kidneys are pale, but hyperEemic in placea. The interstitial 
tissue is oedematouB. The tubules contain numerous red blood-globules. 
The eiiitlielium cella of the tubules are partly granular, partly desqua- 
mated, aud in placea in a condition of coagulation necrosia. These 
changes are degenerative in character, and result from the impurfect 
oirciilation of the blood. 

Ilenirn-rhages and exfoliation of epithelium are often observed upon 
the mucous membrane of the renal pelvis and the bladder. The latter 
is generally empty or contains a few drops of arine mixed with mucus 
and shreds of epithelium. Diphtheria of the vesical mucous membrane 
is sometimes observed. 

The mucous membrane of tho uterus ia not infrequently gwolleu and 
suffused with blood, and may also contain blood on its free surface. 
Hemorrhages are sometimes foond in the ovaries. 

The sinuses of the dunt mater are usnallv filled with blackish blood. 
The pia mater is often moist and sticky. Meningeal and cerebral hem- 
orrho^ea have been described. 

iV. Diagnosis. — During an epidemic of oholera, the disease is 
easily recognized. This is not true of the first cases, in which chief 
reliance must be placed on the discovery of comma bacilli. In dis- 
tinguishing Asiatic cholera from cholera morbus, it must be kept in 
mind that the latter mav occur in our latitudes at any time, and that 
it rarely turminutea fatally. According to Finkler and Prior, the stools 
of cholera morbus also contain curved bacilli which look very much 
like Koch's comma bacilli. Whether the former are found constantly 
in cholera morbus is still undecided. 

The bacilli of cholera morbus are thicker and less curved than the oommL 
bacilli, thej hsTe more at a spindle shape with rounded ends; they develop j 
fewer threads whicli are not so long or ao twiated as those uf the comma bacilli. 
Cultures of Finbler'a biicilli on pUtes o£ nutrient gelatin first fonu rfgular disks 
< witli smnuth borders, which liqiiety the gelatin much more vigoroualf than do 
tho comma bacilli. The two varieties of iKkoilU also present other biological 
differences. 

The diarrhcea of cholera presents no specifio characteristics, so thatil 
it is well to regard as choleraic every diarrhcBa which occurs during aal 
epidemic. Poisoning with arsenic, tartar emetic, and corrosive sub- 
hmste, and incarceration of tho intestines may be mistaken for cholera 
daring the prevalence of an epidemic. Even the gross anatomical 
lesions of arsenic poisoning may bo similar to thoee of cholera, so that 
crimes may escape discovery during an epidemic. The diagnosis is ren- 
dered positive by the discovery of comma bacilli in the intestinal con- 
tents. * 

V. PBOsyosis. — As a matter of courae, the prognosis is ao much more 
favorable the milder tlie form of tho disoaae. In asphyctic cholera re- 
covery is exceptional. The averogc mortality is about aixty per cent of 
all cases, although it varies greatly indifferent epidemics. The sudden 
cessation of vomiting and diarrhcea is regarded by many as an unfavora- 
ble aign, and the formation of blackish specks on the sclera is consid- 
ered a foreranner of impending death. After the symptoms of cholera 
taATe sabsided, the prospects of recovery are so much more favomblo the 



236 INFXOTIOUS DISEASES ZNYOLYING THE DIOBSnYB AFPAIUTUB. 

earlier the urinary secretion is re-established. If this does not take 
place within three days^ death is almost ineritable. 

VI. Treatment. — A country can be protected against the importa- 
tion of cholera from an infected country only by the strictest quaran- 
tine, although practically this is extremely difficult to secure. Those 
vessels which come from tropical cholera districts must be watched with 
special care. 

When cholera appears in any locality, the inhabitants must be warned 
against excesses of all kinds, against eatinjg unripe food or vegetables, 
or anything which is liable to produce diarrhoea. Suspicious wells or 
other sources of water supply must be closed, and it is best to drink 
only water which has been boiled and to which brandy or wine has been 
added. Festivals and other large gatherings should be prohibited. If 
diarrhoea sets in, medical aid should be sought at once. Water-closets 
are to be disinfected daily. 

If cholera appears in a certain house, the healthy inhabitants should 
be removed forthwith. Special care must be devoted to the disinfection 
t>f the stools, vomited matter, and clothing. The best disinfectants are 
carbolic acid (5^^) or corrosive sublimate (1 : 1000). 

Cholera corpses should be placed in hermetically closed caskets and 
should be buried privately ana quickly. 

A patient suffering from cholera diarrhoea should be kept in bed, 
and given only red wine and meat broth (mutton). We may order the 
following prescription : 

ft. Tinct. valerian. SBther., 

Tinct. opii simp a& 3 ss. 

M. D. S. Ten to twenty drops every three hours. 

Italian physicians recommend intestinal infusions of a lukewarm solution 
(one per cent) of tannin (one liter). 

Cnolerine may be treated in a similar manner. The violent thirst is 
quenched with pieces of ice, severe vomiting by subcutaneous injections 
of morphine in the epigastrium, cramps in the calves by injections of 
morphine in this region. A warm poultice should be applied to the ab- 
domen. In asphyctic cholera, warming flasks are placed in the bed, and 
a warm poultice on the abdomen; wine, brandv, and champagne are 
given as stimulants, ice to relieve thirst; internally, we may order laud- 
anum or 

3 . Pulv. ipecac, comp gr. vij. 

Hydrarg. chloride mite gr. iss. 

Sacch. alb gr. vij. 

M. To be taken every three hours. 

Cramps in the calves may also be treated by friction with dry cloths^ 
alcoholic inunctions, or mi\ftard poultices. 

In the stage of reaction, extensive use should be made of lukewarm 
baths (28'' R. twenty to thirty minutes' duration, t. i. d.); otherwise 
symptomatic treatment. Great caution must be exercised for a long 
time as regards diet. 

The following are some of the other remedies which have been employed in 
this disease: a. narcotics: opiates, strychnine, cilabar, curare, bdlladonna, 
ergotin, chloroform, chloral hydrate, amyl nitrite, etc. ; b, styptics: tannin, bis* 
muth, alum, etc.; c, drastics ; d, emetics ; e, nervines: arsenic, nitrate of ailTer, 



m TEOT I OTia DISE1A8BS mTOLVTNQ THE I 



(i. yellow Fever. 




I. EtioLOOT.— The home of yellow 
greater Antilles. It is alaii vndeaiic o 
coast of Africa. 

From these regions the disease has often been convefed to other parts of 
America, and also to Eumpean couatrieB. eapeciallj to aea-portH. 

The aprea>l of the iIiBaase ia associated with communication by water, and 
hence it appearB chiefly in aea-porlB or cities situated on large rivers. It often a;)- 
pttars on Bbi|iboard; or Tensels coming from yellow-fever localities, despite tlie 
fact that the disease does not appear upon the vessela themselves, infect other 
ports when they discharge Iheir cargo, bilge waier, or other refuse. 

It was formerly Btippoaed that the disease may develop autochthonously tipiiti 
vessels as the result of bod ventilation, overcrowding, and stagniuit bilge n ' 
but these conditions simply oflei' a favorable soil for the vinu. 

The nature of the virus is unknown, but It probably consists of bacteria. Ths- I 
virus directs its attack mainly agaiiist the liver, and gives rise to changes similar- 1 
to those of acute yellow atrophy of the liver. 

The outbreak of epidemics d^)enda mainly on the temperature. The majority 
of American epidemics appeared from July to September. They generally dis- 
appear rapidly after the occurrence of frost. The continuance of the epidemic is 
tftvored by protracted rains or great moisture of the atmosphere. 

Those parts of the city are in greatest danger which are nearest to the hiir. 
bor or hanliB of a river. The poorer the hygienic conditions in any quarter of the 
town the more favorable the conditions for the spread of the disease. 

Negroes escape almost entirely. In American epidemiCB, recent immigrants 
are most liable to be attacked, and the danger lessens the longer they are accli- 
mated. If they leave America for a time and tlien return, the susceptibility to tliu 
disease also returns. According to recent reports, the importance of acclimatiM- 
tion has been greatly overestimated. 

The male sex is more affected, especially in middle age. Old people and 
infants are rarely attacked. Jones reports a (doubtful) case of infection of the 
fiBtua by the mother. It is said that those who are much exposed to heat (bakers. 
cooks, etc.) are very susceptible, and that those who are accustomed to foul 
odors (tanners, soap-makersj are not attacked. £xces8eaofaUkinds favor the out- 
break of the disease. 

More than one attack is very rarely experienced by the same individuals, but 
relapsFS are more frequent. 

The infection is not conveyed from one individual to another by simple con- 
tact, and the virus does not appear to proliferate in the body of the patient. He 
simply acts, like inanimate objects, as a carrier of the virus. 

O. SyuFTOMs. — I'he average duration of tlie period of incubation is said to be 
two or three days. Si)me authors claim to have observed an incubation period of 
only a few hours, others of two weeks or even more. 

The disease is often preceded by prodromata (niiusea, anorexia, malaise, etc.). 

The disease begins not infre<)uently with a single vigoroua chill or several 
slighter chills. The bodily temperature rise« very rapidly and soon reaches 40° C. 
or more. At the same time, the pulse is accelerated (one hundred to one hundred 
and twenty beats or more). The patients complain of throbbing in the head, and 
intolerable unilateral or bilateral pains in the temples, more rarely in the ooci. 
put or other parts of the body. The gaze is fixed, the conjunctiva injected- 
The tongue has a gray or grayish-yellow coating. There is nausea and not in- 
frequently repeateif vomiting. The jiattente feel unusually weak and despondent. 

They often emit a cadaverous odor, which Stoonu claims to have detected 
before the outbreak of other Bymptoma. It ia said that the [latients. after recov- 
ery, are no longer bitten by mosquitoes. On the other hand, it is claimed thit the 
diuense may be conveyed by these insects. The majority of patients complain of 
severe pains in the lams, and pains in the joints aod muscles are also common. 

Tha heart and lungs remain unaffected. 



i 



lao neart anii mngs remam unanecieu. ■ 

^^^pStw giuoa are <^teii looRe, and covered with desquamatcl epithelium; ^^^J 



I 



ft 
ft 



mracmons uisgasgs ikvoltisq the DioBsrirs appabatos. 

this may be followed by ulcers and hemorrliages. Tlie ppigastrium Is often 
sensitive. There is usually conali patio ii, rurply liiarnitBa. The urine btoiti 
scanty and soon contains albiiuiiu. Complete uuuria occasionally develops. 

This stage of the disease lasts one to (our days. It is followed by the aecond 
stage (stage of remission), which generally lasts one or two days. Profuse 
diaphoresis suddenly uppears and the temperature and pulse become normal in s 
few li ours. The patienlH fee) better, and sometimes recovery ensues forthwitli. 
Nest foUons the stage of blood dissolution and jaundice, which lasts, on the 
aversKe, one to three days. An icteric color of the conjunctiva has not infre- 
auently been noticed on the preceding davs, This now increases and extends to 
tne general integument, and mav attain tfie most intense K^de possible. 

Diuresis, which hail increased during the period of remisiion, a^in becomes 
Bcatity, and the urine contains a large amount of bile pig(ueat, while the biliary 
acids are sumetirnen abtent. Anuria and death from urtemia are not infrequent. 
Ullei'sperger described lipuria. 

This author found that the blood was dark, some of the red blood-globules were 
destroyed, and the plasma was stained by the free pigment; it also contained 
drops of fat and pigment detritus. 

Hemorrhages appear beneath the skin, from the nose, mouth, and pharynx, 
stomach, inteslines. kidneys, urinary passnges. and genitals, 

Gnstric hemorrhage is especially dangerous, and is regarded b^ some as an 
infallible sign of impending death. The vomited masses often look like soot, and 
contain, according to UJboe, epithelium, debris of food, red blood-globules, and 
sometimes capillaries which are filled with red blood-globules. 

Roseola, urticaria, vesicles, pustules, and, in rare cases, herpes facialis may 
develop. 

The temperature and frequency of the pulse again increase. 

Some patients are apathetic, others are delirious and die in convulsions: still 
others have no susiiicion of their condition, attempt to leave the bed, and perhaps 
fall over desd. 

The abdomen is often tympanitic, the gastric and vesical region tender. 

The majority of pstientsdie in collapse;in8ome, death is the result of ur 
is a small percentage of cases, gradual recovery ensues. 

Purulent parotitis, multiple cutaneous abscesses, and suppuration of the glands 
may occur during convalescence. 

111. ANATOMlCALCHANQCa.—Tlie skin is jaundiced sometimes to amore marked 
degree than during life. Jaundice is also noticeable in the internal organs and 
other tiasues of thelKxly. Kigormortlsgeneratlyappearsquickly and is very pro- 
nounced. 

Hemorrhages are found in the subcutaneous tissue, muscles, epicardium, 
heart, pleura, lun^, liver, kidneys, stomach, and intestines, urinary passages, 
meninges, and brain. Transudations or exudations, which may be present, also 
often contain blood. 

The heart muscle is often flabby, brittle, pale, and fatty. The spleen is un- 
changed. 

The sise of the liver may be increased, diminished, or normal. It is generally 
pale and flabby, as in acute yellow atrophy, and the microscope shows marked 
fatty degeneration. The gall'bladder is either empty, or contains mucoid black- 
ish-green, inspissated bile. The latter is sometimes bloody. Hemorrhages, 
rarely abscesses, are found in the mucous membrane of the ^l-bladder. As a 
rule, there is no catarrh of the biliary possaKes, so that the jaundice is probably 
heematogenous, and due to destruction of the red blood-globules by the virus. 

The capillaries of the gums and the epithelium of the buccal mucous mem- 
brane are in a condition of fatty degeneration. The gastro-intestinal mucous 
membrane presents hemorrhages, from which superficial losses of substance 
orten take their origin. The intestinal lymph follicles and even the mesenteric 
glands may be slightly swollen. 

The kidneys are swollen, their cortex congested, and sometimes infiltrated 
with bemorrha^. At a later jieriod. the tubular epithelium undergoes marked 
fatty degeneration. Hemorrhages may also be found in the mucous membrane 
urinary passages and uterus, and * '' 



I. .= -..^.e-" ■"■" ['■"■"(''^ effects are produced by quinine. 
le spleen and liver nre enlarged, and spirilU are found inthtt 

is poL"aiii:!g; recogB!?''.'! by the history, the garlic "' 




urECTiocs DisEASEe isvsfmsa the obhual craoAss. 339 

the expired air and contents of the stomach, and the chemical dBmonstratioo of 
phosphorus in the latter, d. Acute vellow atrophy of the liver; llie liver rapidly 
diminishes in size, e. Grave jauuaice: these cosea not infrequently remain ob- 

V. Proonosis is grave; the mortality in some epideoiics was seventy-five per 
cent. Black vomit, stinking exlialations from the skin, pronounced albuminuria, 
and anuria are unfavorable eigus. 

VI. Trbatmcnt. — Sbtps. passeu^rs. and meruhandiae from yellow-fever ports 
must be strictly quarantined aud disinfected. 

In the first stage ol the disease, we maj' order mild laxatives, fluid food, and 
wine. Later, lukewarm baths and stimulanta. 
~ Some recommead quinine, othera carbolic acid, salicyUc acid, and kairin. 



i 



PART VI. 



INFECTIOUS DISEASES CHIEFLY AFFECTING THE GENITAL ORGANS 

(VENEBE4L DISEASES). 

1. Oonorrhtea, Urethritis Blennorrhoiea. Urethral Pyorrhea. Clap. 

I. Etiology, — Gonorrhcea is an inSammatioa of the urethra, cansed i 
by a definite form of bacterium, the gonococctia, first demonstrated in ] 
the inflammatory products bv Neisser, afterwards cultivated and suc- 
ceesfully reimplanted in the human urethra by Bockbard, Welander, 
Chameron, and Bumm. 

The mncous membrane of the vagina and neck of the uterna is a 
very favorable site for the development of the gonococcue. It may de- 
velop in the rectum, and cause clap, if the diacharge overflows from the 
vagina, or is introduced unnaturally. The conjunctiva is a favorable 
spol, and the introduction of the secretion from the urethra greatly en- 
dangers the eye. Infection of the mucous coat of the nose and mouth, 
though reported, is regarded by the most experieuced recent authorities 
as rather theoretical. I 

Mucous or purulent diaoliarges from the urethra do not always constitute clap, 
i. e., they tre not ulwaya duo to the gonococcus. Many persous haves discliarKa 
from the urethra after oeing catheterized; others, when a stone has been caught 
by the urethra and irritated it. 

Chemical irritants, as diluted sal ammoniac, may cause inflamtnalion and dis- 
charge. So can coitus with women suSering from simple fluiir albus. the lochial 
discharge, the irritating discharge of uterine cancer, or the tiiBnstr-.<al discharge. 
These inflammations are not specific urethritis in our sense of the word. Neither 
are those discliarges of fluid which are described in a few cases of sarcoma of the 

Sanis; uorthat sticky secretion which cornea from the penis in very small amount 
uring violent erection in great sexual exntement. The latter fluid comes from 
the glands of Littr^ in the urethral mucous membrane. Purulent discharge may 
be a sign of a soft, or hard " masked " chancre in the urethra, or urethral polyps, 
or herpes of the mucous membrane. Qouty petaona sometimes have a non>gonor- 
rboeal discbarge. 



cure 



GonorrhcEa is almost always acquired by impure coitus. It rarely oc- 

vu.-B in children, neually through violation; iu the case of boya, in tha . 

rectum. Most of the caaes occur in bachelors, especially between 30 I 

and ^ years of age. " 

The attempts often made by patients to deceive the physician are hidioroua t 
enough. Some will sny it is the sequel of a mere pollution in sleep; others, of 1 
taking cold, or bad liquor, or making water against the wind or agamst the our- I 
"WA in bathing, and milt more incredible things. * 




ISTSCnoCS DtBBA«E8 ATFULrtUC THE OSJOtAL 

A fint tttack inereue* th« predinontioD to a speond. Hi 
to stuck after almoet ewerj coitus. Une is almoit templed to _ 
the exislcooe of a mtt of gonorriiceal constitutiofi. Experienoe ilMnn 
that when ferenl men oopfilate in sacceoaioa with one wbon, thtj do 
not all get ebp. Then ii least riak irfaen th^diaetwrge of aemeii ocean 
<{Dickl7, and most vbeo it is iDteDtiooallT ntaided, for, the longer the 
back and forth mmvmeats coatinoe, the more abnadaDtljaiuI deeply dcMS 
the infecting fiuid penetntc into the arethia. 

The trpics] localitr of the disease in man is the urethra; in wonuu, 
the ragina. Gonorrhcra of the female oretJiia, bowerer, is mom commoo 
than is sappoeed. 

The aaection ii at first local, and then spreads to the neigiiboriiig 
partt. InftctioD of i!ie conjuiictira at birth, when the mother h 




m smorTbu, with gaa> 



rboea, is not ancommon. A man sometimes has sereral reaereal d 
at ODCe, caught either from one person or from eereml. 

II. SYMprous. — Gonorrh<Ba, like all other infective diseases, has a 
period of incubation. The first symptoms nsually appear from twenty- 
lour to seveaty-two hours uft^r coitus, though many authors mendoa 
shorter periods; for example, Kuhu declares he has se^u it begin in six 
hours; while othera still allow a much longer periotl. as two, three, four, 
and even eight weeks. Statements going oeyond the second week mast 
be looked upon with enapicion. Many patients have the effrontery to 
fix the date two or three weeks back, when they are not in a position to 
deny that it may have occurred two or three days before. Others still are 
drawn by anxiety to consult their physician the very next morning; but 
Buch belong to tne inexperienced sinners, and learn afterwards to take 
a moie coolly. 



HTFECnOirs DISEASES AFFEtTTINO TOB OBSTTAL OBaASTS. 



The course of eonorrlicea may be acute or chronic; there is also aii{ 
intermediate or s'joacute form. We shall, for practical reasons, describe 
the (liaeaije separately in the tiro sexes. 

Acute gonorrhoea in man, in the majority of cases, is first indicated 
by a peculiar tickling and prickling sensation in the anterior part of the 
urethra. This sensation is at first perceived only after urination; it soon 
becomes permaneat, and changes to a painful, burning seiiautiou. while 
the incliDatioo to pass water becomes frequent, and the act painful. 

The lips of the urethra become red and swollen, and if separated, a 
secretion is seen, mucous in the early stage, and soon becoming purulent. 
The front part of the uretlira, corresponding to the fossa naviculnriB, is 
very eensitivo to pressure. Drops of greenish -yellow pus soon flow . ., 
either spontaneously or on pressure; these foul the clothes, aud leave 
8t iff enetl spots with marked edges. 

If the patient is careful of his person, and diets properly, he may ex- 
pect the disease, if left to itself, to diminish gradually after the'first 
three or four weeks, and to recover spontaneously from the fourth to the 
sixth week. The purulent fluid usually grows more mucous towanls the 
close. 

It is different when the patient observes a bad diet, or is treated on 
too irritating a plan. I lately saw a married man suffering in the ninth 
month moat acutelv from purulent discharge, in spite of medical treat- 
ment. Cases in which the discharge becomes very inconsiderable for a 
time, or even disappears, and then returns on sliglit provocation, so that 
the disease hangs on for maoli longer than a year, are not specially 
rare. 

Examining the discharge microscopically (with precautions), we find 
cast-off pavement epithelium and pus-corpusclea, but especially sjieoifio 
gonococci (Fig. 42). 

These bodies may be demonaCrated thus: Place a little drop of gonorrheal pus 
between two covering glasses, press the glasses together so that the pas is dig- 
tribut«il between them in a very flne layer, and wipe the edjces with blottingpaper. 
Then separate the glasses, hold each with forceps, and pass it slowly ten or nrt«ea 
times through an alcohol ftaine till the puruleot coat is quite drj. Then lay the 

fUsaes witli care on the surface of a concentrated watery solution of inelhyleue- 
lue or gentian violet, in a t^atch-glass, letting them Hoat if they will, and allow 
them to remain half a minute. Then take out the glasses with' a pincette, and 
i; dry them asat first in a spirit flame, an ' ' 
ha drop of Canada balsam, dissolved in cl 
form, is laid. The preparation ia now ready for microscopic examination. 

The inexperienced observer should take notice that the pus-corpuscles seem 
enlarged ana transparent, so that only their nuclei aredistinctly recognizable. Tha 
gonococci at once attract attention by their deep color. Tliey are roundish, 
with sharply marked outlines, large, with diameter about 0.83 /i(l fi = 0.Ol mm.). 
They often lie in pairs, so close together that they might almost be taken for one 
individual <diplococci). They often lie in masses of ten or twenty, or more, often 
surrounded by agriatinous coat, which is best seen in a moderate light, but never 
take the form of a chain. They often cling to the pus-corpuscles; more rarely to 
the epithelial cells. They perhaps force themselves into the pus-cells, causing 
their destruction, by making the nuclei diminish and gradually disappear. 

Nelsser states that they multiply by the prolongation of the individual, a par- 
tition forming in the middle and makmg two. The same process then takes place 
In eaob of the halves, the new partition taking a direction vertical to the first 
one. 

IG 



I 
I 



urvBCTToce dkkases affzctixg the obnttai. obqahb. 

Gonorrhoea haa a great many complicatiooB, and patients are rarely- 
free from them. 

The discharge may become bloodv. This is especially the case when 
venereal excesses occur dnring the disease: it may also accompany obsti- 
nate erections, and excessirely frequent pollutions. This form issaid to 
have been common among the Russian soldiers at the time nf Napoleon's 
wars; hence the name of Russian clap. Sometimes the blood is in the 
form of little streaks, sometimes it is intimately mingled. A change in 
the coloriti^-matter of the blood may give a brownish or blackish liae; 
hence the expression black clap. 

Erections are commonly troublesome, and chiefly by night, and in 
the recumbonl posture. Tliey give pain by mechanically stretching the 
inflamed urethra. Sexual desire is mncb iucreased in many, and this 
favors the occurrence of erections. 

Pollutions freauently occur by night, sometimes by day if the fancy 
is allowed to dwell oneeKtiai thoughts oris excited by bad pictures, read- 
ing, and company. The pollutions are painful, because they are at- 
tended by erection. Thov weaken the patient, and keep up the inflam- 
mation. I have repeatedly observed a gonorrhceal discharge cease for 
two or throe days and then return after a nocturnal pollution. 

Chordee ia rather rare, and greatly alarms the patient. It consists in 
rigidity limited to the posterior part of the penis, the anterior part hang- 
ing down flaccid, forming an angle to the other part; the shape is like 
that of a flail. There is severe pain, as if a cord were stretcheo through 
the pmiis. The cause is probably the pressure of thrombi in some of toe 
canities of the corpus oavernosum which prevent the distal parts frdm 
becoming filled with blood. Circumscribed periurethral inflammationa 
and cicatrices may also form a cause. 

A painful desire to pass water is frequent; the urine comes slowly, in 
a thin stream, sometimes in drops, through the swollen and contracted 
urethral canal, causing very severe pain. 

A great number of complications are dne to extension of inflamma- 
tion to the neighboring parts. First, periurethritis. Here the inflam- 
mation attacks the submucous and periurethral cellular tissue, and 
causes chiefly local points of inflammation, which may be felt as painful 
swellings along the track of the urethra. The process may go on to the 
formation of abscesses which may break outwardly or inwardly, or in 
both directions at once, and gives rise to urinary flstula. In man; 
cases, the abscesses are limited bo the follicles of the mucous coat (follic- 
ular ulcers). 

If gonorrhceal pus accumulates in the sac of the prepuce, inflammation 
of the glans often occurs, balanitis; or of the inner layer of the prepnce, 
posthitis; or balano -posthitis in one. These parts are reddened, and a 
stinking, rancid purulent fluid flows from between them when they are 
pressed. The smell comes from decomposed sebum preputiale. The 
patients complain of itching, turning to painful burning when they 
scratch. Sexual passion ia usually increased. Along, narrow prepuce 
increases the danger of accumulation of pus. 

Erosions sometimes occur upon the glans and inner surface of the pre- 
puce; if the surfaces happen to be in contact, adhesions may form be- 
tween the glans and prepuce which afterward cause pain whenever the 
sexual act is performed, and cannot be easily remedied by surgical inter- 
ference. 

The prepuce often swells up with inflammatory tedema, becomea red 



^^ 



UTFEOnOUa diseases AFFECTOTO the QEBTrAL OBOAira. 



MS 



►tie 



iernaUy, and cannot be pnshed back over the glana. This condition 
7a called phimosis. The orifice may be so narrow that tlie opening of 
the nrethra can hardly he uncovered. Phimosis occurs much more 
readily and severely in persona whose prepuce is congenitally narrow. If 
the swelling and compression of the prepuce go on, they may turn to 

.ngrene unless arrested; black necrotic spots appear, the necrosed it 

'Is out, and the freed pus escapes throngli the hole. 
Attempts to drawback an inflamed prepuce in phimosis may load to 'I 
paraphimosis, popularly known as the Spiiuish collar; the prepuce 
springs back behind the edge of the glaus and clasps ic so tightly that re- 
dnction is almost or quite impossible. The prepuce is turned inside out 
and thrown hack. If the glans is not released, it may become gangre- 
nous through compression and aneemia; and the like may oucai' to the 
clasping prepuce. 

Inflammation of the lymphatics of the dorsum of the penis is not a, 
rare complication. Sometimes one, sometimes both of the chief ducts 
which accompany the artery are attacked. The back of the penia i 

f>aiuful; a roa streak is seen under the skin, marking the course of the J 
ympathic vessel, and a rather hard cord is felt, in places knotty, seusi-1 
tive to preaaure. Abscesses very seldom form. The lymphangitis may ' 
sometimes be traced up to the ay mphy sis pubis, and the inguinal glands 
Bympathize, with acute painful swelling. Inguinal lymphadenitis, on one 
or both sides, also occurs, very rarely with suppuration. 

One of the commonest complications of clap ia acute inflammation of 
the epididymis, due to the passage of material which excites inflamma- 
tion from the prostatic part through the vaa deferens to the epididymis. 
As gonorrhoea generally begins at the front part of the urethra and extends 
backwards, the epididymis is not usually affected lilt the second week. 
Both aides are affected with equal frequency, but seldom both at once. 
A distinct cauae is commonly to be traced: long walks, dancing, gym- 
nastic exercise, ridhig, or long standing without a suspensory band^;e, 
or tight trousers which mechanically irritate the testes, or too irritating 
injections, or an accidental blow or squeeze of the testis. If epididymitis 
has occurred once, it may easily recur in a second attack of gonorrhcea. 
Taricocele and scrotal hernia predispose to inflammation of the epididy- 
mis of the corresponding side. But there are also cases in wmcb a 
cause is not easily found. 

The flrst symptoms are sometimes general, as a chill or chillineas,. 
headache, dulness of the head, rise of temperature. Some vomit repeat- 
edly. The organ at first feels heavy, and very soon becomes intensely 
painful, Ibe yiain becoming intolerable with every movement, and on 
standing, Tne patient stoops and straddles and walks slowly. The 
F|tpidtdymiB is very sensitive to touch; feels doughy and lumpy, and is 
Enlarged. A frou exudation soon occurs in the cavity of tne tunica 
jBginalis propria —acute hydrocele. The inflamed organ swells to thosiae 
Tilt a man's flat and more. The half of the scrotal sac ia distended, loses 
it* folda, its skin shines and is often reddened, hot, and ffidematous— in- 
flammatory oedema. The tostea and skin of the scrotum seem grown 
together. The testis often turns upon its long and transverse axis; if 

I the oedema and hydrocele are great, it may be hnrd to gain certain eri- 
Sence by palpation. If the patients take care of themselves, the swell- 
big disappears after about four weeks, the inflammatory finida are re- 
Mtsorbed, and retrogressive change occurs. But if injuries are inflicted 
It the time of the acute inflammation, an abscess may form, though 




^ 

» 



i 



JSTECnOUB DISEASES AFFEOTINO THE OENITAI. 0R0AV9. 

that ia very rare; even gangrpno of the teatis may be caused by the hy- 
drocele preaeing very severely on the testis. 

Ill the Favorable case of absorption, a complete retnrn to the former state 
is rare. Lumny hardness usnally persists, whioh takes a long time to go 
away, or may laat a lifetime; tubeFciilosie of the mino-genital apparatus 
is a quite common result, through bacillary infection find caseous degen- 
eration of the inflammatory deposit. Impotence has been much dreaded 
in bilateral inflammation, through ohliteratiou of the vaea deferentia. 
This occnra, but not so often as many think. Atrophy of the testis, 
mentioned by many authors, can hardly occn r except as a consequence of 
too tight bandaging. Absorption of the Suid may not occur, aud the 
consequence is chronic hydrocele. Neuralgia of the testis after gonor- 
rhteal epididymitis has been seen to occur. 

TerillOD examined the Beminal fluid during acute double e[iidid;niitis. and 
found it purulent, with a large number of granular globules; the spermatoxos 
diminish progrcMively in number. He suspects purulent catarrh of the smaller 
seminal ducts. The eperniHlozon may quiti^ disappear, and may remain absent s 
long time after recovery. In unilaleral inflammaiion. the changes are harder to 
recognise, as they are pnrtl; concealed by the normal semen d( the other side. 

General symptoms may continue daring the height of the developed 
disease; meteorii^m, vomiting, even vomiting of froces, presenting the 
appearance of ileus; obstinate constipation, giving rise to the suspicion 
of acute incarcerated hernia. Many patients are tortured by very vio- 
lent shooting pains in the legs and loins. Others complain of panes- 
thesia in one or both legs, or slight paresis. The purulent discharge 
from the urethra generally becomes less or disappears, but usually re- 
turns as soon as the acute inflammation is relieved. 



Inflammation of the vas deferens, deferenitis gonorrhoica, may 
accompany epididymitis. The vas is as large as a finger, can be traced 
as a cord, with various knots, to the inguinal ring, is very painful to 
pressure, and the akin above it is reddened and often cedematous. De- 
ferenitis without epididymitis is rare. Abscesses may form, and burrow 
outwardly. 

Gonorrhceal prostatitis is a rather rare complication. It often begins 
with general symjitoms. Patients soon complain of a sense of burning 
and painful pulsation in the region of the perineum. It is difiicnit or 
impossible to urinate, and the catheter meets an obstacle. The gonor- 
rhoaal discharge usually ceases. Pain is intolerable at defecation, and 
makes many faint; the stool is intentionally held back, but the suffering 
ia only the greater. The perineum is reddened and swollen, usn- 
ally warm to the touch, and very sensitive. The finger in the rectum 
feels the gland swollen, hot, aud very sonsitive to pressure. Ohiils 
sometimes occur, abscesses form in the inflamed gland, bursting into 
the rectum, or urethra, or though the perineum. There is danger of 
pyeemia and death. 

After an attack of gonorrhcea, the prostate sometimes remains per- 
manently swollen, and pro3tatorrha>a ilcvelopa ; compare Vol. II., page 
350. 

Acute inflammation is sometimes propagated to the glands of Coi 



avxonocB diseases affixtiinq tuk oknital oboass. 




or the Bemioal vesicles, which may caase abscess. lu the former case we 
Qad, about half-way between scrotum and anus, laterally from the 
middle lino, a promment spot covered with red and tedematous skin, 
hot to the feel, and painful when touched. Pus usually breaks into 
the arethra. Infiltration of the surrounding connective tissue with pus 
and urine may cause pysemia, as in the case of suppurative prostatitis. 
In inflammation of the seminal vesicles, the flnger in the rectum feels 
swollen aud tender bodies at the sides of the prostate. Inflammation uot 
seldom passes from the urethra to the neck of the bladder and the 
bladder. There is dysiiry and ischury ; the urine is very rich in mncua, 
n US-corpuscles, and epithelium from the vesical mucous membrane. 
ileniorrhage from the bladder may occur. I lately treated a laborer whose 
gonorrhcea had been cured for several weeks, but who was suffering from 
very violent hemorrhagic cystitis. The diagnosis is established by find- 
ing gonocoGci in the sediment of the urine. 

The inflammation sometimes creeps along the ureters and pelvis to the 
kidney, causing albuminuria; the sediment contains epithelium from, 
the mucous membrane of the pelvis aud ureters and urinary canals, tiud 
casts. Abscesses are sometimes found in the kidney, and ursmia und. 
pyeemia may then cause serious danger. 

All the complications here described are mentioned as caused by es- 
tensiou of the disease by continuity. But this does not exclude the oc- 
currence of general disturbances during the course of acute conorrhtea. 

Some patients have a slight fever, especially if found to labor Jiard. 
Others soon become strikingly pale, lose strength, can hardly stand. 
Many are greatly depressed in mind. But a special group of complica- 
tions is formed by tne metastases of gonorrhcea. which, without doubt, 
are due to the transference of gonococci, contrary to rule, to distant 
organs, whore thoysetup afresh inflammation. The only case where, 
gonococci have been demonstrated is that of articular disease. 

Shifting, BO-called rheumatoid muscular pains are often comtiiained 
of. and my experience agrees with that of authors who have observed 
symptoms of acute muscular rheumatism io connection with gonorrhoea. 

Many authors describe neuralgia and neuritis, especially sciatica, 
which last has recently fallen under my own notice. Paretic symptoms 
are also decribed, which, probably, are connected with neuritis or 
myelitis. 

Fournier lays emph.isison gonorrhceal periostitis, which causes pain- 
ful swelling of the periosteum, most frequently on the spine of the sca- 
pula, OS caTcis, phalanges aud trochanter major, lasts one or two weeka, 
-and sometimes suppurutes. 

The long-debated question as to whether the occurrence of gotior* 
rhceal arthritis is duo to mere coincidence is at last settled by Petrone'* 
and Kammerer's demonstration of gonococci in the inflammatory fluidi 
of the alTected joints. Petrone states that he has even seen them in th^ 
blood. The attack usually occurs later than the fourth or siith week oP 
the gonorrhcea, often sometime after the purulent discharge hasceiised. 
Acute chin in men is the most frequently combined with rheumatism.' 
The attack may come very gradnally, and may bo limited to one or s 
few joints, the knee bein;: one of the favorite points attacked; in oth6r< 
oases it is acute and multiple, and is entirely like acute non-gonor- 
rbteal rheumatism of the joints, 

French authors have pronerly divided the affection into distinct 



\ 



j-rencn autnors nave proneriy diviaea tne atieotion into dtstmot j 

^^biBBce. Soma cases arc gradual and painless, developing without inflam- . ^^J 




MBHCSBS TKS GEXIZAL OBOAXB. 

t IptartAvMH. In other necs, there are 

*.» u «.-uK r^eanutioa. In u third class, 

— - .ir mortnienl vithonl local 

■ nil siippnrjtion, pTiemia, and 

.; '.<!6is, and perni)uient stiffDesa 

..,-. ■■■,.:i.iA seen cases of inflamed jointa 

untim like those of errthema nodoaum. 

t ploamj, and meninptia occur. Schedler 

_A iduefBtive endocarditis aftcrclap. Srythema 

• of tha larjnx are reported b; Lieoennann and 

t iMMi ofaserred. The sheaths of tendons and 

■ attacked like the joints. 

_ _ lias been observed in patients with gonorrh<Ba 

I joint disease. The commonest forms are iritis 

. -lutiietimes associated with opacity of the vitreona, 

ir in the cornea. Pauss describes descemetitis; 

I also with radiating keratitis. 

l^iMulf wt[u«lw of gonorrhcea may be again named: Azoo- 

apermia, tuberculosis of the epididymis and uro- 

* — ** xenital apparatus, chronic hydrocele, stiff and de- 

^^^^^^. furmcd joints, eynecbiee of the eye, etc. Pointed 

^^^^^^^^^^ condylomata sometimes develop after clap; some- 

^^^^^^P^^^B times at the meatus, usually in the sulcus of the 

^^^^Hf ^^^H corona, bat also at the opening of the preputial 

^^^^V^^^^^l sac; they are warty excrescences with many pro- 

J^^^^TJ^^^^^ tube ranees, sometimes surrounding the entire 

l^^^^H^^^^^L [ttiuis (Fig. 43), caused bythe Irritatiug secretion. 

^^^^^^^^^Hp Chronic gonorrhcea in men is extremely com- 

^^^^^^^1^ mon, almost always due to badly treated or ueg- 

^^^^^J looted acute gonorrhoea. There are various ana- 

^^^ tomical changes: chronic granular inflammation, 

iSM%^u?i>r«p"'<>^ or chronic ulcers of the mucous membrane with 

"juwij^i"* A"- granulations that bleed easily, or contraction of 

tv^Uuu, or jj^^ urethra with protracted inflammation behind 

the stricture. In all cases the membranous por- 

V or exclusively affected. 

II continuous discharge, but a mixture of purulent frag- 

yiktvHkta. or ahreda with the urine, especially in the morning, when 

^, . II Ikiui been accumulating for some time. The meatus is often 

,_i Wgulhor in the morning before water is passed, and a drop of 

L> otvtiMms rather than purulent fluid wili flow out or may easily be ' 



\\ uul, the pressure beginning as far back us possible and going 

tie raiiitaire" is a slang term for this affection; another 

liMtuurii'olap." 




VWiuiiimmKipe shows that these discharges contain piis-cornuaclea, 

uUr ttUil ahrunkou, forming a sort of clot; andpavement-epitheliam. 

H(un iu a iitate of hyaliuo dogoueration (Fttrbriager) (Pig. 44). There 



llj'iiiiuru nf thn urethro is the cause of chronic clan, there will be 
'ly III piMaliiK wntur; the atroam is weak, twisted, forked, or drib- 
' Itrwiun* Hiid muoh straining are necessary to start it utd 



tITEEOTIOUS DISEASES iFFEXTTISQ THE OBinTAL OBQANB. S4 

Iceep it going. If there are ulcerations with bleeding granulations o 
the mucous membrane of the urethra, little streaks or clots of blood may I 
be seen in the discharge. I 

Chronic urethritis involves many dangers. Patients are liable to be- I 
come hypochondriacal, collecting every discharge in a special glass to 
count the fibres, and manipulating the penis to get out the last drop of 
urine. Many keep up the disease by these measures. The secretion 
not being contagious, there is so far no reason against marriage. But 
the danger of a new infection is greater than in the case of well persons, 
though subaeq^uent attacks are less violent than the first. There is dan- 
ger from a stricture — or the contraction caused by gradual cicatrizatioD 1 
of chronic ulcers in the urethra. 




TbnaiijiiKbarge in old goiioiTbcM. Author's obMrrMlon, Zurlcb clinic. aSO diun. 

Aonte gonorrhcea in women most frequently affects the vagina, 
Tnlva, and vaginal part of the uterus, less commonly the urethra; though 
the latter is oftener affected than is generally supposed. Bspeoially 
Then urine has not been recently passed, pus may often be made to 
flow out by pressure on the urethra. In acute gonorrhcea of the vulva, 
the labia are often swollen, reddened, hot, and cedematons, the inner 
surface thickened, secreting purulent fluid, which is partly dried in thin l 
yellow-brown crusts, and the labia are often stuck together. There is a | 
tickling sensation which excites lust, and often turns to pain. After 
every diBchargo of urine, there is pain if the urine touches the ioflamed ' 
parts. 

Swelling, redness, pus, and erosions are also seen in the vaginal and ' 
"Tical affection, (ionococci in the pus prove the virulent (or rather, 



848 



IHFEonoira DraEAara AFFBOTDfO THS OEHITAL OBOA.n. 



contagions) nature of the discharge. If the urethrals affected, there 
are frequent desire to pass water, acd bnrning sensatioiia while passing it. 

If a woman goes about a good deal while the secretion ia free, it nins 
down and causes eczema intertrigjo of the inner surface of the thigh, 
with redness, moisture, and burning of the skin. 

The inflammation sometimes extends to the orifices of the glands of 
Bartolini, exciting secondarj inflammation. There is pain behind one 
labium, and a tumor is visible, which forms an abscess and may break 
into the Tagina or through the skin. Para- and peri-metritis have been 
known to occur after acute gonorrhcea; even peritonitis has been de- 
scribed, in which it has been assumed that the morbid agent succeeded 
in finding a passage through the Fallopian tubes. 

Cystitis or nephritis sometimes follows go no rrhc&a of the urethra. 
In other respects, the complications generally resemble those in man. 
Rectal implication, by the pus flowing down into the anus, is said to 
take place readily: there is a burning pain in the anus, especially atatool; 
the folds of the anus are red and swollen, and purulent secretion escapes. 
The fingers must be free from wounds in examining the rectum; the latter 
is felt to be hot and swollen, is sensitive, and purulent or muco^puruieut 
secretion is left on the finger. 

III. Anatomical Changes. — As gonorrhoaa seldom causes death, 
there are few autopsies. In place of such examinations, mncb has been 
observed with the speculum in the vagina, and with the endoscope in the 
urethra. The latter is a tubular instrument through which light is 
thrown into the urethra. Desormenx in 1855 made the first thorough 
studies, andGrunfeld some of the best in German v. The whole anterior 
half of the urethra can be seen with an ear-speculum and mirror. 

In acute urethral gonorrli(Ba, the mucous membrane is much swollen 
and reddened. In some places, vascular trunks full of blood ran b] 
recognized; in others, the epithelium is gone; there aresmall ac<^iimiila- 
tions of pus here and there. The membrane may bleed very easily. 

In the chronic affection, the mucous membrane is most commonly 
swollen, diffnsely reddened, and granular — chronic granuUr ure"- 
thritis. In other cases, there are ulcers in the membranous part of the 
urethra, some of which are grauulatiug. Stricture may be added. 

IV. DiAONoais. — The microscope renders this easy, for every in- 
flammation containing gonococci in its products is gonorrhcBa. Neisser 
has demonstrated them m the purulent secretion of blennorrhoic con- 
junctivitis neonatorum, communicated from the mother's vagina at 
birth. 

In diagnosticating chronic clap, we have chiefly to ascertain whether 
the acute disease has preceded it. As regards the anatomical lesion: 
the presence of stricture is indicated by certain characteristics in the 
stream of urine, but the sound is necessary in order to prove ite 
presence. If we cannot prove it, our diagnosis first ties betweea 
granular iufiammation of the mucous mi'mbrane and chronic ulcera- 
tion; the latter will bo inferred if the sound, or pressure from out- 
side, gives sharp nain at any special poiut of the pars membranaoea, 
or if streaks of blood are seen iu the secretion, or if bleeding easily 
occurs in passing the sound very carefully. The endoscope is not yet in 
the hands of the profession at large. 

V. pEOONOSia. — This would be favorable in all cases if persons had 
not the habit of regarding the disease with as little concern as they do a 
common cold. The result of their eareleasnesa is rarely death, butof' 



^^^V IKFECnoUS CtSE&SICS ATFECTDIO THE 0E5ITAL OBaASH. SiM 

^^^Bmsh the health is impaired for a long timo or permanently. Tbs^ 
^^^Sronio disease often resists riidical treatment for u very long time. 

VI. Treatment. — The best safegutird is to avoid diseased women. 
The frequency of disease could be much restricted by having women in 
brothels strictly ezaniined several timoa a week by physicians, who 
should be instructed how to make the certain diagnosis by the micro- j 
scope. The more completely the profession of prostitutes is brought J 
under police control, and private proatitution checked, the leas thefl 
danger of contagion. ' 

An Suglish physician named Condom is the author of the india-rub- 
ber ba^ used to protect the penis in copulation. Aside from the un- 
naturalness of this procedure, the danger of contagion is by no means 
avoided, since the thin coating is easily torn in coitus. It has been 
recommended to wash the penia in a solution of carbolic acid, two to five 
per cent, after a suspicious connection; to pass water after coitus, in 
order to washout the urethra; and afterwards to inject a solution of two- 
per-cent carbolic acid, or dilute vinegar, to destroy the virus. Such J 
preventives are not absolutely sure. Another thing to avoid ia, visiting 1 
nouses of prostitution after indulgence in couviviality. I 

Many plans for cutting abort or aborting the disease when it appears J 
have been invented. As a rule, it is said that such treatment must not I 
be applied later than two days from the beginning of the purulent dis- 1 
charge. The remedies advised arc nitrate of silver (one part to thirty I 
for injection), or solution of caustic potash, or aqua caJcis. This 1 
method is theoretically justifiable, but in practice almost alwaysdoes great I 
harm, for the discharge is not generally suppressed, while severe diseasea I 
of the bladder, epididymis, and so on, are readily excited. 1 

Much experience in our own practice has led us to the following 
plan. The patient lies abed, drinks no strong coffee or tea, eals no 
highly seasoned food, avoids all aexnal excitement through converautiou, 
reading, or pictures, and uses, instead of coffee, milk or weak tea or coffee 
au lait. Carbonic-acid waters are not to be used. The patient injects & J 
two-per-oent solution of carbolic acid into the urethra every hour ia I 
order to get rid of the secretion as soon as possible, I 

^^^If the disease lasta longer than six days, use au injection of M 

^^H S Zinc. Sulph .gr. vi. I 

^^^H AquEB fl-lvi. I 

^^^V lodoformi ^ iiss. -% 

^^^m Solve; misce. Shake well before using. I 

^^HpFhia is to be injected every second hour, directly after using the " 
^lOTmer injection, which is not to be suspended. But the zinc solution 
must be retained fully ten minutes by closing the meatus with the 
fingers. I have cured in a very short time cases which had lasted for 
months, and had resisted various treatment. The physician must never ^ 
neglect to warn the patient not to apply his dirty finger to his eye or to j 
other mucous membranes, or sore places. I 

The eyringea that we prefer are the Klass one«, with the tip rounded to avoid 
injuriuK the urethra. The piston must fit well and druw well. It is filled with 
the 6uid, nnd held point upward, and the piston puelted forward U) expel the air; 
then the point is dowl; and carefully introduced into the urethra, till the nozzle 
i^Il witnin the canal. The thumb and forefinger then preiw the meatus t;entlj 
^^■^t the noEzle ao as to keep the fluid from escaping, aud the pistou is pressed 



250 iNFBGrnous disbasbs affsotinq- thb genital OBOAm. 



▼err gradually, so that it requires ten or fifteen seconds to discharge the syringe. 
If the fluid is to remain, the thumb and finger keep the meatus closed while Uie 
nozzle is drawn out. Qreat care in performing these operations is necessary in 
order to insure success. 

Tin or rubber syringes are inferior, because they are opaque and hard to keep 
-clean. Rubber syringes with long nozzles, introduced to the full length, are 
irritating. 

For injection in acate olap a namber of astringents or disinfectants 
have been recommended^ none of which seem to be eqaal to the aboye 
treatment. We should in general begin with weaker solutions and 
increase to stronger ones by degrees. It is adyisable to change the 
remedy once in five days^ as the mucous membrane grows accustomed to 
one. We mention the following solutions: Tannic acid, gr. xy.-Ixxy.: 
5 vi. ; Crude alum, gr, xv.-lxxv. : | vi. ; Acetate of lead, gr. xr.- 
XXX. : 3 vi. ; Nitrate of silver, or acetate of zinc, or sulpho-carbolate of 
zinc, or sulphate of copper, gr. iij.-viij. : | vi.; Snlphale of cadmium, 
gr.-^jT^: § vi.; Subnitrate of bismuth, gr. xv.-xxx. : S vi.; Kaolinum 
purum pulveratum, gr. Ixxv. : § vi.; Corrosive chloride of mercury, gr. 
i^TT-y^ : I vi.; Permanganate of potash, gr. iV4' I ^^-' Muriate of 
quinine, gr, xv.-xxx. : 3 vi.; Chloral hydrate, gr. xv.-xxx. : 5 vi- 

Insufflation into the urethra has been employed. 

If patients will be so foolish as to go about their business while sick, 
let them at least wear suspensory bandages, which support the tester 
without compressing them, as pressure might cause inflammation. 
Standing, running, heavy lifting, and wearing too tight trousers, should 
be avoided. The internal use of cubebs, copaiva, Peruvian balsam, Toln 
balsam, turpentine, may be conjoined with the injection treatment when 
patients go about. 

Cubebs is given with cinnamon or liquorice, a teaspoonful three 
times a day. Balsam copaiva, best in gelatin capsules, each containing 
"ni X., five to ten to be used daily. The others are less active. 

Leber recommends tincture of sandal-wood; Vidal, gurjun balsam; and 
Dupoy, cava (cava-cava or piper methysticum). 

When the discharge of pus ceases, the convalescent must avoid ex- 
cesses in Baccho et Venere for a long time; too early return to beer 
often produces relapses. 

The treatment of complications can onlv be sketched. For large 
hemorrhage, raise the penis against the belly and wrap it in cold com- 
presses; if bleeding continues, inject the following: 

3 Liq. ferri perchlorid gr. xv. 

Aqu8B fl. 1 vi. 

For erections and pollutions, direct the supper to be taken seyeral 
hours before bed, and to consist chiefly of fluids. Also give 

3 Potass, bromidi gr. xxx. 

Lupulini gr. viij. 

Pulv. camphorsB gr. iss. 

Morph. hydrochlor gr. | 

Pulv. GlycyrrhizsB gr. viij. 

M. f. pulv. no. ij. S. One before bed*time. 



IHFEOnOUS OIBBAHBe AFFEOnSO THE GENITAL OBQANS. 



951 



Cold compreasea by day for the same trouble. Digitalis la recommended 
by B^reiiger-Ferawd. 

For cfiordee, the treatment just described; if ioduratiou ia felt in 
the regiou of the urethra, inunction with iodide of potassium ointment. 

For frcqueut micturition, suppositories of opium or morphine, and 
not belladot'ia, which often increaseE the trouble. 

f). Morphini hydrochlor gr. viiss. 

01. TheobromtB q. s. 

F. Bupposit. No. iij, 

AToid also the too free use of fluid and carbonic-acid drinks. 

Periurethritis requires poultices, and sometimes opemng of abscesses. 

Balano-posthitie: bathe the penia every three hours iu a lukewarm 
tvo-per-cent solution of carbolic acid, and insert with an olive-tipped 
sound, between glana and foreskin, some thread-charpie covered willi 

l_ Q Ac, tannici gr. xv. 

j^v Yaselini 3 ss. 



"We hsTe also found it very useful to touch the glans and foreskin 
with lead-water just after wasliing. 

If there is phimosis in addition, inject solution of carbolic acid every 
three honrs with a syringe between prepuce and glans, besides the oint- 
ment on charpie. If the phimosis is excessive and inflammatory, use 
lead-water compresBes, and if this does not relieve inflammation, the 
prepnce must be divided to avoid gangrene. 

For paraphimosis, flrst use cold lead-water compresses, as the trouble 
often auDsides after the inflammation is relieved. If it is thought neces- 
aary to relieve it at once, embrace the foreskin between the fore and 
middle finger, and push the glans back with the thumb of the same 
hand. If gangrene threatens, incise the inner lamella of the prepuce at 
the point of tension. 

For lymphangitis and lymphadenitis, rub in gray mercnrial ointment. 

In case of epididymitis, the patient must go to bed. The testis is 
kept high by a small cushion, and cold lead-water applications are made. 
All injections into the urethra to be suspended. The bowels to be 
opened daily with: 

»B Hydrarg. chlor. mit,, 
Pulv. Jalapie, 
Sacch. alb aii gr. viij. 
M. ft. pulv. No. ij. y. Take one powder. 

Place three to six leeches around the anas if pain is excessive. If the 
inflammatory Byraptoms diminish, wind the testis every day in a wet 
gauze bandage beginning at the upper part. This is much hotter than 
shaving the parts and applying stickiue plaster iu strips, as it is easy to 
remove the bandage if it presses. It is also snperior to the rubber 
bandage of Neumann. Scarifi cat ions have been successful in case of 
great accnmnlations of inflammatory fluid. 

For persistent induration of the epididymis, give iodideof potassium 
(jiiss. in 5 vi- of water, a tablespoonfal three times a day), or for 
anemic patients iodide of iron, and frictions with ointment of iodine 



252 nfFKcnouB disbases affecttsq the obnital orqahs. 

If there are symptoms of yesical catarrh or inflammation of the kid- 
neys, suspend the injections, and give tea of uva ursi leaves, tannic acid, 
or arbutm; for severe pain in the bladder, warm cataplasms to thai 
region. 

In inflammation of the prostate, seminal vesicles, or Gowper's glands, 
use warm poultices to the perineum; for violent pain suppositories of 
morphia, or leeches to the perineum, suspend injections, and secure 
daily stools. 

For inflammation of joints, iodide of potash or salicylic acid (gr. 
viii. hourly till the ears ring), but neither gives prompt relief. Of late, 
I have often found benefit from pencilling the joints with iodoform- 
coUodium and ice-bladders. Puncture of the joint and drainage may 
become necessary. 

Condylomata acuminata are to be removed with scissors; small ones* 
dry up if pencilled daily with Fowler's solution. 

Chronic gonorrhoea is often very obstinate; the list of remedies is 
enormous. Blackwood reports that the galvanic current applied to the 
perineum and urethra has proved succes^ul. 

The first step is to find the cause. If it is stricture, treat it with 
bougies, and do not be alarmed if the discharge increases and becomes 
purulent at first. If it is granular ulceration in the membranous part^ 
use bougies dipped in oil or glycerin, and then sprinkled with tannin, 
bismuth, alum, or starch. It is better to apply remedies directly to the 
spot by special instruments; such remedies may be nitrate of silver. In 
granular urethritis, use same injections as in acute gonorrhoea, only 
more concentrated. Inlections of tannin with red wine and hyposul- 
phite of soda are specially praised. 

Urethral suppositories of tannin, lead, lunar caustic, iodoform, or 
starch mixed with glycerin or cacao butter, are allowed to melt in the 
passage. 

Patients must be warned not to force the discharge out by manipu- 
lating the penis; and must be encouraged. 

For acute gonorrhoea in women, use sitz-baths, followed by syringing 
out of the vagina with astringents. 

3 Aluminis 3 iiss. 

lodoformi 3iv. 

Vaselini 3 iss. 

M. S. To be introduced into the vagina morning and evening, spread 
on a pledget of cotton. 

For infiammation of Bartholini's glands, warm cataplasms and inci- 
sion when suppuration begins. 

2. Soft Chancre. Ulcus Molle. 

{Pseudosf/philitic Ulcer. Chancroid (Clerc). Ulcus Cotiiagiosum 

Simplex {Sigmund). 

I. Etiology. — Soft chancre is a contagious sore, commonly seated 
on the genitals, and caused by impure coitus. The virus is found in the 
inflammatory secretion of the ulcer, but its morphology and chemistry 
are unknown. The ulcer loses its contagious power when it cleans up 
and begins to heal. 




nrfBonocs diseabks apfeotinq the genital oroanh. 363 

n at its height, the ulcer is very contagious. A sinKle drop of pus has 
I mixed with half a glass of water without losing ita activity. In closed 
_ a tubes, the inouulabilii; remains longer tiian a fortnight. The dried secre- 
tion m.t]' be found active if softened in water a long time after. Placed in boil- 
ing wat«r, alcohol, concentrated mineral acid, caustic alkali, or astringent fluids, 
It entirely lost its comniunicahiJity. 

Physicians or midwivos may ousilv get Boft chancre on their fingers 
in examining dirty persons, if there is a lesion of the skin of the finger. 
Chancres of the nipple, lips, ala nasi, lobe of the ear, eyelid, or hairy 
scalp are caused by pus reaching those places. In the rectum of man, 
they indicate unnatural practices, while in woman it may be transferred 
by pas running down from the genitals. Kissing, the use of water- 
closets after chancrous persons, the use of drinking cups, ea ting- v easels, 
and pipes, foul linen and bandages, and infected wash-tuba are other 
ways. But such cases are rare compared with those of contact in 
coitus, and' stories are not always to be believed. 

It is said that men have lain with diseused women without becoming aSeoted, 
but have transmitted disease to other women whom they have visited directly 
after, the eipianation beina that thev havo carried infecting pua under the pre- 
puce from one to the other (Sicord, Puche). 

The danger of contagion is much greater when there are wounds 
about the genitals, and wounds may be made during violent coitus in 
the form of epithelial erosions or cracks of the surface. It is probable 
that the secretion may penetrate parts where the epidermis is very thin, 
thongh there be no lesion. 

Soft chancre is more common among men than among women. One 
often sees a series of several cases at once; and I havo repeatedly beard 
natienta trace all the. cases to one woman. The soft chancre is seldom 
fonnd in ohildren; if seated on the genitals or anus, it may be caused by 
violation; if elsewhere, it may be due to accident. 

Soft chancre, like clap, while uncomplicated, is a purely local lesion 
of the genitals; at fartliest, the neighboring lymphatic glands are impli- 
cated. The disease is not hereditary, nor does one attack insure against 
another, in ease of new exposure. A coincidence of soft chancre, gonor- 
rhoea, and syphilis i^ not rare, as one form does not exclude the 
other. If a man with soft chancre cohabits with a syphilitic person, his 
sore may bo changed into a syphilitic or hard chancre. While his soft 
chancre, [lerhaps, heals by degrees, the hard chancre develops very 
alowly, becomes more and more indurated, and in the place of the former 
soft sore, a lamp of cartilaginous hardness rises, which is afterwards fol- 
lowed by sj"philitic changes of the skin and mucous membrane. ■ Wo 
must, therefore, be a little careful about prognosis. Such a case is called 
a mixed chancre (Cierc). 

II. Symptoms. — The duration of the incubation is well known from 
experimental inoculations of well persons. It is so short as hardly to 
exist. The patients usually say that they noticed the first symptoms on 
the second or third day, but that proves nothing. Many consider that 
the period may possibly be from fourteen to thirty days (?). 

If the inner side of the thigh or upper arm is inoculated with infectious pus. 
a red border is developed around the puncture within twenty-four hours; ia 
~*~~-ei){Iit liours, there ia n red papule, quickly turniosr to a pustule, with pus 
- the epidermis; this bursts, and dries to a crust. If this is removed on the 



!^ 




UiriXTIOCB OUEASES AjrrEOIIXC TBS S^EZTU. 



Adh or diUi <\»T. tt>«ra mnutini a deep nLeer vilh the 
t!lM*cf*. Th» *lnM la Inoculsble on 

Tb» chMvotAriitics of the ioft cbsoon an oanAlIr nrj 
\a HWtHJIy tiMp. with «tt<cp edgea, formiagscnter'; often perfect] j nsad 

t» if i>iiii' l<"-l out. ntiilf at ntner timea its edge has ban, mt if ntcaiBto. 

I' I I < isimrply defiued, often ■ littJe nued in Tarw and 

tlii>l> i Tlio iuimediHte vicinitr is inflamed and red. 

Tlx ' i<>[i hoe u yellowish or gr««iiuh'gray, tallowy, ne- 

t>tiiti it, uttliK period of full deTclopmeot, and the aectv- 

tjiii. ' M long as this coat continaes. The surfaee taalM 

fvill :n-oaten. The pnralent cost oontaiiu pas-oeOi^ 

4U.I <: - iif amnionio-magiiesiaii phosphate and eariioiuti 

uf 111 i jins itaelf afterwards, the secretion becomea pnni- 

t^ot <»»1 granulations, and cicatrixation ocean; tt tiii 

KM, I lotioii is produced. If the nicer is pr«ned with 

,v << -idti, jiain iafelt; prickling, itching, ood pcin nu; 




\m l*ili BpontanuiiiiRly. The uloer bleed§ easily when compressed or 
|l4Uiiiiiiit Willi u opdiifce. The base and vicinity are often slightly hard- 
Df)Pili fniiii iulluniniution, but this hardueas passes graduallj into the 
H|tt|(itlK<fiiijf parU. 

Ill U«> iiiuJoHty of ciuiea, soft chancres are multiple; the edge of the 

iir()ptiu(), ihti lahiii. otn., being fringed with them. Opposite surfaces of 
klU in nloiM iiniiiatit often liHVu ulcers of exactly corresponding size and 
Ntilll'ai Wti out) aoiuollmes see the auto-inoculation of snperiaceat skin by 
IfH nliiur. 

Tbu sIm) vurioN from that of a pin's head to tliat of a finger-nail or 



^% 



Th" uonimonost seat of ulotTa in man is the external prepace. They 
hICii uuiiur itii tUi< udgfl of th« prepuce, its inner surface, and the sulcus 

El'ii|iuriii«i in thii litltiT coao, they may destroy the frsenum, or perforate 
ur (ituv iijiitii tilt) arlurv of the frioniim and cause very troublesome 
Kudiii^ MliuiirmiM ulcnrs may he found at the meatus or in the 
UfKlljlUi l'>il nut iti'Djii'r thun the fossa navtcnlaria. In the latter coae. a 
mflifidii ^I'tr uuuiir* front tho nrethra, and the disease may easily be 



^^V IKFBcmoTm DISEASES A^FFBOrmO THE OBKITAI. OBGASB. SoH 

^^Btaken for gonorrhcea. They occur alao on the skin of the scrotum, ■ 
^^Sthe genito- crural fold, on the aymphysia pubis, and the navel. 

In women, soft cliaucrea are most commonly seen on the inner surface 
of the labia and the posterior comniisBure of the vagina. The labia are 
often gwolleu and red, and the ulcers corered with honey -colored 
or brown crusts. They also occur on the prepuce of the clitoris, the 
mons, and the genito-crural fold; more rarely on the mucous membrane I 
of tho vagina or the vaginal portion of the uterus. The rectum has been | 
montionod. 

Chancroids usjiially cicatrize by degrees. The cicatrix is soft, and 
leaves on tho skin spots which are at first pigmented, but afterwards 
grow white, with occasionally a brown pigmented edge. The ulcer 
usually begins to clean up in the third or fourth week, and cicatrizes in 
the fifth and sixth. ■ 

The follicular chancroid and the superficial chancroid form a kind of 1 
transition to the complications. I 

The follicular chancroid is a very deep, narrow ulcer, originating in | 
a hair- follicle, and seen with especial frequency in women; the super- ] 
ficial chancroid spreads laterally rather than deeply. The latter sort arft | 
common on the glans. Juliieu has lately described bullous chancre, 
which leads to vesicular elevations of the skin. Ulcus moUe elevnlum 
sive luxurians is a term for cases which have abundant granulations at 
the time of recovery. Diphtheritic chancre is more serious. Besides a 
true diphtherial coat over the ulcer, there is often extensive destruction 
of tissue. The gan^nous chancre is nearly related to this; gangrene, of 
the ulcer and its vicinity, often spreads very fast, so that in a short time I 
extensive destruction of the penis and skin of the scrotum, the perineum, I 
inguinal region, and abdominal wall occurs, ^uch cases have been oh- 1 
served with special frei^uency in hot summer weather, and in atiiemic' I 
pereons. those tar gone m consumption, and persons addicted to drink. I 
The use of mercury causes a predisposition to gangrene. Phagedienio 1 
chancre also causes rapid destruction withont decided gangrene. In these ! 
oases, the parts below the skin (as the muscles of the abdomen) may be J 
exposed, as if dissected with a knife. {Serpiginous chancre is u term for 1 
cases iu which a chancre heals and cicatrizes at one point, while extend- I 
ing in another; it is often protracted, and causes cxteusive ulceration I 
and cicatrization. 

Complications may originate from local circumstances, as when the I 
fmnum is perforated, or its artery. On tho edge of the foreskin, ulcers ] 
often have the form of fissures or rhagades, and cause swelling, narrow- | 
ing of the outlet, and inflammatory phimosis. Ulcers on the inner la- I 
mella of the foreskin and the fossa of^ the glans may also cause phimosis ' 
through inflammation and cedema of the prepuce; if the foreskin is drawn 
back forcibly, this may be converted into paraphimosis. Balanitis also 
often exists. Ulcers on the glans often go so deep as to destroy a large part 
of it. Ulcers at the meatus or in the urethra interfere with urination. 

Infiiimmation in neighboring organs often causescomplications. Es- 
pecial attention is due to inflammation of the inguinal glands, which is 1 
usually acute, and is designated as acute bubo. This complication is J 
favored by irritating local treatment of the ulcer, or by irritation | 
through bodily exertion, tight trousers, long marches, gymnastics, daiic- ] 
ing, riding, etc. Continued excesses with wine and women favor it. The I 
Ig^ity has some iafluuuce, for buboes often accompany oloers of the J 



S56 tnwMxmavB DisBASEa AyrBcnua ths GBmrxL OBOun. 

fnennm or fossa, sinco numeroLiB lymphtttica originste in thoee parte, 
and their nearest meeting-place is the glaods in the groin. 

The lymphatics of the dorsum penis are also often iaflami^, and then ^ipeu 
OS a tender cord, round, soinenhac hard, often knotted, tbe akin over which ma; 
be reddened: pus is rarelj formed. 

tricers on one side of the penis cause bnbo in the corresponding 
groin. This is evidently due to the anatomical connections of the 
^mphatics. Both groins are affected when the ulcers are in the tne- 
aian line, on the frsenum, or dorsum of the glans or prepuce. 

Uuboes may (w sympathetic, in which case they resemble those which 
arise from the presence of any inflammation in the vicinity of thoglanda. 
The swelling ia usually multiple; the glands tender to pressure, painful 
in walking, and gradually disappearing when care is taken. Snch swellingB 
are always more common in people «-hoare predisposed to glandular en- 
largment'-that is, the scrofulous. They often remain for months or 
yeara, and this form has been called strumous hubo. 

Chancrous buboes affect onl^ one or few adjacent glands, and 
have a tendency to acute suppuration. The gland Bwells, and is often so sen- 
eitive that the patient can only walk slowly and haltingly iu the stoop- 
ing position; the skin over it is (Bdematons, then reddens, and sdbereE 
to the gland; periadenitis sometimes develops meanwhile. Suppuration 
of the gland gives rise to a fluctuating tumor which may burst during 
any violent movement, or may gradually work its way out through seve- 
ral orlGces. In many cases, the pus burrows deeply and may erode blood- 
vessels in the leg, endangering life by bleeding; or circumscribed or dif- 
fusejperitonitis occurs. 

The chief point that diatinguiahes a chancrous bubo from the pnm- 
lent sympathetic kind is the inoculability of its pus. which can be demon- 
strated by producing chancroids either on well or on affected persons. It 
is therefore natural that, after breaking, these abscesses sometimes 
display such phenomena as gangrene, phA^edeeua, or a serpiginouB 
tendency. Acute chancroid buboes are sometimes accompanied by very 
violent general symptoms, as a chill, vomiting, constipation, and fever; 
I have known several cases in which the physician had thought of incar- 
cerated hernia. 

French authors speak of the possibility of the virus passing through 
the skin without causing a sore, and giving rise to a bubo — bubon d'em- 
blie. The point is disputed, and more than doubtful. 

Among the sequelte of soft chancre is destruction of large parts of the 
sexual organs; in some coses only the stump of the glans or penia re- 
mains. Perforation of the fnennm is usually of no consetjuence. Ulcers 
of the meatus may contract the opening when they oicatnze, which will 
require an operation for relief. Pointed condylomata may spring np 
whore the external genitals are irrigated with irritating secretiona. Fis- 
tulous paasages may remain for a long time after suppurating buboes. 

III. Diagnosis. — Soft chancre is not usually nard to distingaiab. 
We must consider especially acnSf herpes, hard chancre, and cancer. 

Acne is connected with aebaceous follicles, and makes abscesses and 
nlcers which heal spontaneously in a few days. 

Herpes produces a group of vesicles crowded together on a reddened 
base; tne contents are at first serum, which afterwards dries to thin 
crusts. After the crust falls off, no deep, crater-like ulcer remains,,^ 



INrSCTIOCa diseases ATFECTXHO the OEinTAL OSGAIIS. 

trouble heals spontaneously in a few days. Patients often state that 
they have repeatedly had similar attacks without having had coitoa. 

Hard chancre, the first distinct symptom of syphilis, differs from soft 
chancre by its sharply defined cartilaginons hardness; purulent destruc- 
tion, pain on pressure, and tendency to bleeding are not generally pres- 
ent; the nearest glands show multiple enlargement, are not tender to 
pressure, and have no tendency to suppurate. 

Catpary gives the tollowiag biatological points of difference: In hard ohan- 



A resemblance between soft chancre and epithelial cancer is most 
likely to occur when parts of the penis have been lost. It will be neces- 
sary to review the early history of such cases. 

In all doubtful cases, try inoculation (on the thigh), but b 
make no errors of detail in performing it, and to take the pus at a time 
when it is yet inoculable. 

I have repeatedly seen cases in surgical wards, of extensive destruc- 
tion of the tiasoes of the skin, in which it was doubtful whether phage- 
drauic or gangrenous chancre was the cause, or not. 

IV. PB0QN08I3. — Though manifold complicatious may he associated 
with soft chancre, and may develop into serious diseases, yet the prog- 
nosis is usually good. The more care u patieut takes of himself in mind 
and body tho better chance of a good sound recovery. Anaemic, poorly 
nourished, or tuberculous persons are in more danger from tho develop- 
ment of complications than robust patients. It is well to keep a patient 
nnd'er one's eye for a time, lest symptoms of syphilis may break out after 
an unrecognised mixed chancre. 

V. Treatment. — As regards prophylaxis, we refer to the remarks 
already made in connection with gonorrhcea. Washing the pent a and 
scrotum with five-per-cent eolation of carbolic acid after coitus is by no 
means a sure preventive. 

Abortive treatment is of no use unless applied within the first four 
days after the ajijiearance of the sore. It consists in canterizing the 
nicer and its vicinity so as to destroy all infection. Nitrate of silver, in 
concentrated solution or in stick, caustic lime, caustic potash, many 
kinds of paste, and the galvanic cautery, have been used. We are per- 
sonally averse to this method, chiefly owing to our distrust of the 
data regarding time given by patients. , 

Excision of the ulcer is almost always followed hy a chancrona stata 
of the wounded surface, which leaves things worse than before. 

The treatment of chancroids and the attendant buboes belongs rather 
to surgery. We mention, however, a few points. Patients mnst live 
moderately, avoid beer and wine, have a daily stool, and avoid bodily 
and mental excesses. Coitus must be avoided. A very thin layer of 
iodoform is to be powdered over the surface of the ulcer morning and 
evening, and covered with salicylated cotton spread with carbolic acid, 
one part, to twenty parts of vaseline. Before each dressing, wash off 
with lukewarm carbolic-acid solution (8?). 

The following dressings are old favorites: solutions of sulphate of 
copper, i per cent; of sulphate of nine, nitrate of silver, carbollo acid, 

tganate of potash, creasote, etc. 




258 iKFBcrnoirs diseases affeotino the nebyoub STfirrmc 

In the case of gangrene, phagedsena, or serpiginous ulceration, try to 
remove the cause {e. g., forbia mercury); give strength by beer, wine, good 
food, cod-liver oil, preparations of iron or quinine; and employ the 
above local remedies, or acetic acid with clay (2^). Cauterizing has 
been attempted. Thiersch recommends for phagedadnic ulcers the sub- 
cutaneous multiple injections of nitrate of silver (1 part in 1,500); they 
are inserted at distances of one centimetre from each other and from the 
edge, but are directed towards the ulcer. Tillot recommended chlorate 
of potash in the form of a salve (1 : 30). 

Phimosis and paraphimosis are treated as before described. 

Buboes. The patient goes to bed, applies lead-water on compresses 
continually, with bits of ice, and lays on the compress a shot-bag or 
a piece of lead to keep up a gentle pressure. If inflammation continues, 
use poultices, and at the proper time open the abscess according to Lis- 
ter's method. We do not think that multiple puncture with pointed 
bistouries, opening by means of caustic paste, or puncture, is of special 
advautaffe. 

Developed glandular chancres are to be treated like others. Daily 
sitz-baths for cleansing the sores are useful. We may try to produce 
absorption of strumous buboes by painting with iodine or ruboinff in 
ointment of iodide of potash or iodoform, giving also cod-liver oil, iodide 
of potash or iron, and arsenic. 



PAET VII. 

INFECTIOUS DISEASES AFFECTING THE NERVOUS SYSTEM CmEf LY. 

1. Epidemic Cerebrospinal Meningitis, 

I. Etiology.— Epidemics of cerebro-spinal menineitis can be traced 
back to the beginning of the nineteenth century. They often attack a 
small village and spare neighboring places. Epidemics limited to single 
houses, especially soldiers* barracks, have been known. They usuidly 
occur in cold, damp, changeable winter weather, and cease in sum- 
mer. Children, especially under five years old, are most frequently 
attacked: after the age of fourteen the disease is rare. The maJe sex is 
more liable than the female; and poverty, crowded quarters, and poor 
food predispose to it. Communication from one person to another is 
not demonstrated, but many cases are reported in which the disease has 
been brought into a place by a patient coming from elsewhere, as in the 
case of recruits (Fraentzel). Many authors, therefore, consider that the 
disease has only a miasmatic origin, while others term it a miasmatic and 
contagious disease of infection. An epidemic may last weeks or months, 
even years; isolated cases may occur for years in a place after a violent 
epidemic. 

At the time of an epidemic, insi^ificant causes often suffice to 
develop the disease; I know a case which developed very shortly after 
the patient had made a dive into the water, without accident. Other 
infectious diseases are often accompanied by a purulent cerebro-spinal 
meningitis, e. g., fibrinous pneumonia. (See vol. I., p. 286.) Other 
epidemics — small-pox, scarlatina, typhoid, relapsing fever, mumps, 
whooping-cough, malaria, etc. — may prevail at the same time. 



^^^^^^HKmocB uisKASse affbctiho the skbtobs srsncK. 959^ 

^^^^^^H^tioQ to purulent iuflammation of other parts—e. g., bolla — 
HHHBKtticed (luring epidemics of corobro-spinal meningitis. 

Sporadic cases of tne disease may be called spontaneous cases; though 
the patients often assisn such causes as taking cold, over-heatiug in tno 
sun, mental over-worE, or excess of drink, which are animportant, or 
at the m<»t only aggravate the complaint. 

Nothini( is certainly knoivn in regard to the nature of the iuFectious mHterial. { 
Gaucher. Leyden. and LeichWnstern observud oval raicrocooci in the inflamma- 
tory products, joined iu paira {diplococci). and according lo Leydeo in chains , 
of from three to eiz. 

II. Anatomical Changes. — The local changes affect principally 
the pia mater and arachnoid of the brain and cord. There is infiammar 
tion (piitis and arachnitis, or collectirely leptomeningitis), oauaing a 
deposit of exudation, which is commonly fihri no-purulent, mor& 
rarely aero- purn lent. Death may occur so quickly that at the autopsy 
nothing beyond severe hypertemia ia found. Secondary alterations of 
the nervous system also occur; and indications of general infection are 
very prominent, 

Tne corpse usually decomposes qoickly. 

On removal of the cranium, nnusuttl tension of the dura mater ia 
noticeable. The bones of the skull are very full of blood. The sinuses 
of the dura mater are often filled with blood and clots. If the dnra ia cut 
and turned back, its inner surface is usually dry, lustreless, and dotted 
with hemorrhages. Id the tissue of the pia and the subarachnoid tisane 

furalent and fihri no-purulent masBea are seen. The veins of the pia, 
all of blood, are often bordered on both sides by streaks of this mate- 
rial. Purnlent secretion is especially common in the sulci of the brain, 
such as the fossa Sylvii, the optic chiasm, the anterior surface of the 

Kns, and surface ol the cerebellum. The tisane of the pia is also swol- 
I, and the sulci of the brain obliterated. ' 

The cortex and adjoining cerebral substance are watery and swollen, 
and the highly hyperaamic septa of pia mater may often be seen at some 
depth. Small hemorrhages, lyin^ close toother iu a group, are often 
seen. Strfimpell described cases of abscess in an epidemic at Leipzig. 

The fluid of tho ventricles is usually increased, often opaque and 
flocky, even purulent. Sometimes this condition is limited to a part of 
the ventricles. Purulent infiltration of the choroid plexus may be 
associated with the other changes. 

The cervical part of the cord is comparativelv free; the posterior 
surface is the part most affected, a phenomenon which has been thought 
to be associated with the effect of gravitation in a constant dorsal decu- 
bitus. The other changes resemble those of the brain — hyperffiraiu and 
purulent-fibrinoiis exudation in the tissue of the pia and arachnoidal 
trabeculie, liyperEemia and hemorrhages in the substance of the cord, and 
rarely an accumulation of pus in the central canal. 

The microscope shows that the blood-vessels of the braja and cord are Kreatly 
affect xl. The inner coat and the adventitia are tult uf numberless round cells, 
which collect on the outxide oC the blood-vesael and form purulent streaka, as 
«een by the naked eye: the same, to a leue extent, is seen in the biood-vesaela 
which enter the aabstance of lh« brain and cord. The corles experiences many 
alUirationa, eep<>cially that of proliferation of nuclei in the neuroKtia, and swell- 
ing of the ganKlicn cells and ganulo-fntt^ degeneration of the finer nerve fibrea. 
lathe cells o( the ependyma of the ventncles, there is clciudinees, fatty degenera- 



260 



mrBtmoTTS diseases AFFEfJirSQ THE KEBT0D3 STsm 



tion, desquamation. laflammatory soCteaiDg may take place in the adjacent braio 
aubstance. 

Interatitial inflammation and granulo-fattjr degeneration of the nerve fibres 
may also be observed in the HUhetance of the briiiii. 

De Giovanni has oboerved hypi^rteiiiia ot the sympathetic an<l peripheral 
nerves, with interstitial nuclear proliferation and fatty degeneration of nerve 
fibiee and ganglion cells. 

Cheesy degeneration of the purulent exudation has been described as a com- 
mencement of healing. Thickening of the soft membranes and adhesions be- 
tween them and thu brain remain permanently. 

The musciee ure naually dry. brown-red, pale- yellow in Bome places. 
The microscope ahowa cloudy awelling (Kleba), fatty and waxy degene- 
ration (Rudnew). 

The blood is generally of a remarkably dark, berrj-jnice color, and 
thick. 

Tlie heart usually relaxed; microBcopic changes as in voluntary 
muscles. 

Spleen not constantly enlarged, often soft. 

Liver and kidneys: cloudy swelling and fatty degeneration have been 
described. 

Stomach: cadaverous softening not rare. Lymph -foil idea of the 
inteatine, and mesenteric glands sometimes enlarged and hypenemic. 

in. Symptoms. — The disease often appears in the midst of healtb 
without premonition. Prodromata may consist of depression and loss of 
appetite for one. two, or threedays. with nothing apecially characteriatic 

The outbreak generally consists of a single severe chill; more rarely 
a re|>Btition of slighter chills. The temperature rises quickly, soon at- 
taining 39" or somewhat higher, though 40° is rare. The pulse in- 
oreased in frequency, often more than the fever seems to call for, and the 
same ia true of respiration. Violent headache is complained of from 
the beginning, referred to the front, the vertes, or the back nart, or 
without distinct localization. The pain ia overpowering ; even wnen the 
conscioueneee ia wholly gone, patients aometimee contract the face and 
press their hands to the head. Giddiness often accompaniea the pain, 
80 that the patient totters like a drunken man, grasps ohjects, and soon 
cannot stitnd upright. There is hyperfesthesia of the nerves of sense; 
patients are greatly annoyed by brigut light, and are startled by slight 
noises. 

Drowaineaa and coma gradually come on, and with them delirium. 
During the aecond period cornea the ominous symptom of stiff neck 
^which gives the German pounlar name of Oenickstarre or Oenick- 
krampf). The back of the head is drawn forcibly backward and 
downward, and so strongly opposes every effort to bend it forward 
that we can often lift the constantly stiffening trunk in that way. 
Forward movement of the head is painful, and even half-comatose 
patients make a grimace and cry out. In many oases, strong back- 
wai-d bending of the head, and twisting movements, are easy and 
painless. The head sometimea goes as far back as possible; Hart 
states that in one case the occipnt pressed between the anoulder bladea 
80 as to cause gangrene of the skin. The rigidity may vary; I have 
repeatedly seen it diaappear in deep coma and just before death. The 
explanations of the symptom are various; we think it a direct symptom 
of irritation of the nerves ariaiug in the cervical region. As theiaflam- 
loatioD extends, opisthotonus attacka an increasingly large part of the 



ISA8E8 AFFEOTIMQ THE WEEVOUS 8TBTEM. 361 ' 

I tho occiput and sacram. There h great 
fi^rdsBiTig the spinous processes — rhuchiulgia. 
In eurly atages, there is great restlessness, but this soon yields to 
stupor, in which a person may remain a long time in moat uncomfort- 
able positions. Sometimes a short, loud, clear cry ia uttefeil {€ri 
hydrociphalique). The pupils are usually contracted, often uoeqnal, 
and sometimes dilated in an oval form. The tougtie is often dry. 
cracked, red, ereu dark with aordes; in other cases, the coating is white, 
gray, brownish, and not characteristic. The sensibility of the skin ia 
DHually excessive, so that slight pinching of the skin causes a loud cry. 
Vomiting is very common and may be very obstinate. The abdomen ia 
nsually snnken, sometimes to the form of a boat or basin, and the ab- 
dominal aorta may even be seen beating. The iliac fosssa present deep 
depressions, marked by the prominence of the crests and spines of the 
ilium. Traube associates the sinking of the abdomen, not with oontrtic- 
tionof its muscles, but with spasmodic contraction of the intestines, due 
to irritation of the vagus (?). The belly is often sensitive to preeaure. 
Spleen often enlarged, but not uniformly. Stupefied patients often paea 
no water ; the bladder may he fnll nearly to the navel, and the catheter 
must he used regularly. Others wet the bed. Tho urine is scanty and 
dark, owing to fever, and the small amount of drink taken in the stupor; 
it almost always contains albumin. Sometimes alargeamount is passed, 
and is light and watery in spite of the fever (urina spastica, vaso-motor 
and secretory disturbances). Constipation is usual, djarrhcea rare. 

«aQd 



Dpkatios. — Death may occur in a few days; or the disease may 
last from two to six weeks, with many improvements and relapses, before 
decided convalescence begins. Great rise of temperature often occurs 

Sat before death (to 43° and over); the rise may continno a short time 
ter death. I have repeatedly seen death with symptoms of paralysis 
of the centre of respiration. 

There are special forms— the abortive, the foudroyante, and the inter- 
mitting. 

Abortive meningitis is indicated by little more than very severe head- 
ache, slight dulneas, giddiness, aud nausea; sometimes there is vomit- 
ing and difficulty of moving the neck. There is hardly any fever, and 
no need to go to bed. All is over in a few days. The symptoms would 
eaaily be misunderstood except during ati epidemic. Sometimes, however, 
the disease develops more or leas suddenly into the severe form. 

The foudroyant attack (m. siderans sive ocutissima) comos on with 
incredible swiftness. Cases are known in which the patient wont to work 
in health, but suddenly broke down and died in a few hours. 

The intermittent form is marked by great elevations of temperature 
at nearly e^ual intervals, connected with exacerbation of other symptoms. 

A quotidian and a tertian type have been distinguished, with exacer- 
bations every twenty-four or forty-eight hours. This is plainly due to 
the fact that the disease makes progress, step by step, at distinct inter- 
vals; there is no reason to infer a relationship to malaria; the spleen ex- 
hibits no ooustant changes, and quinia has no effect. 

Complications. The nervous system is often involved. Paralysis may 
^^fafolly devebpul, or merely paresis. The facial nerve is often aSected. 



262 nfFBcmous diseases AFFEcrriNa the nebyoub ststeic. 

In the limbs there may be monoplegia, hemipleria, or parapleeia. Para- 
lysis of the tongae, and dysarthria, or palsy of swallowing, haye been 
seen. In the latter case, we must consider whether the trouble in swal- 
lowing is due to the stiff neck. Paralysis may occur very early. Eraser 
mentions a child that had spasms with left hemiplegia as the first symp- 
toms. General oonyulsions, or twitching and contracture in certain liml]^ 
sometimes occur. Trismus or attacks of gnashing the teeth are included 
in this. 

The nerves of special sense are often involved. Catarrhal conjuncti- 
vitis is not rare; occasionally the secretion becomes purulent. In many 
cases, important changes in the iris and choroid are added. Ohemods 
sometimes appears very early, and develops surprisingly fast, usually in- 
dicating intra-cerebral pressure and impeded circulation, though it may 
also indicate that the inflammation has pushed forward from the cranial 
cavity through the orbital fissure directly into the retro-bulbar cellular 
tissue (inflammatory csdema). Lagophthalmus sometimes develops, 
stated bv Wilson to be due to rapid shrinking of the orbital fattj tissue 
and sinking of the eyeball. The oculo-motorius or abducens is often 
paralyzed, causing strabismus, ptosis, and double vision. Keratitis some- 
times occurs, leading to perforation externally and to anterior sjmechia. 
Purulent inflammation of the uveal tract is not rare— iritis and irido- 
ohoroiditis — causing accumulations of pus in the vitreous and the anterior 
chamber, and thickening and opacity of the lenticular capsule, and clos- 
ure of the pupil; separation of the retina may also occur. Neuritis and 
iieuro-retinitis occur, indicating increased intra-cranial pressure. 
Ziemssen once found apoplectic retinitis. Permanent amaurosis may 
remain after recovery from the disease. Transitory amaurosis often 
occurs, connected with temporary disturbances of central innervation. 

Radnew found purulent inflammation of the uveal tract to be the rule in 
^rebro-spinal meningitis, at least when microscopic examination is made after 
Hleath. The disease usually begins in the choriocapillaris, and afterwards extends 
to the entire choroid. Badnew considers these changes as primary, not depend* 
ent on the meningitis. 

The organ of hearing is very often affected. There is tinnitus, noises 
of various sorts in the ear, and deafness gradually comes on; when stupor 
is present, this cannot be well ascertained. Heller, and Lucas and Moos 
found the trunk of the auditory nerve bathed in pus; its neurilemma 
swollen and hyperaemic; purulent inflammation in the tympanic cavity; 
hypera&mia, bleeding, and purulent inflammation in tne membranous 
labyrinth. The last may be spontaneous, but the other lesions are mostly 
propagated along the sheath of the auditory nerve. Many patients are 
tortured with violent pains in the ear until the tjmpanic membrane is 
ruptured and discharges purulent fluid. Meningitis often causes perma- 
nent deafness, which involves dumbness in children who had not learned 
to speak. 

The skin is often affected. Herpes facialis often appears on the second 
or third day; more rarely not till convalescence. It usually begins on 
the lips, on one or both sides, spreads to the nose, eyelids, and ear, and 
even covers a great part of the face. It is much rarer on the extremities. 
Extensive erythema, resembling scarlatina, roseolar and rubeolar exan- 
themata, urticaria, erysipelas, petechiae, ecchymoses, ecchymomata, 
vibices, sudamina, ana bullous and pustular eruptions are not rare. 
They appear at the beginning or the end of the disease, sometimeB dur* 



IQgO 

oal, I 



nrFEonocB dibs&sea ArrExmsG the irsRTOue ststeh. 

oonvaloscence. The diBtribution is somotimes remarkably Bymmetri- ' 

f, reminding one of the inflnence of trophic or vaao-motor nerrea. 
Bed-sores or Kttogrene of the skin ma^ develop eo suddenly that they 
appear to be dnetodirecttropho-nenrotic disturbances. Multiple joint- 
swellings have been repeatedly observed, shown by autopsy to be due to 
purulent disoharge or ^eat swelling of the synovial membrane. Eusto- 
nopolas, in an epidemic at Nauplia, 18G2 to 1864, found joint -affections I 
preceding meningitis. 

Catarrh of tuo throat is much commoner than is usually stated. 
Diphtheritic changes may occur. Broueiiiu! catarrh is one of the com- 1 
monest complications; more serious ones arc broncho-pneumonia, fibriu- 
ons or hypostatic pnonmonia, and later abscess or gangrene of the lungs. 
Pleurisy has been named as a complication. 

The respiration often becomes irregular in its rhythm and in its depth I 
as the disease progresses, but pure Cheyne-Stokes respiration is seldom | 
observed. Biot's breathing is more common; respirations of equal depth 
are interrupted by occasional intervals of apncsa. 

The pulse often shows irregularity in the succession and force of the 
individual pulsations. Irritation of the centre or the trunk of the vagus, I 
from meningeal inflammation, causes retardation of the pulse, while , 
paralysis of the vagus {a much more ominous symptom) causes enormous , 
aoceleration. The former is more likely to occur at the beginning, the 
latter at the close of the disease. 

Pericarditis and endocarditis are among the rarer complications; this 
is true of parotitis, icterus, and glycosuria. 

Some of these complications are more properly sequelae; as paralysis, 
contracture, deafness, blindness. Permanent mental disorder has oc- 
curred. Headache often lingers a long time, and is made worse by men- 
tal application and by stooping. Giddiness sometimes continues long 
tSter recovery. Leyden described aphasia and aniesthesia. Sometimes 
there is a peculiar tottering of the body, reminding one of Meniere's 
disease, and perhaps related to the trouble of the middle ear. I have 
Been chronic hydrocephalus in a child jnst one year old, which caused 
enormous dilatation of the skull. Ktultiple boils of the skin or muscu- 
lar abscesses occur. 

IV. DiAONOSLS. — This is usually easy, and rests on the presence of 
stiff neck, headache, stupor, inequality of the pupils, irregularity of 
pulse and breathing, vomiting, sunken abdomeu, constipation. For 
tubercular meningitis, see a subsequent section. In children, febrile 
conditions, especially if connected with intestinal disorder, often cause 
rtifl neck, so that this symptom must be estimated with caution. In 
deep stupor, the disease might be confounded with typhoid fever or central 
fibrinous pneumonia. In typhoid, there is meteorism. diarrlima, an early 
eruption of roseola, enlargement of the spleen; in fibrinous pneumonia, 
the sputa are rusty, if any are ejected. 

V. Prognosis. — This is always very bad: in some epidemics the 
mortality has exceeded eighty per cent. 

VI. TREiTHEST. — A quiet room, not too light, easily ventilated. 
Diet liquid; chiefly milk, moat-soup, eggs, diluted wine. If there ia 
stupor, nave the bladder emptied regulariy three times a day with the 
oatneter. Secnre one stool a day. giving, if necessary, two tablespooufula 
of castor-oil in beer foam; or calomel and jalap, gr. viij. each; or com- 
Doaod infusion of senna, nine parts, E|wom salt, one part, tablespoonful 

^^^BB times a day: or ulysters. On the head place ice-blodders reaching 




mwBCjnaus dobabbb Arrscnso thg me&toub sTSnai. 

from ear to ear; also under the back of the neck. It is tpfj desirable 
to lay the spine on ice, by means of ChapmaD'e bags. If pain is violeot. 
use repeated injections in the cervical region (hydi-ochlorate of morpbioe, 
15 grams; glycerin, water, aa i oz. M.: ^ of u syringefal). 

The following methods are mentioned among many. a. DeriTatJTes to the 
bead; rubbing pustulating salve on the ahaven head, moxB, painting with iodine, 
blisterBor Binapismson the back of the neck, cupa at the same place and along the 
spine, tbeactual cautery, salt or mustard bathe for hands auit Feet, etc. b. Antiphlo- 
gistics: ice-bladder, leeches to the forehead or maetoid processes, bleeding, limnc- 
Bon with mercurial ointment, ether spray on the back of the neck, calomel 
int«mall7. nitre, etc. c. All kinds of draaticH, d. Diuretics, e. Abaorbents. as 
iodide of potaaaium. /. Narcotics: opium, bromide of potaasium, chloral 
hydiste. ericotin, conium, etc. g. Nervmea. aa preparations of dnc. h. Febii- 
fogee: batbs, quinine, antipyitn, eto. t. Electiicit;. 

3. Simple Cerebrospinal Meningitis. 
Meningitis Certbro-Spinalii Simplex. 

I. EnOLOQT AND AxATOMiCAL CHANQEa.— Punilent inflamiiiation 
of the pia mater and arachnoid may occur noder other conditions than 
ae an independent infectious disease. It is then of a secondary nature, 
but agrees in its anatomy with the epidemic affection as far as concerns, 
the membranes of the brain. 

The inflammatory changes are often most marked on the convexity of 
the brain; bat the base may be the part chieSy aQccted. " Meningitis 
of the convexity" is therefore a false term. '■ Basilar-meningitis," as a 
name for the tubercular form, is also erroneous, since the convex portion 
is almost alivays affected. 

Meningitis may be transferred from another locality. Simple eczema 



of the scalp and face, and still more erysipelas or boils of the face, are 
capable of exciting it; it m^ occur during purnlent catarrh of the 
frontal sinuses. A few cases nave occurred after operations on the eye. 



especially enucleation. It has originated repeatedly from disease of the 
ear: foreign bodies intheear, with purulent inflammation, inflammation 
in the middle ear, polyps, caries and tubercle of the petrous bone. 
Wounds on the scalp, fracture of the skull, thrombosis of the sinuses, 
local points of encephalitis on the surface of the brain, superficial ab- 
Boesses or tumors of the brain sometimes cause it. 

Purulent meningitis may originate by metastasis from many iofec- 
tioos diseases if the bearers of infection find their way from the original 
disease to the meninges. This may occur in fibrinous pneumonia, pleuney, 
pericarditis, nlcenitive endocarditis, pulmonary phthisis, gangrene or 
abscess of the lungs, peritonitis, erysipelas, diphtheria, dysentery, 
cholera morbus, parotitis, typhoid, typhus, relapsing fever, chc4era, 
pyiemia, puerperal fever, septiciemia, rheumatism of the joints or 
muscles, scarhitina, measles, small-pox, whooping-cough (Bierbaum), 
etc. It is said to have occurred after vaccination. 

Those who believe that suppuration is impossible without the action of 
lower organisms will at once conclude tliat every purulent meningitis is 
an infectious disease in the modern sense. Ebertn and Klebs described 
micrococci in the fluid of the ventricles and the pus of meningitis com- 
pUoatiog fibrinoue pneamooia. If it ie associated with inflammatiw 



TUBEBOULOeiS. 

^borine organs, it may be that the excitants of inflammation find ' 
.ftir way through the blood -vessel a and lymphatics to the meninges. 

II. Stmptoms. — The symptomB agree with those of the epidemic form, 
depending in both cases upon altered circulation of blood, and increased 
pressure in the cavity of the akull; btit in the simple form they are 
usually slower in their approach, and may be overlooked, owing to tbfr 
severity of the original diseases. ^ 

III. pBOQKoaia AND Tkeatment as in the epidemic form. / 



I 



INTEOTIOUS DISEASES WITH VARIABLE LOCAI. 
IZATION. 



TUBEECUL08IS. 



TabereuloBis inclndea all the changes ascribable to the presence of ] 
the tubercle bacillns discovered by Koch, Almost any tissue may fur- 
nish the soil to develop this fungus, and it is not strange tha't the 
domain of tuberculosis is so broad. 

The symptoms of tuberculosis in difterent organs vary so very greatly 
that they often leave ns in doubt. Hence the great diagnostic value of | 
the bacillus, which assures us of the nature of the complaint. Many 
diseases have been included as tuberculous since Eoch's discovery: 
lupus, fungous inflammation of joints, scrofulosis, etc. 

Almost any organ may be tno seat of tubercle, but certain ones are 
far more subject to it than others. The internal organs chiefly affected , 
are the lungs; next the larynx and intestine; then the urino-genital 
apparatas. In case more than one organ is affected, the original disease- 
waa probably situated in one and was transferred to the other. 

Solitary tubcrculoaia, as opposed to tuberculosis of organs, belongs 
chiefly to the domain of surgery; it includes, e, g., the affection 
of the joints, bones, single lymphatic glands, etc. It is oliDically 
marked by being often accessible to local treatment, so that by destruction 
or operative removal of the diseased centre the disease may be cared. It 
may be that secondary infection will follow in other organs, ae tubercle 
is very variable and mixed in its forms. 

General tuberculosis is a third form; also called general miliary tuber- 
culosis; it usually originates from oue infected spot or organ, indicatea 
a general affection of the body, and takes an acute or subacute course. 

The following pages describe the various forma of uou -surgical tuber- 

^^^1 1. Consumption of the Lungs. Phthisis Pulmonum. 

^^V {Chronic Ulcerous Tuberculosis of the Lungs.) 

1. EnoLOGT, — A chronic destructive process of the lung tissne, with 
cheesy degeneration of the morbid products, followed by softening and 

fiurufent wasting; excited by the proliferation of tubercle bacilli in the 
ung tissue. It seems doubtful whether there exists, in addition, a duu- 
bacillary form, as has been asserted. 

The disease is very common. Ilirsch states that one-seventh of all 
^dM]ibsartse from it; two-thirds of all chronic diseases. It is certain!/ 



m S06 TDBEBODLOeiB. 

I favored by modern Bi>eial modes of life. In factory tovna and cities, 
I where the proletariat supportH on scanty food its overtasked life, in 
I damp, dark, crowded cellam, it is commonest. But it was known to an- 
I titjntty, and the writinga of Uippocmtes contain excellent observations. 
r Scarcely any disease is so mncn affected by the influence of constitu- 

tion. Weakened, feebly resietant, aniemic persons are in special danger. 
It would seem as if the bacilli were distributed in the air and inhaled by 
everybody at times, but found no fit ground in sound persons, while in 
others they easily i)ropagHte themselves. Not that they are found every- 
I where; for they seem to find the couditiona favorable to their growth 
I only in human and animal organisms, and at a permanent temperature 
I of 30" (Koch). 
B A morbid eonstitntion may be inherited, congenital, or acquired. 

I There can be no serious doubt that pulmonaiy consumption ia inherited in cer- 

I tain families: but it is uncertain what the mode of iaheritance is. The fact that 
I it does not alnaye paas directly from parent to child, but often is derived from 

graudpareuts or, collateral relations, seems to show that a weakness of constitu- 
tion is traosferred rather tban germs of disease. In rare cases, the contagious 
material seems to pass directly from mother to fcetus, causing severe injuiy to 
the lungs in atero. Damme sawa caseof extended phthisical changes with cavi- 
ties in the lungs of a girl .iged 13 days. Berti has found exteusive phthisical 
olumges in the lungs of two new-born infants. Jobne describes a similar case in 
a fcetal calf, with tubercie-bacUli in the diseased spots. I^ndouzy and Martin 
obtained equally positiTe results in eicperiments. In addition to predisposing 
causes, there must be special occasions tor the development of cunsumplion: such 
occasions, however, occur very often, and only those will escape disease whose 
constitution reeists them with sufficient force. We cannot be too cautious in our 
views of hereditary consumption: it is so common a disease that it may easily 
happen that several members of a familjf are attacked uurely by accident. 

To hereditary weakness of constitution we must add that which affects chil- 
dren whose parents were debilitated by chronic disease at tlie time of begetting. 
Persons having tertiary syphilis or cancer beget cbildreu that are weakly from 
birth, and often fall victims to pulmonary consumption. So with cbildreu whose 
parents married late in life. 

Acquired weakness of constitution is very common, sometimes due to improper 
food and mode of living during childhood, sometimes developing later in conse- 
quence of bodily or mental overwork, or of certain diseases. It occurs frequently 
. in diabetes mellitus, owing cliiefly to break-down of the constitution, as consump- 

^^^ tion usually belongs to the late stages of the disease. Ouanism, excesses in wine 

^^H and women, protracted lactations without sufficient rest bieiween assist the 

^^H development of couBumption. 

^^M We have stated the frequency of direct exciting causes. ASectiotiB 

^^H of the lungs are natnrally the most frequent excitants of consnmp* 

^^H tion; broncbial catarrh or fibrinous or catarrhal inflammation of the 

^^B lungs may lead directly to consumption Jn s person predisposed; while 

^^ in others they run their course qnickly and favorably. Symptoms 

r of consumption very often appear some time after recovery from serons 
pleurisy. Inhalation of dust Is often fatal in its effect, hence the bad 

L reputation for producing consumption attached to certain trades. Con- 

^^B tinnous residence in close rooms may be harmful; consumption is ex- 

^^H ceedingly common in prisons and pensioners' establishments. 

^^1 Defects of eonstitntion conjoined with these exciting causes do not 

^^1 form theonly way in which consumption is developed, The disease is 

^^B contagious, and close intimacy and frequent contact with a consamptiTe 

^^H person may easily cause the disease in a person not originally predisposed. 

^^^L A long observation of phthisical patients and their families often ahowa 

^^^L QB ioatances in which a consumptive wile infects her husband, and rke 



J 



TCTBEBOrLOSIS. 36T^ 

versa. Years often inteirene; the one is long since dead, the other may 
have married a^ain in perfect health, but the eigas of the diseaee come 
gradually to view, OonBamption was thought cootagiona in the last 
century, especially by physicians south of the Pyrenees and Alps (Bris- 
seau); a Neapolitan decree of the year 1783 ordered the destniction by 
fire of all the clothing of dead phthisical patients. 

Contagion is plainly furthered by the sputa, which often contain num- 
berless tubercle- bacilli. Persons seldom care where they spit; the dis- 
charge easily dries, and may be transferred to well persons in the form of 
dnst. The material seems not to pass directly through the air from the 
sick to the well, at least. GelH and Guarnieri could not find the bacilli 
in the air of hospitals for consnmptires. 

Villemin, Lippl, Schweninger, Bod others have shown that animals 
may be made consumjitive by inhalation of pulverized phthisical spnta. 
A similar experiment has been made accidentally in the human snbject. 
Tscherning reports that a healthy girl injured her finger while cleaning 
a glass containing sputa abounding in tubercle bacilli; she very soon 
had a severe tnberculosis of the sheaths of the tendons and lymphatic 
glands, which made an operation necessary. An observation by Beicli 
deserves notice here; the caaeof a tuberculous midwife who gave tubercle 
to ten new-born infants by sucking mucus from their air passages with 
her mouth after birth. Infection by dried and pulverized fsBces loaded 
with the bacillus is possible, but not demonatrated. Villemin has shown 
by experiments in inoculation that the sweat is not infectious. 

Tuberculosis of the lungq may bo duo to secondary bacillus infection 
from other organs. It has long been known that scromlosis, called tuber- 
culosis of the lymph-glands, leads to consumption, but it has been known 
to originate from tubercle in other organs. Such conditions cannot al- 
ways be demonstrated duriug life, for tubercle, located primarily in the 
lung, may often develop to so small ail estQQt oa to be overshadowed by 
the development in other organs. 

Food may in rare instances be the bearer of infection; for example, 
milk from consumptive cows or women. Unboiled milk, and raw flesh 
from consumptive animals, are infectious. 

Transportation of tubercle bacilli through wounds of the skin or 
mucous membrane to the lungs may perhaps occur, but requires more 
proof. 

It has been usually supposed that consumption destroys most victima 
from the fifteenth to the thirty-fifth year of life, but Wiirzberg has lately 

Subliahed extensive statiatic-s (relating to Prussia) which show that the 
ighest rate IB at from five to ten years, followed by a minimum, after 
which there is an increase with every decennial period to the end of life. 

As regards sex. the frequency varies, being greater for men in Prussia, 
but somewhat greater for women in England and the United States. 

The poor are more affected than the rich; but there is a sort of com- 
pensation, since among the well-to-do hereditary influence comes more 
into play, and acquired disease among the poor. 

Climate iahardly of great importance, though there are certain regions 
where consumption ia hardly known, as the high plateau of Mexico, 
Peru, Costa Rica, the interior of South Africa, Egypt, Iceland, etc. 
Absolute temperature seems to be leas important than (Iryneas of the air 
and absence of violent changes of temperature. Altitude is unqnestion- 
Ably important. Consumption occurs only by exception in places more 
"-- 600 metres high. A change of residence may oe fatal; persons in 



^^i 



d 



B98 TDBEBODl/WB. 

plaoes free from consumption moving to nnhealthj places often are at- 
tacked with surprising rapidity fiace seams to have less influence, ami 
must be considered with caution. 



I 



I 



year. Early marriages and exceaaire toil a: 

Much haa been said of mutual exclusion between coaBumption and 
other diseaies— as malaria. This is surely incorrect. Consumption 
occurs in malarial places; Sangalli reports lH cases of splenic tumor 
after intermittent fever, in 25 of which consumption existed (eighteen 
per cent). The same is true of cancer. Garcin has lately collected 
sixty-two eases of combination of the two diseases, cancer of the stomach 
or digestive tube being most frequent. The exclusion between heart 
disease and consumption must not be overstated; Frommelt especially 
has shown a frequent coincidence (23 times in 27? cases of valvular 
lesions). One form of valvular disease (congenital stenosis of the pul- 
monary artery)aImost always lias consumption associated with it, (See 
Vol. I., p. 101.) Alveolar emphysema of the lungs is a rare associate. 

Saai^li' 
gumption, e 

II. StmpTOSTS, — They usually develop very slowly, often leaving one 
in doubt tor months before decided signs are given. In advanced stages, 
diagnosis is seldom difficult. 

Chlorosis sometimes conceals the first advances. Pallor is conspicuous; 
the patient is easily tired, complains of heaviness in the legs, of palpi- 
tation on bodily exercise, and is often hoarse. Menstraation Is often 
disturbed. 

We must be cautious when the patient comes from a consumptive 
family. Our apprehension is increased when, in addition to chlorosis, 
there are Bcrof ulous changes — the frequent predecessors and accompani- 
ments of consumption. It is suspicious when a judicious course of iron, 
in good sanitary circumstances, gives no relief, and pseudo-chlorosis and 
emaciation persist. Such persons sometimes have a transitory bright 
redness of ttie face while taking iron; or the sputa contain small blood- 
vessels or dots of blood. 

In other cases, symptoms of stomach catarrh are prominent at the 
outset. The patient loses appetite, eructates much, and sometimes 
vomits frequently: the stool is irregular, and constipation and diarrb<£a 
often alternate, The complexion is very pale and sickly, flesh is lost 
continuously, there is an increasing feeling of debility, and at last con- 
sumptive symptoms are quite manifest. 

Consumption sometimes begins with symptoms of frequent and ob- 
stinate bronchial catarrh, sometimes generalized and by degrees retreat- 
ing to the apices, while at other times it is limited to that region from 
the first. 

Catarrh of the larynx is often the first symptom; beginning with 
hoarseness, continued tickling in the throat, often irresistible impulse to 
cough, before the diagnosis of consumption can be made. Persistent 
marked auiemia of the larynx has correctly been remarked aa euspioious. 
Samoa speaks of a rapid change fro:n anemia to hyperseniia. 



loasscvuxa. 



sea 



Repeated hsemoptysia, when the first in the train of aymptomB, ia 
■ Commonly thought decisive, though years may pass before unquestion- 
able alterations of the parenahyma of the lung are physically demon- 
strated. 

I in penooB who atterwarda became 



Fibrinous or catarrhal pneumonia must be expected to give rise to 
consumption in debilitated persons; in auch case, the upper lobe is 
known to be mostly afleeted. 

Pleurisy often causes consumption. It is suapicioiis, when dry 
pleurisy occurs repeatedly in the region of the upper lobe, because latent 
phthisis often causes it. Moist pleurisy, without demonstrable cauaet £ 
mnning a alow insidious course, sometimes affecting both sid<^a at ono»l 
or alternately, is usually referable to phthisical changes iu the lungs. 







^yut 



We see, therefore, how manifold and insidious the beginnings are, 

aod can understand how great the need of care to avoid errors. We 
would add that tuberculousdisease of bones, joints, and skin, or fistula in 
ano. or tubercle of the testis are often brought for treatment, and ex- 
tensive tuberculous disease of the lungs is found on examination. 

In advanced stages, consumption is usually easy to recognize, especially 
when the bacilli are found in the sputa; the local and general symptoms 
are also generally distinct. 

The very appearance of the patient often betrays him; the constitn- 

a is seen in tlic face. 

Many patients »re persons that have grown tall (quickly, and have 

g nerks. The skin is delicate, poor in fat, and strikingly uale; the 
muscle^i small; the bones slender. The face ia often so lean and 
sunken that the cheek-bones project sharply. The eves are sunken, 
and often have a dark circle around them; they often nave a peculiar 

itre, and the sclerotica is strikingly blue. The teeth are often long. 



S70 

bluish-white, traoi^nrait, and inctined to caries. The gnniB have ■ red 
border next to the teeth. 

The chest ia quite pecaliar; Dsnall; reiy long and flat, aa may be 
beat Been by the cyrtometer caire (Fiff, 46). In yonng persons, it ie 
often very resistant, owing to prematare oesification of the cartilages. 
The intercostal spaces are broad and annsnally deep; the angle at which 
the ribs are attacned to the atemnm is more acnte than normal. The 
jnnction of the mannbriam and body of the sternum (angulus Lndovici) 
IS tmuBnally prominent, owing to depression of the npper part of the 
manubrium. 

The depressions of the upper part of the chost are eztremelr deep 
(Fig. 47). The pectoral and dorsal muscles are nsnally very smalf. The 
■boulders come sharply forward, often giving a marked stoop to the 
trunk, so that the body threatens to fall forward in rapid walking. 



PbttaMMl tbonti li 




iUmt*! atMBiratkin. Znriob cUnlc 



Seen from behind, the posterior edges of the shonlder blades are raised bo 
that the hand can be partly thrust in under them (wing-shaped, scapuln 
alatie. Fig, 48). This form of thorax hoa been called paralytic thorax, 
because supposed to be partly due to weakness of the intercostaLs, serra- 
tus anticus, etc. 

The last joints of the fingers are often enlarged (like dmm-sticks), 
and the nails curved like claws. This pecnliaritjr has been explained by 
deficiency of tatty tissue. The hair of the head is scanty and inclined 
to fall out. 



The complexion is usually pale. If the disease in the lungs is ez- 
tensive, cyanosis occurs, proanciog a livid tint when slight, but veil 
marked in advanced cases. 

The vaso-motor system is very often very excitable. The faoe, or 



TUBEBOULOSIS* 



271 



the prominence of the cheeks^ tnms bright red on slight exertion of 
mind or body, and fever is often marked by the same appearance: the 
hectic flush at the time of the evening rise of temperature. The flush 
may be more marked on the side of the diseased lung. 

In many cases light-yellow or brown-yellow spots, smooth, shining, 
non-desquamating, appear on the forehead and upper part of the cheek, 
sometimes singly, sometimes forming large patches— chloasma phthisi- 
corum — and if Jeannin's statements are correct, hsBmoptysis does not 
occur in these patients, while the spleen and lymphatic glands are often 
found diseased. In other cases, the skin takes a more diffuse grayish- 
brown or gray almost light-blackish color, most marked on the face. 
Near the end of life the dark pigment often becomes rapidly much more 



Fio. 48. 




The same, rea^ Tiew. 



distinct. No demonstrable disease of the supra-renal capsules is neces- 
sarily associated. 

We must not confound with chloasma those light-brown spots char- 
acteristic of pityriasis versicolor, which are not shiniuj^, and are slightly 
raised; scales can be taken off by scratching^ and exhibit roundish shin- 
ing microscopic spores, withlongish multilocular fungous threads, when 
examined after adding potash lye, etc. The fungus is the microsporon 
furfur. (See Vol. III., page 376.) 

Pityriasis verdoolor is most common on the skin of the breast and lower part 
of the throat. It be^ns in spots, spreads over larse connected surfaces, and may 
at last cover great tracts of skin before and behind. Its frequency in consump- 
tives depends on the sweating, which favors the growth of fungi, and on we 
teadency of the skin to scale, which assists their attaqhrnent. 



272 TUBEBOULOfilB. 

Pityriafiis tabescentinm is a distinct affection with branny scaling ct 
the epidermis, occurring in many debilitating diseases besides phthisis 
which prodace loss of fat and abnormal secretion of sweat and aebnm. 

Miharia or sudamina are not rare — ^vesicles, clear as water (m. crys- 
tallina), or with a little milky tnrbidity (m. alba), or snrronnded by a 
red areola (m. rubra), usually liberally sprinkled and easily recognised. 
They show that profuse sweating has occurred, and are seen almost ex- 
clusively on the covered parts (breast and belly). M. crystallina is 
transitory, disappearing when the sweat accumulated between the rete 
Malpighii and stratum comeum has disappeared by evaporation and ab- 
sorption. It is often seen in the morning exclusively. 

Herpes zoster of the trunk or limbs may occur; I have seen it in a 
few cases, in which tuberculous caries of the vertebr» occurred some 
time later. The zoster seemed to indicate a latent inflammation, per- 
haps pointing to inflammation of the intervertebral ganglia. 

Leudet found seventeen cases of zoster in one thousand of consumption. He 
often noticed a combination of disturbance of sensibility and motility, and thinks 
protracted cases are the ones chiefly affected. 

Sweating is very common. A patients skin often becomes moist, or 
covered with drops of sweat when he is excited or tired. The sweating 
is often confined to the night, especially between midnight and early 
morning. It is very profuse, weakens the patient, and is well known as 
hectic sweating. There sometimes is a very penetrating odor of fatty 
acids. 

The cause of sweating is not certain. Some connect it with fever; but fever 
is not necessarily present when the sweating exists. Others assume general re- 
laxation of tissue as an explanation. TrauM suspected that the skin excreted 
water vicariously, as the lung performed that function imperfectly. Lauder 
Brunton says that the respiratorv centre being depressed in activity, carbonic 
acid may accumulate in the blooa to such an extent as to irritate the centre for 
sweating. 

I have seen a few cases of unilateral sweats; the patients had symptoms of 
caverns on one side, corresponding to the side of the sweating (implication of the 
sympathetic?). See Vol. III., p. S48. 

The fat almost always disappears from the skin, which is raised in 
folds, transparent and thin, like paper. But I have in a few cases 
noticed a good, even an unusually good development of the panniculus 
adiposus in spite of extensive disease of the lungs and general loss of 
strength. 

if the patient has remained long in bed, bed-sores may appear, 
especially ii frequent change of position and a smooth surface to lie on 
have been neglected. The commonest position is the sacrum, owing to 
the pressure and the superficial position of the bone; then the heels, 
trochanters, malleoli, and shoulder blades. Such occurrences are very 
unfavorable, paining and weakening the patient and giving trouble to 
the nurse. 

Many patients attend to their business quite regularly in spite of 
advanced disease. Others have occasional bad turns, which keep them 
in bed, caused by changes of weather or taking cold. Others remain in 
bed for months or years. In advanced cases, especially if want of breath 
is felt, patients prefer to have the body raised in bed; the choice between 



ft 



TTTBEECm-OBIS. 



378 ■ 

Jde and back ia a matter of individual preference, thongh inflftmination 
of the pleura of one side may lead the patient to lie on the other aide. 

Extraordinary development and activity of the mind is often ob- 
served. Wise children are popularly said to die young. In the late 
stages of the disease, mental power is usually retained: it ia characteria* 
tie to see the mind chieer/ul and courageous, often busy with plans, 
while the body ia slowly perishing. Delirium is very rare; it is almost 
alw^a a very unfavorable sign, indicating the approach of death. 

Fever is almost always an accompaniment, though there may be long 
periods free from it. The rise of temperature ia often very slight; but 
very high tempeiatures may occur at noon orevening, often preceded by 
a slight chill with great pallor of skin. If the morning temperature la 
normal or beneath normal, while the evening heat ia excessive, we have 
hectic fever (Fig. 49), due, as it often ia, to absorption of pnrulent 
Continuous high fever is especially common in very rapid cases 



(pbthiaie florida). 




obsemtloiL) 

Inverted types of fever with the ereateet heat in the morning are not rare, 
u Traubti showed. Br&nniohe sbjh he Radt it chiefly when there is associated 
millnry tub^rculoaia. 

Peter and Vid&l state that the akin temperature ia raised over cuTeraa and in- 
flltratEd spots, and tliat the thermometer can be used to define the diseased dis- 
trict. 1 have not found it so. McAldowic found in cases of unilateral diseas« 
that the tenipemture in the axilla ■)( the sound side was higher than iu the Other 
as oft<-n us the contrary; but if inHltration existed on one sidp, and caverns oa 
the other, the former aide usually had the higher tempxrature in the axilla. 

The pnlse gives no characteriatic signs; it ia nsnally accelerated: aa 
emaciation and weakness increase, it becomes small and aoft, and In fe- 
brile states dtcrotiam is usually ijuitc striking. 

Dyaimcea may give no trouble during the whole disease, probably be- 
oftose the wasting body requires less air and gets used to less. In bron- 
ohittl OKtarrh, or if the disease becomes acute, it is generally felt; febrile 
•tfttoa may excite it. 

(Edema is one of the late symptoms. It may be simply due to ma- 
rasmna, or may form a symptom of nephritis. It usually begins in the 
lower extremities. If patients are onliged to lie chiefly on one side, 
cedema of the subcutaneous cellular tiasuc affects one side chiefly or 
solely. Id one extremity it may be caused by marantic thrombosis. 
18 



TUBBBOULOfilB. 



) lungB almost always begin at the ap* 



Local changes i _ 

often are wholly confined to tEo upper segment of the long. 

The cause ot this may be that the apioes are the parts least used in breathing, 
whence oome opportunities for deposit and long reieDtion of inflammatory pro- 
dueta. especially in thealveoli. In addition, thia re^onhasapoorsuppljofDlood. 
In persons of cousumptiTe habit, the poor development of the upper chest-moB' 



The local changes in the lunga may long consist solely of catarrh of 
the apex. Rough vesicular breathing, interrupted vesicular breathing, 
decided prolongution of espiratiou localized at the apex, or unequal in- 
tcQsity of respiratory murmur at the two sides are often the first atid 
only signs. These symptome are especially important when confined to 
one aide and varying in intensity: if on both sides, they may not denote 
phthisis. Sibilant ruonchue or single moist crepitant r&lea may occur. 



BouD Jarles ut percus»iou 




Tier. Author'Bol 



Eccentricities in the respiratory movements are often connected with 
the above symptoms. Parte of the thorax where respiration is abnormal 
may be seen — or more readily felt with the flat of the hand — to move 
leas actively than other parts. 



the excuraiOQB of fl 



k 



Abnormal percussion sounds are often the first signs; slight dnlnew 
in the upper fossa on light percussion, and increased resistance to pal- 
patory percasaiou. 

Blight differences often occur in health: a fuller development of the mneclM 
on the right side often gives a greater dulneaa on percussion. 

A rery important sign is the difference in the height of the 



TCBESCDLOBIS- ^ 'O 

by percussion, aa was first stated by E. Seita. This Bymptom in- 
dicates simply contraction of the apices, but it ia asnecially frequent ac- 
companiment of chronic tuberculosis of the lungs (Figs. 50, 51). 

When consumption is allied with extensive contraction of the lungs, 
the thorax is retracted, sometimes in the upper fossse, sometimes over 
oue whole side. 

The diagnosis is usually certain when there are signs of extensive infil- 
tration or caverns in the hings; the symptoms agree in all points with 
those of similar conditions due to other causes. 

Infiltration of the alveoli with firm, usually cheesy raaaaes is indi- 
cated by increased vocal fremitus, dulncBs, bronchial respiration, in- 
creased bronchophony, and consonance of crepitant riles which may be 
present. Williama' tracheal tone may also be formed. 

Cavern-symptoms are distinct in proportion aa the cavern is near the 
rarfttce, and is large and smooth- walled. If situated deeply, they ro- 
■ e stronger percussion. Over those of the size of a walnut we hear a. 




tympanitic percassion-sound, bronchial breathing, and tinkling crepitus. 
If the cavity is about six centimetres in size, with smooth walls, metalUo 
symptoms oocQ r, both on percussion and auscultation (cracked-pot aonnd, 
increased vocal fremitus, bronchophony), but only when the cavity contains 
air. If quite full of secretion, there la dnlness; and the alterations from 
dulnesB to tympanitic sounds may be a very imfwrtant fact in diagnosis, 

The sound of a falling drop, and that of succussion, are rare. Con- 
sult special works for Wintrich's variation in pitch; the interrupted form 
of the same; Oerhardt's variation in pitch, and the respiratory variation 
in pitch. 

It is not always easy, though desirable, to makea certain diagnosis of 
caTerns. E. Seitz gave na a sign the raetamorpbosing respiratory mur- i 
mur. though BotuwschikoS states that he has observed it in flbrinooKij 
pneumonia. Baas gives post-expiratory crepitus as a, sure sign. 

Uetallio eymptomi have r«petitetU; been heard over smaller cavities (Kolisko, 
Wintriob), but it Beems neceasary that tlie cavprn abouM be auperficial, regularly 
formed, and eapecially smootli- walled, should lie near a Uxge bronchus, and tie 
oonn«ot«d with a bronchuB with wide opening. Symptoms which are connected 
with the movement of tlie heart, eBpeciallj- systolic ccuptUw, nvo.-s e-c»\. «^~ 
oaverna. Peculiar roaring or hieeicg aounda aie eotacA.vca«% \««x^\'<^»^ '^'c^ 



I 



mU I ■! t- air tfagy — ■ hi I 




iicli project pvniallj- 

■aue. The demonstratiAD 
. En the sputa of no other 
iftiini. tbey are not foaTici 
-tI tiniM u day; this hap. 

. W letting tbo eputa stand 




\Vi|* tliewltrea. if necefaafy. with b ^ 

'■■"r-HVN, Iti ili«i material dry half a minute; 
< I.I imrmit through the flame of analoolicil 
: "ti liiui'e, about as fast as one cats bread. 

.1 itvnii rverj-time. A concanlratcd alco- 
il. pure nitric acid, and solution of 
i>:!nally almoGt as clear na water, 
rl in a box. 

vLl to mi the bottom, then add 

' '>li the thumb, and shake vtxor- 

■ fd. Rlter, and collect ibv^iear 

loiilentaof the watch-ghua five 

I plai-e ihe two coreriuK-gUcaea, 

''■ii-l. Cover the watch-gius with 

L >ii^ij I twvutyfour honr«. It p c ow a ry to 



M 



i 



TDBEB0UL0S18. 

flnish quickly, h«t the solution (as Rindfleiacli proposed) over a flsme until bub- 
bles begin to form; let the cover-glass lie in it ten minutes, and prepare it tat 
microscopical examinatiuii. We prefer the former waj. 

The next step consistB in BUing a watch-glass with pure absolute alcohol, add- 
ing to it by means of a glass rod a drop of pure officinal nitric acid, and mining 
carefully. The two cover-glasses are laid in this with the sputum side up, when 
the diffused fuchsine tint will quiekly depart, and by de^e<» the glasses 
pale. When the coloi is gone (or, if there are many bacilli, nearly gone), 
them quietly in distilled waler. The bacilli now show the stnininR. while the 
other parw are colurles.1. A pretty contrast, useful for a bef;jnner. is uiade by 
lloring the other pans with nuother tint: we prefer malachite-gretrit ns giving 
' For this purpose, lay the glass one minute in the malach"' 




N 



Tubercle bacUU trUti spaiVH 

green solution, face downward, raise it with the pincette, and wash off ngalttj 
quickly Indistilled water, Then preaa both surfaces xently on clean blottiug-pa^H — 
to remove the water, draw it nevera! times through a spirit or gas flame, wil 
sputum side up, and finally treat with chloroform-C!aiiada-bal^m. PiRce 
drop of the balsam on n dean slide, and lay the cover-gla»s. aputum down, i 
the drop: the later apreads en nally under the glass, ■•la moat cnsea, ordinary 
lenses or ihree hundred to five linndred diniueters nulflce, but in doubtful cases 
we require Abbe'd apparatus fur illumination and oil immersion leases. 

The tubcrcle-hacillua i.h a rod, sometimes straijjht. Bometimes bent at 
an aiiRlc. from li to^^ ^ long (1 ;* = 0.001 millimetre), equal to about 
'third or one half of the diameter of u red blood-corpuscle. They 



%n^l 



^^Iie-1 




p 



' 9T8 TCBEBODL08I8. 

are often very mimerous, and distributed with much aniformity in the 
preparation (Pig. 52), while at otiier times they are groujied, and bo 
crowded that tiio groups can haidlybe analyzed into their elements (Fig. 
fi3), or they are single, and careful inspection is required to hriug to 
view one example. Sometimes one glacis shoivs some, while the other 
does not. On euccesaive days, the number may vary greatly. They 
are usually mimeroua in propornon to the acuteuessof the proeeas in the 
longs. Fine glohulea are often found in^^Me of the bacilli which do not 
take the aniline stain; they ave spores (Fig. 53). 

Tlip chemical ejCHiiiinalion of sputa ia not or great importance, B''nk estimated 
the duitj mmia. ol tlii'ee patients at tliu average of one liundi-ed arid twenty-foui 
grama. The average composition by percentage was aa followa; 

Wat«r 04.5a 94.97 m.U 

Solids B.42 6.03 0.16 

Organic components 4.60 4.13 C.36 

InorgBDic componenta 0,73 0,90 0.80 

Mucin.. 1.80 2.66 8.84 

Albumin 0.49 0,11 0.S9 

Fat.-.., 0.86 0.80 O.M 

Elitractive matter 2.01 1.16 1,71 

The phosphates preponderate among the inorganic components; they 
may amount to two grams daily (Stokvis). 

One who constantly examines the sputa will rery often find elastic 
fibres, constituting evidence of consumptive disease, at a period before 
the other methods of physical examination can give much information. 
At later periods also, when the disease is well marked, we should never 
omit to examine for elastic fibres, as they indicate the activity of the 
destruction of the lungs and the effects of treatment. 

Elastic Sbren are easilj' recoi^ized by their curled, sharply outlined, often 
divided form (Fig. 64). The addition of potash solution causea the cell-compo- 
nents to disappiear, while the elastic fibres become hiore distinct. They are 
distineuished f rom cryslals of fatty acid i>y not dissolvinz in ether or boiling 
alcolim, not melting when warmed, and showing no varicose swellingB when 
pressed. The fatty acid crystals are dissolved by long treatment with caustic 

in consumption, the loss of tissue is almost always very gradual, and the par- 
ticles in the sputa are generally micToacoplcally small. Visible fragmeiite (as 
seen in absceas or gangrene of the lung) are very rare. Hence it requires botli 
patience and skill to And elastic fibres. 

In microscopic worh, select very smalt bits, and work them out finely; pay 
Special attention to peculiarly opaque and slightly grayish spots, which often 



I Fenwick gives a convenient and certain way of finding elastic fibres, which 

I we repeat wi til a slight pniciicitl change. Put the sputum into a beaker glass 

I with an equal quantity of distilled water and as much of a solution of caustic 

potash (1:3). Tlie thickish gelatinous moss is heated to boiling, being constantly 
L stirred meanwhile, which makes it perfectly fiuid. Tlie glass is allowed to 

cool, the clear fluid is poured ofl from the sediment, the latter is poured into a 

pointed glass, and the sediment having settled again, is taken by a pipette for 
I examination. The method is very accurate, and not only discovers the fibres, 

but enables us to estimate their number. 

Sawyer recommended caustic soda instead of potash, other points remaitiing 

the same. 

Remak's statement that elastic fibres from the bronchial mucous membrane 

are distinEuishabte from those of the lung- parenchyma by being finer, is not of 

practical use. 



i 



TOSBHODtOSTB. STO 

^ The presence of alveolar epithelium in the spata ie of much less im< 
^ irtance. It has diagnostic value only when very abundant, and when 
there are also signs of apes-catarrh. The cells are usually roundish or 
roundish-angular, and in the condition of fatty or myelin degeneration; 
partly broken down, bo that little granules of fat and drops of myelin 
have been set free (Fig. 55). They often compose almost the whole of J 
the sputa. They are blackened by (,amic acid, like all fatty suhstancea. 1 
They may be taken as showing that active throwing off of epithelium is 1 
taking place in the alveoli, with degeneration of the cells. 

Choleaterin-crvBtalfl, earcina. and mould-fungi ate of less consequence. For 
the latter, see Vol, I., p, 326, Plithieical changes due to inhalation of duet may 
exhibit the duat free or inclosed in cells. We give a view from Traube, showing . 
pneumoconioais anthracotica (Fig. 56), ' 




EkMJc dbres from Uie spi 



ronsumpUre pAClenl. 



s obBervaUaiL) . Si5 dltunetera. 



" Lung-stones," expectorated calcareous concretions, are not of great import- 
ance. They may be calcified parts of lung, when the addition of muriatic acid 
will restore the outline of the tissues (Rindfleisch). Klomao also found in them 
elastic Qbre«. lung.pigment, granular detritus, and tablets of cholesterin. Manf 
consumfitivee cough up such lumps bo frequently as to give rise to the K — ' 
"phthistB calculotia," 

Lime concretions sometimes originate, not in lung-ti«Bue, but in cretaoeous 
changes of bronchial glands which afterwards break through into the air-paa- 
sagee. They may be so large that they cannot pass the vocal cords, and suffocate 
tl,e patient (ROhle). 

Bone- formations occur in the sputa; originating in thejlung, or passingfrom a 
vertebra into llie lung (Charon). 

The gross appearances vary greatly. At the beginning of the disease, 

we often have n tough, glassy, slimy, transparent apntum, which differs 

^J^tle from that of bronchial catarrh. It is sometimes gelatinous, oi 



^ 



tubkbohlobo. 

like frog's epavn, which indicates & Bimilar alteration in the Innf;. It 
coDBumption follows fibriaouB pneumonia, the expectoration is often 
green (Traube and Nothnagel). 

The more estensive the dieease in the liin^s the more abundantly is 
pua foand is the sputa, which may often be chiefly purulent. If cavities 
form, the sputa often take a distinct characteristic form, either that of 
coin (sputum rotundura, nummtilare, aive nummuloHUta), or tliat of 
balls (9. glohosnm). Nummular sputa consist chiefly of opa(|Uc green 
purulent matters, found at the bottom of the spit-cup in Ibe form of 
regular round lumps, usually sharp-edged. The globular sputum is a 
roundish, gray-greeu, separate ball of pua, with a tore and r^ged sur- 
face, somctimL-s kept flouting by uir-bubbles, sometimes sinking to the 
bottom of the glass. 




FBtV ■iTOOlar eplthelluD 






, Also, nireUii fonnt. 



The peculiar form ot these sputa is due to the cohemon between the particles 
or pus. If sputa are coilected in water, a crumbly sediment is often deposited ; 
if the sputa are very thin, the same occurs without water. Exactly aimilai 
masses are found after death on the walls of caritiee, and Viicfaow long ago 
showed that they proceed from the purulent decay of lung-tiBaue. They form no 
Dnimportant sign of cavities : they often contain large numbers of the bacilli. 

Bloody sputa form a very important sign, often gi\*ing the first indi- 
cation of consumption; though not every one that has had haemoptysis 
becomes consumptive. Tbe demonstration of the bacilli in the bloody 
spit is decisive. The sputa may be pure blood, or tingeil with blood. 
In the later course of the disease, severe hsemoptyais may occur repeat- 
ed}j. It IB either provoked by bodily and meutal exertion aad f — ^*~ 



TUBKBODLOBIB. Ml ' 

ment, or occnrs BpontuneouHly. Very profoee bleeding may proceed 
from the riiptnre of aneurisms of arteneB ia the walla of caverns. Ras- 
mnsBen has studied this form of bleeding cIoBely, and Fraeutzel has 

added observations, ' 



-taggerated. Among 3G9 




Bputa In poeujuocoDiouui uitLrauutlca: atla Trsulie. )lagtillli.'(l ^00 iliaiut^ien, u. TiL|jfe]ui[K 

cases, Coudie found only 87 (24 per cent) at any time of the disease; in , 
11 per cent it formed the first symptom. Williams' figures are con- j 
siderably larger; 70 per cent, or 569 in 1,000 eases. 

Expectoration is difficult, especially at the beginning of tbe disease; 
the irritation and the eSort involved in coughing are a torture, the sleep 
is disturbed, and there are pains due to the violent contraction of the 
moBoles of the chest and abdomen. At a later stage, expectoration is apt 
to be easier, and usually more copious. 






I exteiuive altjbtW.^a«» (A. 'Cb* I 



I 9S3 TUBEBOCLOSIB. ^^^H 

ItuiK-parenchj'nia; but ihe wastiog of Uie body sliould arouse miBpicioD bo^^^H 
vent error. ^^^H 

The heart is very often involved. The second (diastolic) puliDODaTy 
Boand is often intensified, a sign of inoreased blood-pressare in the dis- 
tribution of tlie pulmonary artery. If there are signs of retraction of the 
InngB, the heart may be dislocated. If smooih-walled oavittea lie near 
the heart, the sonnda of the heart sometimeg receive a metallic character, 
through resouanci^. 

The subclavian tnunnur, described bf Stokes, is thought very important by 
some autliors. Rfihle considerB the subclavial expiralorj' murmur a valuable 
diaKDOstic sign. 

Itia heard during expiration oa a hissing or roaring sound with thesj^stole. It 
has been explained by pleuritic adhesions excited by lung-changes, which have 
involved thesubclavian arCerj, and thus cause bending and nairowingof theart«- 
rial lube during the movements of respiration. It is tound in healthy persons. 

There are no characteristic peculiarities in the nrine; its amount is 
commonly lessened, and the urea and chlorides are nsually diminished. 
Some authors affirm an increase in the phosphates (Teissier), but Stokvia 
rightly denies this, and found them usualty diminished. Stokvis. op- 
posed to Beneke, found no characteristic change in the earthy phosphates. 
Senator mentions increased excretion of Hme. Traces of albumin may 
be foand in very exhausted patients. Vlbert found sugar three times in 
fifty cases. 

All the other functions may he unaltered, though such is not the rule; 
couEumptioQ very oltea has complications, and almost every organ can 
be involved. 

The bones are often cartona— tuberculous caries. The extremities, 
spine, skull, may be the seat of this caries. In the skull, the petrous 
bone is chiefly attacked, causing loss of hearing and paralysis of the facial 
nerve; or thrombosis of the sinuses, meningitis, or absceas of the 
bruin. The presence of tubercle bacilli in the uiBchargos from such dis- 
ease demonstrates its nature. 

Tuberculous (fungous) joint inflammation is closely related to tuber- 
culous processes in the bones, though more properly pertaining to the 
domain of surgery. 

lu very weak patients, the muscular excitability isoften increased. If 
we give the pectoral muscle a light blow with a percussion-hammer, the 
spot struck rises, and remitine so for some seconds. Graves and Stokes 
described the phenomenon, and correctly stated that it is not pathogno- 
monic of consumption, but occurs also in other states of weakness Tait 
has studied it carefully, and culls it myoidema. Without assenting to 
all that he says, I have often seen (as he states) that it sometimes occnn 
on one side only, and is apt to be stronger on the side most diseased. 

The peristaltic contraction (beat described byAuerbach) is essentisJIy 
different. In this case, when a muscle is tapped, there is a rising on 
both sides of the spot struck, which gradually extends in a slow wate to 
the two attachments of the muscle. This form is not frequeut; is some- 
times limited to single muscles: is not characteristic of consumption, but 
exists in tlie marasmus of gastric and intestinal disease, and probablv in 
mar_y other weakened states. The symptom is often unilateral in tnese 
cases al^o. In a case lately seen by me in Konig's clinic, the musciss 
were fountl microscopically unaltered. 



^^p TEmEBOITLOaiB. 9(93 

^•- Tuberculous inflammation sometimes occnre in peripheral lymphatic 
^B^nds; tbej swell and are hard, but mav afterwards Boften and become 
puruleQt, buret, and lead to protracted sinuous fiatulte. 

The larynx ia very often attacked. The trouble may be purely func- 
tional — obstinate hoarseness, eillier without anatomical change, or 
caused by paralysis of the Tooal cords. The latter is probably due to the 
atonic state of the muscles of the larynx, dependent on general maras- 
mus. Permanent hoarseness ia, however, more commonly due to catarrh, 
which may be limited to one side, or to one of the true vocal cords — not 
always on the side of the lung disease. 

Tuberculous ulceration of the larynx {laryngeal phthisis) is as dan- 
gerous as it is painful (see following section). The pain, difficultr in 
swallowing, and other troubles are often so prominent as to throw tnose 
referred to the lunss into the shade. 

In rarer coses, there is paralysis of the recurrens, which may be due 
to compression by enlarged trachoo-brouchial Ij^mphatic glands (cheesy 
metamorphosis), or to the retraction of pleuritic adhesions. Brieger 
nnblished a case of double paralysis of the rectirreus, due to enlarged 
bronchial glands. 

Inflammation and ulceration of the trachea are common, and may 
often be detected during life by tracheoscopy. 

Bet£ states that goitre ia found in youthful phthisical subjects. 

Consumption rarely develops into gangrene of the Inngs; Tranbe ex- 
plains this by the iufreq_uency of stagnation of the excretion in the air 
passages. If expectoration is checked, the sputum is liable preaentlj' to 
acquire a fetid smell, especially when the patient's strength is insufficient 
for vigorous expectoration, or the consciousness is obscured. Both the 
latter circumstances are unfavorable; fetid sputa in phthisis are there- 
fore a bad ei^n. 

Pleurisy is sometimes associated with consumption; it may be dry or 
moist, and in the latter case may cause n serous, or purulent, or hemor- 
rhagic exudation. The exudation is susceptible of absorption, even in 
tuberculous pleurisy; though usually this improvement is onlv temporary, 
and fluctuates greatly. Fluid exudation sometimes checks the process of 
degeneration in the lungs, and therefore must not be regarded as entirely 
a bad symptom. 

Pneumothorax in consumption is very much rarer than pleurisy (see 
Vol. I., p. 374). 

I lalel}' saw a cnse in which adhesion to the costal pleura preceded rupture of 
a cavity, so that subcutaneous emphysema covering a spot aa large aa a dollar 
occurred nt the poiul of perforation. 

The bronchial glands (as has been stated) sometimes cause paralysis 
of the recurrens by swelling and compression. 

Abnormal dulness above the manubrium sterni somettmee enables ns 
to recognize enlargement of the lymphatic glands. If cheesy glands be- 
come softened, they may rupture into a bronchus or the trachea, or if 
calcified, masses of calcareous material may be thrown out, simulating 
lung-stones. 

'ericarditis is not frequent in phthisis; it may be tuberculous. In 



^VX3 



r; 



ly cades, it seems to be excited oy previous pleurisY; it la.t^i.V') 



t 



984 TTTBEacnTLoeTs. 

in conBeqnence of ruptore o( a cavity into the pericanliam. Cardiac 
thrombi are soaietimeit importaut as causing embolism of thg pulmonary 
artery. Thrombosis of the pulmonary arteries and veiuB occurs, ana 
the latter may cause embolism of the peripheral arteries, e. g,, the cere- 
bral. 

Digestive troubles are very common. Sometimes they are purely 
functional and uuaccompanied by anatomical changes; for example, 
great want of appetite, or unconuuerable dislike to certain articles of 
food. If this dislike is felt towards eggs, milk, meat, or other desiiuble 
things, tliB medical treatmeut is greatly interfered with. 

Many patieuts suffer from troublesome eructations or obstinate vom- 
iting ; or profuse diarrhcea occurs, and continues for awhile, without uuy 
demonstrable changes in the intestines. 

A feeling of heat, dryness, and burning pain in the mouth, especially 
on the tongue, is often encountered. The mucous membrane is of a 
peculiar bright red color, the papillte of the tongue are swollen and prom- 
inent, the secretion of saliva lesBened, and its reaction often sour; symp- 
toms of catarrhal stomatitis. Superficial, partially aphthous ulceration 
may accompany it. 

If the patient is very feeble, and his mouth is not kept carefully clean, 
oidinm albicans develops {Vol. II., p. 10). The tongue is covered 
with a thick, greasy- looking, yellowish -gray coat, easily recognized by 
the microscope as composed of roundish-longish fuugus-sporea and 
jointed myoehum. Excessive discharge of saliva often accompanies this, 
the fluid running from the open mouth almost continuously. The disease 
may extend to the throat and gullet, occasioning difficulty iu swallow- 
iog. 

Tuberculous ulcers are sometimes found on the tongue, said by He- 
verdin to have been first described by Ricord. There may be also a deep 
diffuse tuberculouB-cheesy infiltration of the parenchyma, which may 
easily be mistaken for cancer of the tongue, or gummata. 

Tuberculous ulceration or diffuse infiltration of the throat may occur. 
It is not nsually recognized until there are slightly prominent yellow 
spots, irregular, often disBemimited, and usually sharp-edged, and with 
indentations and angles, These cause very great trouble and pain in 
Bwallowing, though tne subjective symptoms are often remarkably slight 
in even advanced cases. (See the following section on tuberculosis of the 
throat, for details, ) 

follicles with gray tnuispar- 



The infefltinal functions are often disturbed. At the beginning of 
the disease, constipation and diarrhcea alternate frequently. Uatarrfaal, 
tuberculous, or amyloid changes in the intestine, with extensive destrnc- 
tion of mucous membrane, often produce uncontrollable diarrhoea; pain 
may be absent, or may only be produced by pressure on the walls of tho 
abdomen. In other cases, there are extniordinarily severe pains, which 
often take the form of attacks of colic. In a case of that kind in which 
I lately performed the autopsy, there were very extensive ulcerations, 
which in many places had approached close to the peritoneum. Shi'eds 
of intestine are sometimes plainly visible in the sbaol, and may be con- 
founded with portions of undigested food. Obstinate constipation nmy 
occur, in spite of extensive changes in the mucous membrane. The best 



THBEBOULOSIS, ! 

proof of tuberculosis of the intestinal mucous coat is the presence of the 
bacilli in the stool, to be detected as before described. Compare a sub- 
■eqnent section upon intestinal taberculosis. 

Ulceration of the intestine may also cause hemorrhage which is apt to be 
Abnndaat and hard to control. Dumas rightly says that hemorrhage is 
not very common, as the ulceration generally extends slowly, and gives 
the blood-vessels time to become obliterated; but very small ulcers nave 
been known to oaose a fatal result. 



Peritonitis may be caused by intestinal nloers; it is especially danger- 
ous when caused by perforation. 

Recta) fistula, usually tuberculous in its origin, is another complica- 
tion of consumption; the older physicians considered that it was not 
injurious, but acted as a kind of denvant, and gave warning of the dan- 
ger of closing it by an operation. 

The liver is often changed in form and consistency, and enlarged. 
The principal changes are congestion, the fatty and amyloid metanior- 
iihoses, or a combination of these. A fatty liver la doughy in consistency, 
blunt-edged, and o' 
An amyloid liver if 



blunt-edged, and often hard to reach by palpation (see Vol, II., p. 213). 
An amyloid liver is usually larger, harder, and more elastic and eht 

edged; it is considerably less common than fatty livt 



associated with hard 
(amvloid kidney). 



plouic tumor (amyloid spleen) and albuminuria 



bplenic tumor in consumptives may depend on congestion or amyloid 
change. Laige dis^minated tuberculous-caaeous spots are sometimes 
found in enlarged spleen. 

Caseo-tul>orculous inflammation of the testis and epididymis forms 
hard, uneven, knobby masses. Virchow has remarked that consumptives 
who marry and indulge too much in sexual intercourse, often have acute 
tubercalosis of the testis and prostate. The sexual appetite is often 
qnit« strong in consumptives, and is retained even when the strength is 
greatly wasted. 

Menstrual disturbances generally appear very early. The menses are 
scanty and irregular, and at last cease entirely. Tubercle of the mucous 
coat of the uterus, the Fallopian tubes, or ovaries, has no chnical im- 
portance. 

Pregnane; ia an unfavorable campltcation; the destruction of the lunga very 
often beoomes rsjiid towaida the cluse of the period, and still more bo tiller deliv- 
ery; or a chronic ca«e becomes acute; or general miliary luberoulosia begins. 
UWriiie diseaiec are not rare in consumption, and very great caution is needed in 
treating them; some dietinguished gynecolngiats have seen nuoh increaite in the 
iihlbisi':iil aymptoms after such treatment that they atrougly advise not to employ 
it at all. 

The urine often contains albumin. If there are but traces, general 
cachexy maybe the cause of its presence; diarrhcea is often attended with 
transitory slight albuminuria. ' 

If the quantity increases, and fibrinous caste are also present in the 
urine, we may suspect parenchymatous nephritis if the urine is also 
scsoty, dark-colored, and of very high specific gravity, 
v^bumiaaria, in the presence of symptoms of amyloid changes of the 



liyer aod spleeD, may be referred to amyloid change of the kidney, but 
pare achy matoaa and amyloid changes are almost always combined in the 
kidney. 

Albuminuria is often due to congested kidney, bat very extensite 
changes in the lungs are required in order to produce it. 

Purulent urine is sometimes found, originating in tuberculoos dis- 
ease of the urinary apparutns. 

Nervous symptoms are almost always of serious import. Violent 
headache is often the first; referred either to tiie frontal or occipital 
regioii. Bepeated vomiting often occurs after some time. If disturbed 
innervation of the iris muscles now appears (one pupil unnaturally large 
or small), the apprehension of tuberculous meningitis becomes almost a 
certainty. Stiff neck usually soon follows; conscioiisuees is obsoared, 
delirium occurs, and death follows, often immediately preceded by very 
great increase in temperature (hyperpyrexia). 

ThesesymptomsarenotconRned to tuberculous meningitis; the purulent fotm 
may occur, especiallj when caries of the temporal bones extends inwardly. The 
oigua of hearing should be most carefully examiaed at the first appearance of 
meningitic symptoms. 

Many patients complain of violent pains. The changes in the lungs 
do not cause pain, but pleuritic complications may; or there may be 
severe musculur pains, duo to the exertion of violent coughing, or to 
parenchymatous cnanges in the muscles. They are either spontaneous 
or dependent upon pressure. Sometimes they are almost periodical, 
aud occur (as I have repeatedly seen) at fixed hours in the afternoon. 

Very severe muscular pains may simulate other diseases. 1 lately saw a man 
of thirty-five years who had been sufFeriii>; violent pains in the muscles of tlie 
bock and belly, whose pliysiciuns disputed whether to call it rbeumatiBin or 
trichinosis. They had forgotten to examine the lungs, which contained cavities 
on both sides; profuse hssmoptysU occurred in a few days, and repetitions of it 
caused death in four weeks. 

Continuous loss of sleep is often complained of, even when there is 
Tery little annoyance from cough and irritation. In my cases, this sign 
has usually been unfavorable, and has been soon followed by death. 

Consumption is usually chronic, lasting many months or many years. 
The average duration of life in one thousand cases collected by Williams 
in his practice was seven and a half years. It is, therefore, easy to infer 
that cases differ widely among themselves. 

The disease may be acute from the beginning, aud last but a few 
weeks; such cases occur chiefly in young persons. The terms " phthisis 
florida" and "galloping consumption" huve been applied to such cases. 
They usnally involve extensive changes in the lungs, or a tendency to 
unusually rapid progress. 

A chronic case may be interrupted by an acute stage, which often 
directly causes death; the exciting cause of which may lie pneumonia, 
pleurisy, pericarditis, or peritonitis. General miliary tuberculous often 
originates in chronic consumption of the lungs. The impulse to the 
acute form may be given by various injurious circumstances. 

Von Buhl 



purulent peiibrouchitia as the cause of a very rapid d 



^m 



^^F nrsEBCCixosis. 287 ^ 

^H^ Though death is the usual termination, yet cure, or decided improve- 
mect nuw and then occurs. If the tubercular parts of the lung heal 
Dompletely, a contracting cicatrix of connective tissue remainB. Imper- 
fect cure IB more frequent than perfect cure; there is a diminution of 
local diseased action, but we are not sure that it will not again become 
progesaive. 

If there is a bIow and steady progress of the disease, the final symp- 
toms may be those of debility. Profuse hemorrhage may cause death 
unexpectedly. (Edema of the glottis, in disease of the larynx, may be 
fatal. There may be such difficulty in swallowing as to produce death . 
by inanition. Suffocation may result from very extensive disease of the I 
lungs, or from compression by pneumothorax or pleuritic exudation. * 
Death may occur with symptoms of general dropsy. Or, it may originate 
in the circulatory apparatus, through embolism or thrombosis of the 
pulmonary artery. Fatal embolism of the cerebral arteries, originating 
in thrombi within the pulmonary veins, has been observed. In a few 
cases, the cause of death was not demonstrated by the autopsy, and nerv- < 
ous disturbances might account for it (Perroud). 1 

in. Anatomical Changes. — Either lung, or both, may b« I 
affected. The iliseuse is often limited to the apices, while iu other cases 1 
an entire upper lobe or u great part of it is involved, and in yet I 
others the lower lobe is involved; out the process is apt to be most I 
advanced in the upper ones. Cases in which the lower lobes are I 
chiefly or exclnsiTely affected are exceptional. The region around the I 
hilus and the lower lobe are mentioned by Michael and Weigert as & I 
favorite spot for the disease (the apices remaining untouched) in children I 
only. 

Among the characteristic macroscopic changes, caseous degeneration 
18 prominent; a more certain sign is the microscopic evidence of the pres- 
ence of the tubercle bacillus. The more recent the diseased portion Ja 
the more abuudant are the bacilli; in caseous masses they diminish, 
though the spores seem to be retained, which must render the caseous 
mass contagious. It is very probable that the bacilli are spread by 
coughing out portions of contagious secretion, which is drawn back on 
inspiration into other parts of the lung. The cheesy masses in the lungs 
originate in a transformation of inflammatory products; the part chiefly 
involved in inflammation is tlie parenchyma; hence, consumption haa 
by many been considered identical with cosenns pneumonia. 

The cheesy portions are easily recognized by their yellow color and 
cmmbly, friaole, pulpy consistency. A lobular arrangement is often 
seen, the lobules often separated from one another by tissue in a state of 
slaty induration. The smallest are less than a pin's head iu size. In other 

E laces, several lobular spots unite to form large caseous surfaces, the lobu- 
ir origin of which may often be traced by the irregular angular contours. 
Uniform diffuse caseous change of an entire lobe is very much rarer. 

The bronchi that pass into a caseous part are frequently dilated. 
They often contain a secretion which is purulent, or thickene<l like 
chee'eo, or translucent like jelly. This can be forced out by pressure, but 
when in situ is easily confounded with miliary tubercle, especially as it 
projects somewhat on the cut surface. Ulcerative changes of the bron- ^^ 
cbial mucous membrane are often seen; or knotty thickening of the ^^^| 
bronchial wall with connective tissue, partly caseous, especially on the ^^^| 
I oataide (peribronchitis). ^^^ 

^^H The cheesy product is not developed as such; it consists of degen- ' ^ 



■ BBS TCBEHOUKMH. 

crated infiammatorj prodncta which hare gnffered the fattr change and 
great loss of water at the eame time. lu t)ie stage preceding, we fiad 
maeses like frog's spawn, translucent-gelatinuus. gray-transparent or 
gelatinous, formerly termed gelatinous ittflammution of the Inog. 

The cheesj deposit may tecome chalky or fluid. In the former ca«, 
salts of lime are deposited, beginning at the centre of the mass, and 
gradually changing the whole to a stony-hard substance. This is a kind 
of cure, as the lump remains as an inuocont foreign body for the rest of 
life. The tissue sometimes softens around it, and it is detached and ex- 
pectorated. The cheesy mass may not take the form of a stone, but may 
condense, and attract deposits of lime salts, till it reaches the consistency 
of mortar; a thick capsule of connective tissue {due to chronic interstitial 
pnenmonia) then incloses it, and renders it permanently harmless. 
Very small caseous deposits may become fluid, and afterwards be com- 
pletely absorbed, leaving a permanent cicatrix of connective tissue. 

Liquefaction in a lar^e caseous mass generally leads to the formation 
of cavities {vomicre). The puriforra mass becomes corrosive, and eats 
into some bronchus or bronchi, is expectorated, and leaves a hollow in 
its place, the inner wall of which is at first irregular and eaten intofold^ 
ana shreds. Several cavities often unite, forming very irregular caverns. 
Their general tendency is to spread peripherally, but interstitial pneu- 
monia often counteracts this by throwing around them a capsule of con- 
nective tissue. When the contents are entirely liquefied and ejected, 
the wall loses its tufted appearance, and becomes a smooth surface, 
usually covered with a more or less thick, caseo-i)uniieDt, crumblymass, 
which can be easily scraped oS with a knife. The oavitv may be much 
larger than a Sst, and sometimes may include almost a wEole lobe of the 
lung. 

The blood-vessels resist this process a great while; they may often be 
seen of the size of a pack-thread, crossing the cavity, their walls thick- 
ened and their opening usually obliterated. Stout branches may project 
into the cavity, sometimes presenting aneurismal dilatations, wnich fre- 
quently cause profuse and obstinate hemorrhage. 

Cavities may also originate in dilatation of bronchi, which may be 
very large, and are usuully recognizable by the direct passage of the wall 
of the bronchus into that of the cavity, and by the internal wall being 
covered with ciliary epithelium. 

Tubercles are very often seen in addition to caseous nodules. Two 
kinds of tubercle are to be distinguished — the local and the dissemi- 
nated. The former is usually best seen near a moderate-sized caseous 
deposit; it forms gray, translucent knots of tubercle, radiating peri- 
pherally, chiefly following the course of lymphatics. Gray tubercles 
are often seun near ulcers of the bronchial mucous membrane. Dis- 
seminated tubercle is scattered in small lumps through the lung-tissue; 
it may be observed on the walls of caverns; it often affects a great nnm- 
ber of other organs (general miliary tuberculosis). 

The above description relates to the macroscopic appearances. There 
exists a great variety of opinion in regard to the histological origin of 
the disease. The study of the disease has been made difficult by the 
fact that advanced cases, with very various combinations of disease of the 
several tissue -elements, are the ones usually examined. 

The first question is, whether the disease begins as an intra-alveolar 
or an Jntcr-alvcolar process, or whether it first attacks the minute broa- 



TUBvaauumB. S89 

AH these proceasea are nsaally foand oombined; but tt may be 
Jht to assnme that one odIj was the original one. 

It is a common error to consider that all cases have one point of 
origin. Of two such excellent obserrera as Oolborg and Rindfleiscb, the 
former affirms chiefly the intra-ah-eolar origin, the latter the inter-alve- 
olar; is it not poaaible that both are right, but with too one-aided a bias ? 
The determination of the point of origin of inflammation may often 
depend on accidental causes — catarrh of the small bronnhi, an intra- 
alveolar proceaa, or (perhaps the rarest) inter-alveolar eliangea. The 
essential point in consumption is baclllar infection of inflammation pro- 
ducts followed by the caseons change. 

Analyzing the processes, we find in the bronchi both peribronchial 
changes and those affecting the mucous membrane. The former is some- 
times peribronchitis fibrosa, characterized by fibrons thickening of the 
adventitious tissue. The caseous form is more characteristio, shown 
by cheesy, often lumpy and Icnotty thickenings, on the outer wall of 
fine bronchi, and not to be confounded with toberculous formations. In 
thecavity of the bronchi, we often see thickened caseous masses, the cross 
section of which in small bronchi may bo mistaken for tubercle (encysted 
tubercle of older authors). 

The intra-alveolar changes are marked by the filling of the alveoli 
of the lungs with cheesy masses. Caseous change is usually preceded by 
active desquamation of alvmlar epithelium, so that at the beginning we 
have to do with so-called desquamative pneumonia. True tubercle 
formation also occurs here. 

A^ Rindfleisch showed, the points where the finest bronchi enter the 
acini are the chief seat of inter-alveolar disease. 

The muscles of consumptives are usually very pale and small. Von 
Buhl stated that parenchymatous changes are not rare. E. Fraenkel 
has further descriocd granular opacity, pigmentation, atrophy of the 
muscular fibres, and hypertrophic changes of the perimysium internum. 
The changes are probably due to marasmus, and vary greatly in different 
mnscles. When affecting the larym, eye, or diaphragm, they may 
account for many functional disturbances. 

The heart is usually small and flabby; its muscle is pale, sometimes 
doep-brown, occjisionally with yellow fatty spots. The right heart is 
often dilated and hypertrophied. Fatty change of the inner coat of the 
pulmonary artery is often observed. i 

The bronchial lymphatic glands are often enlarged, or caseous, with 
taborcle or lime concretions. Large cheesy masses of lymphatic glanda > 
•re eapeciatly frequent in children (Michael and Weigert). 

The liver and kidneys may show marks of venous congestion. 

IV. DiAQN08T8. — It is extremely hard to recognize consumption in 
its earliest stages. Wo may consider every case of apex catarrh as seri- 
ous, and treat it with great care, but it is g-)ing too far to infer consump- 
tion and an inevitable doom .is necessary consequences. It is here that it 
is of great importance to demonstrate bacilli. And the same is true of 
hamftptyais, which may often de the sign of established tuberculous 
disease of the lungs. We must not forget that there are patients who 
have no expectoration and consumptives whose sputa are free from the 
bacilloa. In such cases, we must make especial use of the accounts 
given us of consum[>tion in the family, scrofulous disease in youth, and 
great tendency to disease of the respiratory organs. Increaeed tempera- . 
19 



390 TUBBBGULOeiS. 

tare at evening Md loss of bodily ireight are symptoms not to be under* 
valued. Night sweats are important. 

The above points must be oonsidered when we have to decide whether 
an existing affection of the larynx is caused by concealed phthisis, oi 
whether cMorosis, or disease of the stomach or intestine, is connects 
with phthisis. 



In doubtful oases, the sputa might be inoculated into rabjits as a test, but it 
would require several weeks at least before we could expect to see taberculoaji 
develop in the animal. 

If consumption follows acute pneumonia, the siras of infiltration 
persist; but there are often cases in which complete absorption and cure 
of pneumonic infiltration ^occur after a long time, and contrary to 
expectation. 

If there exist signs of infiltration or cavities, we have to make a differ- 
ential diagnosis. In case of infiltration, pneumonic disease is to be 
thought of; consumption has not the cyclic course of pneumonia, and 
the fact that the apex is chiefiy affected majr often be decisive in favor 
of consumption; an affection of both apices is in favor of the latter. 

Tuberculous cavities have not the stench of those caused by gan> 
^ne, or the characteristic three layers, or the mycotic bronchial pTu^ 
in the sjYuta. The same is true in the case of bronchiectaaia with putnd 
destruction of tissue; this is also chiefly located in the posterior and 
lower parts. In consumption, we do not generally see the pieces of lung 
tissue in the sputa which we see in cases of abscess, nor the abundant 
mass of hsematoidin crystak. which are almost always seen in the latter. 

V. Prognosis. — This is very serious, and in the majority of cases 
unfavorable. Recovery is hardly to be expected unless the case is seen 
at the first stage, and unless the patient can make pecuniary and other 
sacrifices; there is hardly a disease in which so much depends on the 
purse. If one can leave home and live at certain spots, free from care 
and bodily exertion, life may often be protracted for many years; or in 
favorable cases complete cure may be obtained. 

The age affects the prognosis, for in young persons the disease is apt 
to run a q[uick course, and is less disposed to recovery or improvement; 
we sometimes find consumptive parents of advanced years who lose one 
child after another by their own disease. 

Hereditary predisposition, being beyond the reach of medicine, makes 
the prognosis more unfavorable. 

External circumstances may make the prognosis very unfavorable; 
for the poor, who are forced to remain in oad lodgings, to eat insuffi- 
cient food, to over-work themselves in dusty factory-rooms, can hardly 
hope for improvement and cure. 

Marriage is unfavorable, for we often see the phthisical process 
increase and become acute very soon after marriage. 

The existence of extensive disease is unfavorable, especially as such 
cases have a tendency to assume the '' galloping " form. 

The prognosis is serious if cavities are present. 

Complications may add unfavorable features; some, as the amyloid 
change, can hardly admit of recovery. 

The number of bacilli in the sputa has been found to bear no rela* 
tion to the extent and probable course of the disease. 

YI. Tbbatment. — ^Bational preventive measures are worth more than 



^^^p TVSEscm/mB. 39n 

^^H^at physic can 3o for an eBtablished cose. There Js little enough, ' 
^^^uwever, that a physician can do by way of prevention, nor will nia 
warnings be of much avail ontil more energetic steps are taken by 
the State or by public associations. Among the chief requirements in 
this direction are healthy and well-lighted tenements for the working 
claeees, State supervision of factories and factory -hours, and attention to 
providing abundant and nutritious food. | 

In individual cases, there is need of special care, dating from the' | 
first day of life, for children that spnng from consumptive families or 
from parents advanced in years or exhausted by disease — such parents 
being often known to transmit a phthisical constitution. The mother 
must be forbidden to give suck, and a good wet-nurse must be provided, 
whose freedom from consumption must bo iiscertuined by examination. 
If artificial food is given, let only thoroughly boiled milk, taken from i 
one cow that is free from disease, be used. As the child grows older, 
let him be well fed, kept from overwork at school, hardened by the 
judicious use of cold-water frictions; let him practice such gymnastic 
drill as is fitted to develop the chest and lung^; and strengthen the chest 
and muscles, and let the choice he made of an occupation which requires 
wholesome movement in the open air. All diseases of the respiratory 
organs in such persons require special cure. We hardly need say how 
often these measures must remain theoretical, simply for want of means 
to carry them out. 

Scrofulous disease mnst receive energetic and persevering treatment. I 
All diseases of the respiratory tract must be treated with uncommon J 
care, especially those which, like measles, scarlet fever, or whooping- ] 
cough, frequently lead to consumption. 

Marriage requires serious consideration in persons who have con- 
sumption or are suspected of having it. They should be dissuaded from 
marriage, it will put thera in danger of a more speedy development of 
the disease, or of hastening its progress; and inflicts a blight on tha 
posterity. 

An important rule of prophylaxisrelates to intercourse with conaump- j 
tives. There can hardly be a doubt that the disease is contagions, and 
we know that the contagious clement is contained in the sputa. As. I 
protective measures, we should forbid the patient's sleeping with ] 
another person. The sputa must be kept in a covered glass and disin- I 
fected with a five-per-cent solution of carbolic acid, of which an amount is I 
added about equal to the daily discharge, Fischer andSchill have proved 
that this destroys the tubercle-bacilli within twenty-iour hours; but they 
also found that the bacilli retained their vitality for six months in dried 
sputa. The bare possibility of contagion makes such precautions 
necessary; nor is it a sufficient answer to point to this or that person, or 
to many persons, who have received no barm from such contact. We I 
must also he careful in using the clothing or linen of such patients; and I 
must disinfect it. 

Consumptives treated in hospitals must be isolated, shut out from 
the general wards, and, in particular, not placed with those who have 
non-tuberculous diseases of the respiratory tract. 

In trcuting developed cases, we must lay much less stress on medicines 
than on residence in a well-selected climate-cure. The " bath-cures" 
or spas are often visited merely as a matter of fashion; but in consump- 
tion the case is quite otherwise, as will bo admitted by every pbysioi&a 
^^^Jifts treated many consumptives of means. 



)|M TUBKRCUU)0I8. 

If oHmate-ctirM are to be of use, they miut be employed as soon as 
MJMtiblis. for Wi» oau expect no benefit from them in those who present 
Mirg«i (Mivitiw or extensire infiltration. Patients with one foot already in 
Ui4» gravu ar0 often nent off at the risk of life, onl^ to return speedilv, 
with ihisir faW hooe KOue» seeking their home to die in it. In the early 
tU|{4M. It will b« well for those who have no restriction upon their action^ 
to viitiL oliiiiatt>«cure«> ereu if there is only a suspicion of disease, for it is 
tH>lU'r to do thill too early, or needlessly, many times, than to do it too 
\kkUy (>iiiH»« 

Tliutv Im a very largo number of climate-cures, and of late the num- 
^Hti Um iiiuoh increased, often to the injury of the cause. We do not 
•tttuiiipl tv* M[iyt^ a long list. It is necessary first to decide between ths 
i I III 1 tint i»r ''olodtnl'' establishments, like Odrbersdorf in Silesia, Eo- 
uig<«U>fu iu tho Taunus, Inselbad near Paderbom, and Beiboldsgrun in 
Mi4\oav, uiul tho *' open'' health resorts. The former have been rather 
uliiuittvtl to rtiuiH) the discovery of Eooh's bacillus; they certainly should 
tiiuv \h> vuitiHl by decidedly tuberculous patients, not by those merely 
^u^HH^tinl, owing to the danger of contagion; and they must be well 
4iiiHi uikil oarefiuly disinfected. Among the latter we can highly recom- 
uiuuU twnw our own experience for summer residence Kroutn in the 
LUvuriuu mountains, wnile we place the localities in the Hartz, as 
Auiiiiuuborg, in the second list. For autumn and spring, select places 
iii 'r.vrul (.Nleran, Qries, Gorz), in Upper Italy (Arco, Gadenabia, Ln^no, 
IHiluiuu), or on the lake of Geneva (Montreux, Clarens). For winter 
riuii(UiU(iu it is doubtful whether to prefer a high region with cold equable 
isliuiute, or a southern place with mild climate. For patients from the 
iituthuru imrts of Europe we prefer high localities; Davos, with its ex- 
iJulUmt arraugenieuts, gives extremely good results. Not a few patients 
(if uilius who have spent several whole winters in southern places, have 
luiuiphiinod that after returning home, with all due precautions, they 
huvi) found the change of temperature so disagreeable that the benefit 
thuy hud (lorivod soon disappeared. The residence at Davos, however, 
had ugruiMl with them wonderfully, and the benefit has been permanent, 
l^uiboiiti diriportcMl to hasmoptysis and affected with laryngeal disease 
tihoiilcl not goiuTuIIy go to Davos, but to southern climates. In all 
cmna, put ion tH must stay as long as possible in the place selected, must 
vitiit it rt^poutedly, and not return home until settled warm weather is 
e^iuhlitshud. 

Amt)ng the climuto cures of the south we mention San Bemo, Men- 
luue, Monaco, Norvi, La Spezia, Cannes, Hy^res, Pan; also Pisa, 
Florence, Veiiioo, Ronio, Palermo, Catania, Ajaccio, Malaga, Cairo, 
Algiers, Madeira, and Malta. We have known several very serious cases 
in which Mudciru, eapocially, produced surprising results, but the 
syniptonis vory quickly returned as soon as the patient came home, and 
it was iicircssary to take up a permanent residence in Madeira. 

In suninicr, much iijood may be done by residence in sheltered coun- 
try places with iijood food and much exercise in the open air. 
Tliuringcn, Huvurui, Badon, and especially Switzerland, are very rich in 
ijunnncr n^Hortn. 

Hcsid(>n(*c on the sea coast has been again recommended of late; 

Uhilattth. among others, siiys that in Nordemev consumption is very 

liii*'. Long sea voyages have been found useful; Maclaren, for example, 

ii'iM.Mh il)(>in Ktro]\gly, but Jones opposes them. The use of the grape 

t'Uft.tiihi (lie ulicy cure is diminishing. 



TUBKBODLOflia. '^'Bl 

Bat n very email part of our patients will be ablo to make use of I 
these remedies; as for the rest, treatment offers little for them. I 

Much care must be taken with the diet and habits; it has been said 
with reason that a phthisical person should consume more food than he 
reallr needs. It has even been recommended by many to introduce food 
by the stomach-tube in cases of unwillingness to eat. i 

Let the patient bave in the morning sereral cups of milk, or cocoa, or coffee I 
with egg. At the second brealffagt. a. aoft-boiled egg, abaved lism. tender meat- ^ 
sausage, white bread and butter, and a glass of port. At dinner, meat soup, good 
meat, well stewed fruit, and half a Ijottln of good red wine. la the afternouti. 
milk or cocoa. At supper, porridge or wheat-grits or rye, soft'egg, ham, cold 
meat, white bread and butt«r, a glaaa of gcmd Bavarian beer. A record should 
be kept of the person's weight. He should go to bod frani 9 to 10 P.M.. and 
rise at 7 or 8 p.U. On calm days, a walk In the open air; but neither go out too 
early, nor return too late. All bodily and mental exertions are to be avoided. I 

Cod-liver oil is an important remedy, especially indicated for thin I 

personB. Give from one to three tablespoonfnls in tlie morning; but I 

feare it off when loss of appetite or diarrhcea occurs. Malt extract has | 

also a reputation. I 

Inhalation of iodine, iodide of potassium taken internally, arsenic, | 

and salts of phosphorus have been recommended as specifics in con- J 

sumption, bnt we must say that there are no specifics known, and thai 4 

our treatment is purely symptomatic. I 

Buchner's recent recommendation of arsenic has aroused attention, 
and both favorable and unfavorable reports have been given. We have 
repeatedly seen very good rcsnlts at the beginning of the disease, but no 
»I>ecific resnlta as against .the lung changes themselves. Appetite was 
improved, weight increased, febrile movement ceased in several cases ; 

afters time, even night sweats were lessened. In extreme cases with I 

great cavities and extreme weakness, we have neither seen nor expected I 

HuccesB from arsenic. We have found the combination of arsenic I 

and creasote often useful, if the secretion was very abundant in the I 

air passages, and expectoration difficult. (IJ Creasoti, gr. vi. ; acidi 1 

arseniosi. gr. sa.; adde vehic. q. s. ut ft. pil. no. 20. Consperge cortice I 

cinnamomi. H. One pill three times a day after eating.) J 

The transfueioD of lamb's binod, and the use of bentoate of aoda, may ba<ra I 

some historic interest; Brachet recommended inoculation with BmBll-pox. saying 1 

that he had seen phthiaia at the lungs cured after that disease. I 

Sleinbrbck and Erull successfully employ inhalation of oxygen. 1 

Surgical operations have been employed, but without brilliant success. Among J 

the elder physicians, Vou Herd! and Hoken bave advised the opening of oavities 1 

and surgical treatment of them; more lately, Mnaler, Pepper, Hutchinson, and ] 

Williams have repeated the experiment, by puncture or incision. Koch advised I 

the injection of irritating fluids (carbolic acid or tincture of iodine) into the lung* I 

Uaaue, to excite cicatrisatiou. I 

In every case, a record of weight and temperature must be kept, and I 

mnat be continued a long time after cure seems to bo attained. The 1 

spirometer shows the vital capacity of the lungs, the pneumatometor 1 

the pressure exercised in expiration and inspiration; both are much used I 

as tests. I 

For violent cough, use small doses of narcotics, but bo cautions with I 

such remedies, as it is easy tor a patient to acquire a habit of using them I 

^ the course of a chronic disease. _ I 



c 



S94 TUBEBOULOfilS. 

For abandant secretion in the bronchi use expectorants. In such 
cases^ the use of the waters in Lippsprunge, Weissenburg, Selters, Emt, 
Soden, Obersalzbrnnn, Oleichenberg, etc.^ has been recommeuded. 

If ansBmia is very prominent, use mild preparations of iron. A mix- 
ture of iron and chaik is often advisable; e. g.y $ Ferri lactat., OBdcii 
phosph.y aa 3 iiss. ; magnesia earb.» sacchari albi^ aa 3iy. M« S« A l^nife- 
point three times a day after eating. 

The iron waters of Pyrmont^ Driburg^ Oudowa, Seinerz, Salzbrnnn, 
Eonigsdorf-Jastrzemb» ^teben^ or Spaa may be useful. 

For loss of appetite bitters are suitable^ as quinine in small doses, 4 
jr. three times a day [? 1^ gr. Transl.]; compound tinct. cinchona bark 
decoct. cinchonsB, 1 : 18, | yi.; ac. hydrochlor, gr. xxx.; syr. simpL, 3 v.; 

S. Tablespoonful every two hours); or folia trifolii fibrini (ft FoL 
trifol. fib., gr. xxiy., boil with equal parts water and claret wine and 
strain to make 3 yi.; simple syrup, 3 v. M. 8. Tablespoonful every two 
hours). 

A careful use of Carlsbad or Eissingen water is sometimes indicated. 
. For febrile symptoms, antipyrin is the surest remedy ( 3 i. in § iss. 
of water by enema). 

Heavy sweating is quite amenable to atropine (Wilson, Fraentzel, 
Williamson) (3 Atrop. sulph., gr. ^»; pulv. althaeae, q. s. ut.f. pil. no. x. 
S. One or two at night). In many, it causes diarrhoea, which oDliges the 
patients to suspend its use. Seifert recommended agaricin (gr. i^ to i) and 
FrsButzel, hyoscine (gr. ^). Cauldweli has lately nsed with success 
picrotoxine (gr. \ for a dose). Eohnhom recommends powdering the 
patient with salicylic acid (IJ Ac. 8alicyl.,3ii.; starch, 3 iiss.; talc, J iij., 
M.). If the skin is very dry, it is to be oiled before powdering. Lauder- 
Brunton has used strychnine successfully. The elder physicians used 
also sage tea, and boletus laricis. I have repeatedly seen good results 
from friction in the evening with cold water, to which a few spoonfuls 
of alcohol or cologne water had been added. 

The treatment of haemoptysis is given in Vol. I., j). 256. That of 
diarrhoea, in a following section on intestinal tuberculosis. 

2. Larynfjeal Phthisis, Phthisis Laryngea. 

(Chronic Ulcerous Tuberculosis of the Larynx). 

I. Etiology. — Laryngeal phthisis includes all those ulcerative pro- 
cesses in the larynx which are produced by the colonization and growth 
of tubercle bacilli, as in the lungs. The disease has a deservedly bad 
reputation, as it causes very painful symptoms which often make the 
patienVs life a torture. 

The disease is more common in men than in women; it is rare be- 
fore puberty, and most frequent between 20 and 30 years of age. 

As a rule, it is associated with tubercle of the lung, and in the ma- 
jority of cases is secondary. It is suspected, not without reason, to be 
often due to self-infection by bacilli in sputa; such infection would be 
favored by accidental catarrh, straining of the vocal cords, and perhaps 
by a want of resisting power in the larynx. The lung disease is usually 
fully developed before signs of the laryngeal trouble appear, and some- 
times it is almost the last symptom during the course of the disease. 
Yet cases are seen in which the larynx is very deeply involved before the 
6r8t symptoms appear in the lungs. 



TCBBBOTTLOeiS. 



I of ( 



99B I 

I made at the 



S36 aatopsies ( 

ipzi|;from 1807 to 1876, 37600668 of laryngeal 

Mackeniie gives a similar rcsalt (33 per ceut) 



Heiose found among 1. 

IholDgicol J natitute of I* 
phthisis, or 30, 6 per cent. 
from his own experience. 

It is stated by good authorities that sometimes all disease of the 
Inngs has been absent, making the ulceration of the larynx independent 
or primary. It is even said that the hmgs have been tlio part secondarily 
affected. The existence of the primary form can only be proved by 
autopsies, vhich at present are wanting, for we cannot certainly affirm 
that the lungs are mmSected merely because physical signs are want- 
ing. We pereonally believe iu the oicisteuco of the primary disease, 
and think that the predisposition of lung-tissue to tuberculosis has been 
overrated. Sommerbrodt has experimentally shown that primary dis- 
ease of the larynx may cause secondary changes in the lungs. 

II. ANATOMICAL Chvnoes. — By Koch's revolutionary dlscovery, the 
domain of laryngeal phthisis has been sharply defined, its sign and stamp 
being the presence of the bacilli in the diseased parts. 

As regnrds the hiatogenesis of the disease, latei- researches, especially 
those of Ueinze. show that the mucous and Hubmncoua coats of the 
larynx are thickened in most cases, owing to the accumiiliition of 
round cells, and more especially to the development of nnmerous tuber- 
cle nodules. The mucous coat is pale, gelatinous, and its surface often 
irregularly nodular. The nodules oecome caseous, and afterwards break 
down, producing tuberculous ulcers of the mucouK membrane. 

The changes above described are not always limited to the larynx, 
but are often met with in the pharyngeal parts, the trachea, and some- 
times the bronchi, showing, as it were, the route taken by the sputa. 
Sometimes the ulceration extends directly from thn mucous menihrand 
of the larynx to that of the fauces or trachea. Tuberculous ulcers ia 
the trachea alone are rare. 

There is much variation in the size and appearance ot the ulcers. 
The size may be that ot a pin's head, or a pea, or large parts of the sur- j 
face may be covered. The shape is often circular; sometimes tliey aro ' 
irregular. The loss of tissue may be superticial or may extend deeply; 
in the latter case, they often have the form of a funnel or crater, which 
is made more distinct by the wall-like thickening and prominence of 
the edges. Papillary excrescences of the mucous membrane or epithelial 
^wths of the edge of the ulcer aro sometimes found. The base of the 
ulcer often haaa yellowliah or tallowy-gray coat; it is more rarely clean 
and red. and a layer of pus is found only at the edge. 

Some of these ulcers can be calledfollicular ulcers of the larynx; ' 
Bindlleisch has particularly studied their origin. They originate in \ 
aloeratiou of the outlets of the glands of the mucous membrane, 
roundish and l!at-funne]-flhai>ed ulcer first apnears. and afterwards 
spreads both downwards and laterally. The glanaular body at the siLme 
time perishes under the same process, and the ulceration finally involves 
the perichondrium. If neighboring ulcers run together, they produce 
indented or (as Rindfleisch wcU says) bunch-of-grapcs ulcerations. 



Harktnl tuberculous tt 



^^^^^ very favorit< 
^^^Ec iiiter-aryt< 






II tbe larynx or tracbea (Chiara, 



very favorite seat of these ulcers is the posterior wall of the larynx 
inter-arytenoid region. They are often lonned on the nLiifl<\«&. J 



296 TUBBBOUL06IB. 

membrane of the yocal processes and the posterior end of the tme vocal 
cords, on the false vocal cords^ the mncons membrane of the arytenoid 
cartilages, and the epiglottis. 

If tne ulcers exteiid, severe secondary alterations of the larynx may 
occur. The insertions of the muscles of the cords are often destroyed^ 
or the cords themselves are separated from the vocal process of the 
arytenoid. Large parts of the larynx may perish completely, the chief 

Sart of the epiglottis especially being often ouite destroyed. Perichon* 
ritis or oedema of the glottis with &tal results sometimes supervenes. 
The changes may be limited to one side, or chiefly so; it is said that 
they often are confined to the side corresponding to the lung which is 
most affected. 

The cartilages are often foand^ossifled, even •'vdion-the perichoBdrinxn is not 
implicated in the uloerattons. 

Fauvel remarked the almost invariable freedom of the laryngeal (i. 6., cervical) 
lymphatic glands from secondary tuberculous changes. 

It is a peculiarity of the tuberculous ulceration of the larynx that it 
has very little tendency to heal, and a great disposition to spread. Cica- 
trization is extremely rare. 

III. S YHPTOHS. — The laryngoscope is of leading importance in recog- 
nizing this disease. The changes begin with swelling, the surface of the 
larynx being often uneven as if warty, and pale; ulceration follows. 
The swelling of certain parts may be so great as to confuse the appear- 
ance of parts. 

Many authors claim to have seen miliary tubercles with the laryn- 
goscope, but this is perhaps not trustworthy. If ulcerations exist, 
we cannot always recognize them with the mirror, even when there is 
little swelling. An ulcer on the posterior wall of the larynx, in particu- 
lar, may escape notice, or its upper edge alone may be seen. Very small 
ulcers may be overlooked. A deposit of pus and mucus may temporarily 
conceal an ulcer. 

Impairment of the voice is a prominent feature, and may vary from 
slight noarseness to complete aphonia. We often perceive a striking 
disproportion between the slight ulcerative changes and the severe affec- 
tion 01 the voice, showing that ulceration is not always the sole cause. 
Swelling of the mucous membrane and paresis of the muscles of the 
cords may be concerned in producing this effect. 

Tickling, or piercing pains in the region of the larynx are usually 
felt; the pain may become intense, and radiate towards the ears. 

There is generally a very strong impulse to cough, not only felt by 
day, but destroying sleep by night. Muco-purulent or puriform masses 
are expectorated, which may be mixed with streaks of blood, and under 
the microscope sometimes show elastic fibres, which are less curled 
than those from the lung. 

Trouble in swallowing is very common; fluids especially go the wrong 
way and provoke coughing, owing to incomplete closure of the glottis. 
The act of swallowing is sometimes so painful that all food is refused; 
this is especially the case when the epiglottis and false vocal cords or 
the arytenoid bodies are swollen and partly destroyed, as in such cases 
every morsel presses on the diseased parts. 

The lungs usually show markea phthisical disease, but laryngeal 
phthiais sometimes seems to stand alone. 



^^m TUBBB0UL06IB. SVf^ 

^^F'Ceath mar be due to exhaustioD with increasing hectic s^mptoniB ; j 

^^Fit is caused suddenly br cedema of the glottic, or is associated with I 

the above-described symptoms of laryngeal perichondritis (see Vol. I., 

p. 189). I 

Cures are excessively rare. I have seen two cases, in both of which 
the disease continued in the lung, and death occurred in the space of 
one year and one year and a half respectively. The farmatiou of cou- 
tractJDg cicatrices is equally rare. 

IV. DiAONoaia. — With the laryngoscope, the diagnosis is easily 
made, for gelatinous thickening of the mucous membrane or ulcerative 
processes in the larynx in a case of consumption are almost decisive. To 
this add that we can remove secretion from the surface of the ulcer ' 
with a clean brush or sponge, and examine it for the tubercle bacitlus. 
The latter point is chiefly of importance when there are no decided 
changes of the lung, and we desire to exclude the possibility of syphilitic 
ulcers. Yet a comDinatiou of the latter with phthisis of the larynx and 
lungs is not rare. An examination of sputa alone is not decisive, for 
the tubercle may come from the lungs; and in taking out the secretion ' 
from the surface of the ulcer we should be careful that we are not takiug | 
apatum that has stuck there. 

V. pROQffosis. — The nature of the disease renders the prognosis 
usually unfavorable. Becovery can hardly be expected. The disease 
usually runs a very speedy course to death, the longest period after the 
first laryngeal symptoms being usually a year and a half. 

VI. Trkatmbst. — We should avoid all energetic local meaaures. If , 
there is severe pain, or trouble in swallowing, muriate of cocaiue may 1 
be pencilled on the parts (solution of one part in twenty) several times a J 
day; this often gives brilliant results, surpassing those of morphine 
given by insufflation, by pencilling, or by subcutaneous injection in the 
neck. Let all food be in the form of thick porridge, as far as may be, 
since that is less apt to go the wrong way. " j 

If inclination to cough is strong, give narcotics and inhalations, for I 
which we especially recommend solution of bromide of potoeh (gr, xxx. r I 
3 vi. of water every three hours) or morphine. 

If the sputum has a bad smell, use inhalations of carbolic acid (0.5 
per cent) or liquor aluminii aceticl. 

Do not relax attention to the main disease; and treat complications 
according to known rules. 

Witli many other pbyBiciana, I have seen no good resutte from touching the 
ulcere, or inButSHlJua: Boraetimes there haH been distinct harm. Nitrate of silvur. 
Iodoform (Lincoln), and bromide of ammonium (Qerhardt) have been recom- * 
mended. 

The two cases of recovery which we meDtioned (demonstrated after death) , 
resisteil tor miLny montlia all treatment bj iolialatioo and touching, and did not 
b»)^a to heal until every kind of treatmeat of the larynx had been given up for a 
oonsiderablf- lime. 

Appendix.— Ciironic tuberculous changes— usually tuberculous ulcere— may I 
affect the mucous membrane of the nooe as well as that ol the larynx. They ara | 
commonly secaadary, but are said to have beeu seen at prituory. 

3. Phthisis of tfte Pharynx. Phthisis Phanpigea. 
{Chronic Ulcerous Tuberculosis of the Pharynx.) I 

-Tuberculosis of the soft palate and' throat may lie 



I. Etiology, 
primary or secoadary, 



In the latter case, tubercle is developed socatid- 



298 TXTBJCB0UL0SI8. 

arily on the mucous membrane of the Boft palate and throat of consnmp- 
tive persons; in the former, the disease appears in otherwise healthy 
persons. It is not always easy to be sure that a case is primary, as con- 
sumption mayjurk concealed. If pharyngeal phthisis appears during 
consumption, we may infer infection by the sputa. If the throat is the 
primary seat of disease, the cause may be eating of tuberculous food, or 
inhalation and retention of pulverized tuberculous sputa. We know 
nothing exact in regard to the mode of infection. 

Most of the cases have been reported by French and Oerman authors, 
and the patients Iiave been all adults, with hardly an exception — Isam* 
berths case of a girl aged four and a half not seeming free from dispute. 
I have been struck with the frequency with which persons have been 
affected who were previously syphilitic. My cases, and those of foreign 
authors, are chiefly of men. 

II. Symptoms. — The disease often gives very little trouble. The 
feeling of dryness, scratching, and tickling in the throat and pain in 
swallowing are often very trifling, even when extensive ulceration of the 
mucous membrane exists; but some patients are tortured by very severe 
pains, which occur spontaneously or are provoked by the act of swallow- 
ing, and often shoot to the ear. The development of the process can be 
followed from the beginning in many cases. Pearl-gray, transparent 
nodules start up, which afterwards become yellow and cheesy, and break 
down, forming shallow ulcers, which spread, unite, and become deeper. 
In other cases, there is loss of substance of the mucous membrane; 
the edges are usually sharp, sinuous, raised like a wall, and fresh 
tubercles may be seen on or near them; there is much disposition to 
polypoid growths of the edges. The uvula is sometimes thickened, as 
if infiltrated with gelatinous matter. If tubercles are not found, but 
only ulceration, the distinction between tubercle and syphilis may be 
very hard to make, but the discovery of tubercle bacilli in the secretion 
of the ulcer is decisive. The loss of substance may be very great 
in the mucous membrane of the hard and soft palate and tonsils; in the 
latter Strassmann shows that tubercle is not uncommon. The cervical 
glands are usually enlarged and indurated. 

The disease has not a fixed course. It may last as long as six months, 
but may be acute. Irregular high fever often exists. In a case of mine, 
general tuberculosis very soon appeared, and the patient died with symp- 
toms of tuberculous meningitis. Death usually occurs through marasmus. 
Consumption of the lungs sometimes supervenes and carries off the 
patient; its relations to pulmonary phthisis are similar to those which it 
bears to laryngeal phthisis. In advanced cases, the larynx and intestine 
are often involved m the disease; or the gullet is attacked. The tongue 
often becomes tuberculous. 

III. Prognosis. — The prognosis in secondary tuberculosis is simi- 
lar to that of consumption; in the primary form, it is serious, but is not 
always unfavorable. Kustner, especially, has cured cases by local treat- 
ment. I lately saw tuberculous ulcers of the fauces heal, in a consump- 
tive patient, while the lung disease continued to advance. 

rv. Trkatmest. — In secondary tuberculosis, let the treatment be 
mainly symptomatic. Give chiefly fluid food; if there is pain, pencil the 
diseased spots several times a day with carbol-glvcerin (1 : 25) or bro- 
mide of potash dissolved in glycerin (1 : 5), or if it is violent, use solu- 
tion of cocaine (1 : 10). In primary tuberculosis, we ought to cauterize 



TTBEBCPLOfllS. 

early and actively, nsing nitrate of silver, chromic acid, or the gaWano- 
caatery. 

Appendix. — Chronic tuberculous change of the tongae has more 
surgical than medical iuterest; it comprises ulcerations or large tumors, 
easily confounded with cuiicer or gummatn. The diagnosia la rendcreii 
certain by discovering tubercle bacilli in the products of destruction. 

Tuberculous ulcers sometimes occur on the mucous membrane of the 
cheek and lips. 

Tuberculous changes sometimes occur on the raucous membrane of 
the digestive tube, either spreading directly from the pharynx to the 
cesophague, or occurring in the latter after a rupture of tuberculou3 
tractieo-bronchial glands. They often cause no ^mptoms during life, 
and seldom lead to cicatricial stenosis (Beck and Chiari). 

Toberculoua ulcers of the mucoug membrane of the stomach are 
sometimes found at autopsies, but not usually unless there is osteneive 
destruction in the intestme also. Litten has described a caaa in which 
there was one tuberculous uloor in the stomauh uloue, which had caused 
no trouble during life. 

Tuberculous ulcera of the atomaeli often do cauae trouble: Paulicki observed 
pertoiation ot the aCotnacU: Oppoleer. fistula of the stomach, and Hattulo sav 
slenoBia at the pyloriu, whioti had been preceded by oicaliisiitioa and rutcac* 
tion. 

»i. Intestinal PlUltisiis. Phthisis Eaterica. 
{Chronic Ulcerative Taberculotia of the Intestine.) 
«'. Etiology. — Tuberculous ulcers of the mucous membrane of the 
iBtestine are almost always secondary to consumption of the lungs, i 
Cases of primary intestinal tuberculosis are so scarce that their existence I 
is often denied, thougli, we think, incorrectly. 

The association with lung disease is even more frequen^than in the 
case of laryngeal phthisis. Heinzo, for instance, found t!30. in 1,226 
cases of pfithisis of the luugs (about fifty-one pet cent), while only 376 
I30.fl per cent) had signs of laryngeal tuberculosis. The ingestion of in- 
leotiouB sputa, or self-infection, is probably the usual method of produc- 
tion in cases of consumption, mure especially us the gastric Juice does not 
kill the bacilli. Intestinal tuberculosis is therefore a sort of food-poison- 
ing. Such poisoning can occur in other ways, as by nsing the unboiled milk 
of tuberouloUB cows, or raw or rare-dona meats fromtuberculousanimals. 
This is the simplest explanation for primary cases; it also explains the 
frequency of intestinal tuberculosis in children, almost exceeding that of 
lung-consumption; and is supported by Zippelius' statement that tuber- 
culosis is especially frequent in countries where the pearly distemper ia 
common among cattle. 

ir, AsATOMif'AL Chanoeh. — Tubcrculous nlcers of the intestine 
agree with typhoid tilcers as regards the locality, being chiefly found in 
the lower part of the ileum, and the upper part of the colon. They 
vary greatly in number; somotimea there is a single one just below the 
ileo-cfecal valve, or ulcers in the vermicular process only, while in other 
oases they are very numerous, and extend over largo segments of the in- 
testine. 

The phthisical changes always originate in the lymphatic follicles of I 
the mucous membrane, either the solitary or the aguiiuAted. i-&.\!a.'%\3>!(<k 1 



8UU TCStfBCITLOeiS. 

ter, the change twaally aflocts a part, and not the whole mass of foUioIfla. 
There is flret hyperplasia of the cell-elementB, bo that the folUcIe en- 
larges, and projects as a little knot into the intestinal cavity. The new- 
formed cells compress each other, causing disturbance of nntrition; 
whence proceed drying, caseation, and breaking down, and afterwards 
softening and bursting, the result of which it< the formation of a sharply 
defined, deep, erater-like ulcer — the so-called primary intestinal ulcer. 
If neighboring ulcers join, they form great patches of destruction — sec- 
ondary ulcere of the intestine. 

TlJe lymphatic vessels which surround the blood-vessels of the mu- 
cous membrane in the form of loose sheaths are especially affected. The 
vessels originate at the mesenteric attachment, and pass around to the 
lymph follicles on the opposite side; and the tuberculous ulcers, follow- 
ing a similar course, are apt to lie tranversely to the long axis of the in- 
testine, forming belta or nngs. 

Through tho medium of the lymphatics, tubercle is found under- 
neath the serous coat. The ulcers are often found under the perito- 
neum, surrounded with a ring of nodules of tubercle; tubercles may be 
traced along the lymphatics tor a long distance, beneath the serous coat, 

Thenlcers can usually be felt without opening the intestine; their 
edges can be foit as hard spots. The neighborhood of such places is 
often much reddened; the serous coat above them is thickened, opaque, 
and sometimes covered with fibrinous new membrane. 

Attempts at cicatrization occur, but usually fail, for while au ulcer is 
healing at one part it is spreading at another. Yet cicatricial flexions 
and stenoses of the intestine are observed. 

The mesenteric glands are usually involved. They are infected with 
tubercle bacilli, swell and become cheesy, and may soften. They are 
sometimes so large and numerous as to be felt through the walls oi the 
abdomen as knobby lumps. 

Koch has shown that tubercle bacilli take a prominent part in the 
origin ot intestinal phthisis. Tho fresher the nodules of tubercle are, the 
more bacilli do they'contain. The same is true of the tuberculous gland 
of the mesentery. The bacilli are remarkably abundant in intestinal 
tuberculosis. 

Ill, Stmitoms axd DIAON03I3. — The symptoms are snprisingly 
varied. Extensive ulcers of the intestines often remain undiscovered 
during life, if tho examination of the fieces has been neglected. The 
process of esamination is the same as in the case of sputa, and its value 
in diagnosis is the same — in spite of the possibility that bacilli may be 
swallowed and mixed with the fseces. 

In other cases, symptoms of sudden peritonitis, perityphlitis and para- 
typhlitis, intestinal perforation or hemorrhage, heematemesis, or signs 
of internal bleeding, suggest the presence of latent ulcers. Perforation 
may occur spontaneously, or may be caused by the lifting of a heavy 
weight, straining at stool, playing on wind instruments, a fall, a blow, or 
similar occurrences. 

We can scarcely name a symptom of intestinal ulceration which is 
pathognomonic of the presence of tuberculous bacilli. The stools ar«of 
chief importance. Diarrhoea is frequent, and is explained by the irri- 
tant action of the fjeces upon the surface of the ulcers, which increases 
peristaltic action; to which add the fact that the absorbent surface is 
diminished by loss of substance. Catarrh of the mucous membrane will 
laarease the tendency to dio-rrhcea. Several thin stools are oftaBJO 



TU UK KOtrtOBld. 



801 



in tho oarly houra (2 to 5 a.m.), which has giTen riae to the expression 
"diarrhoja nocturna." In many cases the stoola are unaffected, or vari- 
ous degrees of cnnstipution exist. Such is the case when the small 
intiC^tine alone is affected, especially its upper pan, as this gives op- 
portunity enough for condensation of ffflces m the largo intestine. De- 
struction of the nerves in the ulcers may annihilate refiex action, and so 
prevent diarrhcea. The muscular coat may be altered, and may lie ex- 
tremely slov in itci reactions and functions. Obstinate diarrhoea some- 
times alternates with perio:l<3 of obstinate constipatiou. The stools in 
diarrhcea are thin, often smelt like carrion, and sometimes contain un- 
digested pieces of food, as potatoes, vegetables, tendon, and flesh, a con- 
dition termed lieutery. Blood, pns. and fragments of tissue are especially 
to be looked for. Bloody stools show the presence of considerable 
amounts of blood, for small amounts are dissolved by the digestive fluids, 
and become unrecognizable. The microscope will discover blood mnch 
of tener than the naked eye. But the presence of blood does not allow us 
to infer an ulcer of the intestiue until we can exclude other sources of 
hemorrhage. 

Undue weight has been laid, especially by Nothnagel, on theoccurrenoe 
of pus in the stool. It is easily understood that pus often is absent 
when there are ulcers, since pus-oorpuscleB can easily be dissolved and 
destroyed by the digestive juices. But in this respect wo must not rely 
on gross appearances alone, for a cloudy appearance of masses of mucus 
found in stools often indicates the presence of numerous epithe- 
lium cells in a more or lees altered state, instead of the suspected ddb- 
corpuacles. Pieces of parenchyma from the mucous membrane will be 
found leas frequently than pus. 

Pain is a frequent, but not a constant symptom. It ia sometimesex- 
treme, and is described as cutting or boring. Sometimes there is no 
spontaneous pain, but it may bo produced by pressure on the abdomen. 
Localized tenderness in the right iliac region is especially important, 
since ulcers are sometimes confined to the neighborhood of the valyula 
Bauhini. 

Vomiting is rare, unless peritonitis occurs. 

Tho appetite is generally poor, but cases of excessive hunger occur, 
especially in tabes mesenterica. 

Indurated portions of intestine or enlarged mesentric glands may 
sometimes be felt through the walls of the abdomen, but fsecal niasBes 
most not be mistaken for thorn. The result ia always fata!, due to in- 
creasing marasmus or the above complications (perforation, bleeding, 
peritonitis). 

IV, Psooyosia and Treatment. — The prognosis is bad; owing ia 
secondary cases to the nature of tho primary affection, and in primary 
cases to the waut of tendency to healing. 

Prophylaxis is important. The patient ia to be warned against swal- 
lowing his SDuta, ana may try to diiiinfect anch oa he may swallow by 
stiff doses of alcohol, which ia alao useful for keeping up the strength. 

If tulierculous ulcers are formed, give easily digested food, sach as 
makea a, small amount of fiBcea: milk, egga, meat soup, solution of meat, 
and meat, but no vegetables, and little bread. If diarrhcea is present, 
give the astringents mentioned on p. 110, vol, II, 

Opium. Dover's powder, columbo, cascarilla bark, and subnitrato of 
biamuth, are eapeciaily recommended. Injections of nitrate of silver 
isB. to viisB.), or injoctious of starch with opium, are useful. Sub- 



4 



i 



302 TUBERCUL06I8. 

eatimaoiu injectionfi of morphine have lately been recommended 
(hydrochlorate of morphia, gr. xv.^ glycerin, distilled water, a& fl. | 
H . M. 8. i-i Bjringef ui). 

We often have to combat constipation; solid masses may easily irritate 
the ulcer to a dangerons extent. 

Use gentle laxatives; perhaps the best are those given in Vol. IL, p. 
122. 

Pains must be relieved by warm cataplasms to the abdomen, snbcn- 
tanaous injections of morphia, and chlonil hydrate. 

Oomplications to be treated as usual. 

ApPSifDix.-— With tuberculous ulcerous changes of the intestine we most as- 
sociate many cases of rectal fistuisB, originating primarily or secondarily, in 
connection with phthisis; they belong to surgery. 

6. Chronic Ulcerative Tuberculosis of the Urinary Organs. 

{Renal Phthisis. Phthisis renalis, sive Nephrophthisis.) 

I. ExiOLOGT. — Tuberculosis of the urinary organs mav lead to de- 
struction of tissues and is always due to the introduction of the tnbercle 
bacillus, which mixes with the remains of destroyed tissue in the urine, 
and is found in the sediment by the method described in Vol. IV., p. 276. 

Chronic tuberculosis, as elsewhere, affects the urinary organs either 
primarily (». e. independently and alone) or secondarily. In the latter 
case, the primary disease may be found in adjacent organs, as the sexual 
iiarts, or m the lungs. In the former case, we speak of a tuberculosis of 
the urino-|2[onital apparatus. The secondary disease of the urinary organs 
usually arises from cheesy tuberculous changes of the epididymis, semi- 
nal veHi(^lo8, or prostate. 

It is by no means easy to distinguish primary from secondary tuber- 
culosis of the urinary organs with any certainty. Not only is it impos- 
sihlo to dett^ct a very slight affection of the lungs, which may have 
boon tho cause of the disease in question, but a primary affection of the 
urinary organs may also have been the cause of the lung affection. 

Olironic tuberculosis of the urinary organs is not rare; many cases 
liavo boon hitherto roganled as chronic catarrh of the bladder or of the 
pelvis of the kidney. It appears most frequently between the fifteenth 
and tho fortieth year of life, but has been seen after the seventieth year 
anil before the completion of the third year. Men are affected oftener 
than women. 

As for the path traversed by the infection, there is probably no doubt 
that when the lungs are the point of origin, the blooa-vessels and lym- 
phatics are the agents of transfer, as the bacilli may very easily enter 
them. This may be true even when the starting-point is in the ^nitals. 
Gronorrhoea with epididymitis is a frequent source of tuberculosis of the 
epididymis. The usual process is that the acute symptoms of inflam- 
mation of the epitUdymis disappear, but that a lumpy hardness remains, 
which subsequenwaV receives baoillary infection, undergoes cheesy meta- 
morphosis, and becomes a jwint for the further spread of disease. Con- 
oubitus also brines danger, for every well person who lies with one suffer- 
ing from tnlH^Milosis of the urim^genital apnaratus is in danger of 
inftvtion with tuln^r^nilous masses, either mingled with the secretions, 
or stagnating, in tho form of tuberculous urinary sediment, in yarions 



^^P TDBEBCITLOBI8. SOS I 

^^EThe cauBGB of primary tuberculosis of the urinary organs are little 
^Hbwn. Simple catcliiug L'old cannot cause it, for catarrli produces ' 
no biKiiUi; the most that it can do ia to make the tissues hyperiemio and 
les8 able to reaist the settlemunt of tubercle bucilli. 

II. Anatomical ChangE8. — The anatomical changes in chronic 
tuberculosis of the urinary organs may affect nearly their whole extent, 
or may be distributed in spot^, separated by intervals of sound tissue. 
A distinction may be drawn between ascending and deaoendiug disease, 
according as the peripheral organs or the kidneys form the starting- 
point. Many autliors douht thj existence of the ascending form. 

The kidneys are uftener alTected od one side than on both; Meckel i 
thinks the right kidney is more frequently affected than theother. The i 
non-tuberculous kidney may he perfectly sound, or may be in a state of 
chronic parenchymatous nephritis; Badt and Rosenstein have described 
an obcrvation in which there was medullary cancer. Chronic tubercu- 
losis of the urinary or;gan8 is rarely limited to the kidneys. 

The alterations are characterized by cheesy infiltrations, at first of the 
mpillffi, then of the entire pyramid, and at last of larger or smaller sec- 
tions of the cortex. At the periphery we find gray tubercles, partially 
caseous, indicating the original point of infitti^tion. The caseous 
masses soften, break down, are expelled and carried off with the urine, 
and thus large cavities are produced in the kidney. There is therefoae 
a true consumption of tne kidney. The papillie are the first to 
disappear, then the entire medullary cone, so that a section of the kid- 
ney shows the pyramidal portion replaced by irregular cavities lined 
with a layer of a cheesv, friable substance. The cavities are separated 
from one another by tne calyces, but their lateral walla are often per- 
forated or destroyed. 

The process of destruction gradually extends toward the cortex. 
Numerous interstitial growths of connective tissue are here developed, 
but destruction of the cortex continues, At last there remains a large 
sac, formed of the connective tissue of the kidneys, but only in rare 
cases studded with miliary tubercles. In other cases, the sac embraces 
shapeless caseous massee, which sometimes have the consisteucy of brain 
(encephaloid). 

The altered kidneys have generally increased a ^ood deal in size and 
weight. In a ease described by Klcbs, the right kidney wei|;bed 4 lbs. 
Vi oz. (normal weight 5} oz.), was 11^ in. long, and 12| in. lu circum- 
ference. 

The pelvis Is usually dilated, as detached caseous masses occasionally 
dog the ureters and dam up the urine. It is probable that tuberculous 
disease of the ureters often lessens the muscular power of ex))elling the 
uriae. Tuberculous ulcers of the mucous membrane of the pelves, a 
cheesy friable sediment, and cheesy tuberculous infiltration of the sub- 
mncous tissue are almost always found. 

The ureters are often changed to rigid, knotty, irregularly dilated 
tubes, marked by the same changes as the pelves uf the kidneys. 

In the bladder, the first changes are usually developed at the fundus, 
near the neck. The cheesy tnbercic breaking down gives rise to sharp- 
edged, sinuous-outlined ulcers with raised borders, at first often no 
larger than u lentil, but afterwards running together and thus gaining 
in size. They do not usually go below the mucouB coat. The bate oi 
tbe ulcers is sometimes iucrusted with phosphates. 






«04 



TrmcBCTijOsw, 



1 of the nrethra not infrequeat^T csoks fta- 



TnbercnloQB utceratk 
urethral changes. 

Rnptnre has often occnrred from the kidneys, the {Klres, or the bbdte. 
into the neighboring parts, such as the paranephritic coiin«ctiT« Iihk, 
the inteatine, etc. Chronic tahercnlouscheeey inflannnatjou an dtBS 
obaerved in fhe neighborhood of the organs affected with tabert^ 

III. Symptoms — These often hardly differ from those of a waifl ca- 
tarrh: frequent desire to annate, cloudy purulent urine, wuBCiuna ^ 
composed urine vith ammoniacal or putrid odor, or that of «Dtpfann0(d 
hydrogen. We cannot be sure that chronic tuberculoos exuca insil 
wo demonstrate the presence of specific tuberculons propertiea ia dc 




■emtion: ZariBh clinic 



uuiEu- I have often succeeded in doing thia br p taeay tt» 
1 a glass slide, distributing the drop liiieiT W i^NnBK 



pa ni len t aedi ment . 

sediment on a gla_ , .. ^ . . . . 

the cover gtaas, shaking off the superflnons part, dnwiaf tits 
glassseveral times through the Same, and then rt ai ain g aeowi _ 
rale given on page 376 of Vol. IV . Such a pr*pai»tio« u getrnt b fc 
67, containing aboudanoe of tubercle bacilli with spoaa^ fc* > 
must add that I have seen not a few cases in vhidu ib wrt» rf aOai^ 
I conld not make the bacilli appear in the aedimefit, thi^j^ ^mt agmt- 
ment was tried repeatedly and the diagnons a oe ied t^Mined. 1n0* 
would then remain the inocolation-test. which is 
of the urinanr aedimeat, with antiseptic 



TDBEBOtTLOBIB. 



308 



chamber ot the eye o( a rabbit. If the sediment containa specific germs, 
miliary tuberculosis will develop in about three weeks, at fir^t in the iris, 
then on the other coats of the eye (Damsch and Ebstein), 

The nrine is usually light yellow, and very often increased in amount. 
Its specific gravity is nsually unchanged. It often contains a very 
abundant purulent sediment, in which cheesy crumbs are often fonnd, 
Bometimes larger in size than a pin's head, the occurrence of which is 
almost characteristic of tubercle. Sometimes, along with wrinkled 
round-cells, free nuclei, and granular, sometimes fatty detritus, we find 
in theao small bodies elastic fibres and components of connective tissue; 
and above all tubercle bacilli. We also find in the sediment round cells. 




ITrilMiT udlment In cbrontc tuberculonla of 'the urinary OTgtHi. Tbe aanifi patient u ta 
Fig. ST. UO dlomeMn. 

mach detritus, epithelium cells from the urinary passages, and triple 
phosphates (comp. Fig. 58); the latter are often found even when uie 
urine still has an acid reaction. The urine usually contains as much 
albumin as corresponds to the pus in it. and contains more only when 
chronic nephritis la added to the tuberculoeis. lleematuria eometimes 
occurs. 

[f the bladder is implicated, the urine eometimes undergoes ammoni- 
acal decomposition. 

Desire to urinate, pricking and itching of the glans and meatus, are 
often complained of; and when large caseous masses pass out, there may 
be symptoms of stoppage of the passage. In some cases, vesical symp- 
toms appear while tne bladder is yet intuct. 

The matter must always seem suspicious when there are hard 
20 



304 TUBSBCCTLOSia. 

(ctteous) lamps in the epididymis, or in the prostate when examined per 
rectum, together with frequent micturition and purulent urine. 

Tlje implication of the kidneys can only be inferred when there are 
local i-eiial symptoms. These include pain m the region of one kidney, 
which is sometimes very severe, and may extend to the back, towards 
the navel or testicle, and even to the thigh. Numbness is sometimes 
felt ill th« latter. The pain may be continuous or paroxysmal. Pain, 
howtiVtiv, id not a constant symptom, and sometimes it can only be pro- 
vokeil hy pressure upon the region of the kidney. 

A very ini()ortant fact is the demonstration of enlargement of 
the kidney 1)v imlpation. The surface is usually smooth and sensitive 
tu iiirtisure. \Ve sometimes succeed in observing alternate enlargement 
aitil (limiiiuti(»n of the tumor. With enlargement, there are usually 
Vers wiviMv puiurt and remarkably clear and scanty urine, while, when 
\\\i' luiiie heoomes freer and cloudy, the pain diminishes. This is plainly 
dui' to temporary stoppage of the ureters by the detachment of large 
t'ht i'^y morsels, and nydronephrosis with retention of the purulent 
uriiir. 1 have repeatedly seen chills and high ferer at the time of these 
*»reurrenoes, 

ill t)ie case of a girl aged fourteen, I was enabled to diagnosticate 
tiihrirle of the ureter by the fact that a thickened, knotty cord was 
fflt alon^ the }>osterior wall of the bladder on the right side, by palpa- 
tion jH»r rectum. 

.similar changes may sometimes be seen in chronic tuberculosis of the 
lilatliler. 

Ill Oiise of rupture outwardly, symptoms of paranephritic abscess, 
lAternal riMial fistula, vesical, rectal, or vesico-vaginal fistula, or peri- 
uivthral abdivss may occur. 

riie lungs are of en tuberculous: and the same disease in the larynx 
a nil intestine may cause profuse diarrhiva. hoarseness, and trouble in 
swallowinjT, Swekt*, chills, fever — in short, hectic symptoms— occur, 
stivr.^^th is liviti continually, and the result is death. The usual average 
ilnvation )s said to be one year, but cases lasting from ten to seventeen 
\oars art* known. 

IV. Hixi^Ni^^l^ — This is based on the demonstration of tubercle 
Khi'^.IU in tho^vliment of the urine, on the success of inoculation with the 
Msl : niont , t he ixvurrtniiV of cheesy f njrments in the sediment, the demon- 
stnu:iM\ of lvv%i] cliancx\< in the t:dneys or urinary passages, and the ex- 
i>tonvVt>f ohtvs> sixM.< in the epididymis or prostate, or chronic tubercu- 

Kv>i^ of ihelr.nc^ 

V, rKiV;Nosis— v*nftivo«ibie, for treiatment is powerless. But I 
hA^c ';*;oiy s^ivn iha^ o^^s ir, the Zurich clinic which recovered — ^both 
*A.^^s .^f }^r:mar\ ;r, VT\^r,K>s:s^ lVr5v>ns with cheesy tubercle of the epidi- 
d\«',;s v^r ^^rA^ti'c sh.'^r/.*? AViV^^ ^wjus, in oi>ier not to infect others. 

\ I Tkvvt\i VN T-— T?\\a: the svTnptoms — cire iron, quinia, and cod- 
V.xev *v,l to :iv,i^rvM^ v,u1r,r.x^r.: :f tV^cTv is ammoniacal decomposition of 
\\\c ;;:iv*e, >fcash ov,i the hU.^xlcr wirh d^ssnfectaint*: »nd the patient toa 
i;\ssi ^vuvJT\ placw Att^r.r,xY care rf ^i.-CkArrhoBa may be of prophylac- 

\ $vNLN\v.v -^^mnn^v i«Nvc<«V>m$ 0^ T^ maW or taaate exaal crgaos is not 
^Mv ,iA»i«'A«tH\t Un4V^ oK)^x ^^f ^KViT^^niu Ji: l> gowC 



TUBEBCCLOSIS. 



6. SoiUary Tuberculosis of Internal Viscera. 

Solitary tubercles are tuberculo-caseous foci which have run together and 
formed oiie cheesf tumor of vftrjioK size. An organ oftnn contains only one 
largo- tubercle-tocua, a solitarj tubercle iu the stricter aense; in other ciise«. sev- 
eral of them are found. They may grow to the size of a Hst and larger. 

The disease is almost always secondary, excited by tuberculous disease in . 
other organs, chiefly the luDgs, The symptoms may be proraineutly those 
caused by a growing tumor. The tumor may soften tmd break; or miliary i 
tub^rculosia may occur. We we will merely give a few special examples. J 

a. Solitary tubercle of the brain is most common in cliildliood. Its favorite 1 
seat is the ^taj subatance. especially that of the cei-ebellum. where it fre- I 
quenlly begins m the boundarv oetween gray and white matter. It may grow to y 
the size of a good -si zed apple, liut ofteD forms only a knot of tbeaize of a pea or a 
hazel-Dut. In moat cases, there isonly one nodule; sometimeij there are as many 
as twenty or more in different parts of the brain. Their form is roundish; more 
rarely irregularly knobby. The ma.sa of the tubercle is dry. yellow, and cheesy, 
while its periphery often formsa gray translucent border. Theniaasissometimes 
«ncyBled, with distinct layers in the outer parts of the tubercle. Small nodules, 
becoming cheesy, are sometimes seen in the peripheral parts, showing that the . 
large lumps were formed by a gradual coalescence of the smaller ones. If Ibft | 
tubtrcle extends close to the meninges, it may adhere to them. I 

Other metaiuorphoges occur besides the caseous, especially puriform liquefao j 
tion and calcification. Sometimes one-halt liquefies, while the other calcines. j 

The microscopic structure is like that of other tubercles. The chief mnsa ift t 
comiMsed of round cells, giant cells also occur, and tubercle bacilli, especially in I 
the latter. In the peripheral layers, fibrous tissue is more prominent, and many I 
cases are distinguished by a etrikiug development of fibrous substance — the so- 
called fibrous tubercle. 

All cheesy subatancesin the brain are not tubercle, for the same change occurs 
in abscess, sarcoma, cancer, and eB[jtcially gumma; the differential diagnosis of 
the hitter would often be very hard if it were not for the presence of tubercle 
bacilli. 

Primary tubercles (or such as are limited to the brain) are eaid to occur. ■ 

" inptoms may be absent; or there may be the symptoms of cerebral tumor I 

il. III., p. S41). Cerebral tubercle may give nse to tuberculous meniugitis \ 

or Kenei'al raiharr tuberculosis, after a previous latent course. i 

o. Solitary tubercles in the cord are said by Hayem to be most common in the 
lumbar enlargment, and to occur in childi'en also. They sometimes reach the 
size of a hazel-nut; they cause no symptoms, or those of a tumor of the cord (see 
Vol. III., p. 88). They may exist simultaneously with solitary tubercle of the 
brain. In general, that which was said of the one applies to tlie other. 

r. Solitary tubercles in the spleen are comparatively frequent in children that 
suffer from intestinal consumption or scrofulosis. Sometimes they are so numer- 
ous that the proper tissue of the spleen hHs almost disappeared. The organ 
muT increase considerably in size, and have a nodular surface, making it pos- 
sible to infer the diagnosis in view of the causation. 

d. Solitary tubercles in the liver are rare: Orth has a good example, 

«. Solitary tubercles in the muscle of the heart occur, but have only an aiUr 
totnical taterest. 



Bympt 
e Vol. 1 



7. General Miliary Tcberculosts. Tuberculosis Afiliaris Disseminata 
aive Universalis. 

I. Etiology. — In this form, the name tubertsle, or little nodule (tu- 
berculum), hae its full auatomical signiGcance, for the disease is charac- 
terized by the appearance of little nodules in many organs— which are 
erajT ana translucent, and iu the older stages opaque and cheeay-yel- 
lowifih. 

Before Koch's discovery of tbe bacillna, it was generally asaumed 
that the process was an infectious one, but the knowledge of the poison- 

elemetil was derived frotn his studies. The chronic ulcerous tuber- 



^gmel 



I 

i 



308 TUBEBCUL06I8. . 

cnlosis of the different organs, and general miliary taberculoBis, have 
one and the same vinis, in spite of the yariety of tneir symptoms and 
anatomical changes. 

General miliary tuberculosis is distinctly a metastatic disease. 

The yirns — that is, the bacilli — ^nass irom any centre where they 
exist into the yenous, lymphatic, and more rarely the arterial circula- 
* tion, are carried in this way to all the organs, and, producing bac- 
terial embolism, cause an outbreak of miliary tubercles. Hence it 
appears that general miliary tuberculosis is, in the majority of cases, a 
secondary affection. Whether the bacilli enter the ^neral circulation 
directly from outside and at once produce general lufection — that is, 
whether primary miliary tuberculosis ezista — is still doubtful. Von 
Buhl was unable to find a primary source of infection in 10 out of 300 
obseryations, but Simmonds lately found such a source in eyery one of 
100 cases. 

The disease most frequently associated is tubercle of the lung; Lit- 
ten found it present in twenty-eight out of fifty-two cases, or fifty-four 
per cent. The same is obseryed next in frequency in tuberculous 
caseation of lymphatic glands, especially the tracheo-bronchial; but also 
aft«r tuberculous psoas abscess, and tuberculous paranephritis and para- 
typhlitis. Tuberculous disease of the bones and joints sometimes causes 
miliary tuberculosis; Doutrelepont has describea it as foUowinff lupus, 
which is nothing else than chronic tuberculosis of the skin. Tubercular 
pleuritis, pericarditis, and peritonitis are among the commouer sources 
of infection. In general, any sort of tuberculosis may become the start- 
ing-point of Koneral tuberculosis. 

Von Buhl has made the excellent obseryation that cheesy tubercu- 
lous foci are less likely to produce general infection in proportion as 
they are cut off from the general circulation by a thick capsule of con- 
nectiye tissue. 

Sudden outbreaks of miliary tuberculosis are unexplained in many 
cases. The weather may be connected with it; cases are sometimes seen 
in groups, like epidemics, and Von Buhl states in regard to Munich, and 
Lebert m regard to Zurich, that cases are especially common in April and 
May. Other direct causes are loss of fluids (as in childbed), or care, sor- 
row, mental excitement. Injuries are sometimes giyen as causes; miliary 
tuberculosis is often said to proceed from operations on tuberculous 
bones and joints, especially when the operation is not wholly limited to 
sound tissue; and similar results are stated to haye followed the remoyal 
of tuberculous rectal fistula. Litton states that general tuberculosis not 
uncommonly occurs after yery rapid absorption of pleuritic exudations. 

Reich has described a very ciirious instance of infection. Neuen- 
burg, a town of 1,300 souls, divided its midwifery practice equally be- 
tween two women, one of whom had consumption, and was accustomed 
to apply her mouth to the mouths of new-born infants to suck out 
mucus or to blow air in. Within two years ten children from this 
woman's practice died of miliary tubercle of the meninges, while none of 
those delivered by the other midwife had miliary tubercle. There was 
no inheritance of disease on the part of those which died; and menin- 
geal tuberculosis was found to be a cause of death only twice in ninety- 
two children that died within the first year of life in Neuenburg. 

Miliary tuberculosis does not exclude other diseases. It may coexist 
with typhoid fever (cases by Lavamn and Burkart), cancer (case by 



Simmonds, caticer and mUiary tubercle of tlit- liver), aud alveolar j 
emphysema of the lung- 

II. Anatohical Chasoes. — General miliary tuberculosis often in- 
fects most of Che organs in one patient. In other caaes, it is limited to 
eiDglo organs. As a rule, the salivary glands and pancreas are the only 
organs unaffected, but Barlow has described a case affecting the 
pancreas. 

Simmonds gives the following table representing the percentage oj 1 
frequency with which the different organs are attacked, based on ouo | 
hundred cases : 



Lungs 

Pleura 

PoricardiuQi . . 

Liver 8; 

Kidney 0: 

Spleen .5i 

Intestine 5' 

Stomach 



as 



per cent 



Peritoneum 

Pill mater ... ... 

Dura mater 

Bmin 

Suprarenal bodies.. 

Thyroid 

Female genitals... 
Striped muscles. •< 



i per cent i 



Tubercle in the heart-muscle iaalaoreportedi fntheendocardiumfbj Weigert); 
the inner coat of vesselB (by MQ^ge ana Weigert); JD the thoracic dncl, Cougue, 
and fauces, marrow of bones (tliirty-one per ceni of LUton'B cbbcs): the oboroid. 
leiina, and iris. 



In general miliary tuberculosis, as in raan^ other infectious ( 
it is usual to find marked rigor mortis, ham-like discoloration of muscle, 
and granular cloudiness and swelling of the muscles and parenchyma- 
cells of internal organs. 

Miliary tubercle of the lungs is eaaily recogniaed by the eye. The 
lung is everywhere filled with little gray transparent nodules, some so 
small as to be hardly visible, others aa large as a poppy-seed, pin-head, 
and krger. The smallest are perfectly transparent, out the larger ones 
often have an opaque centre, or even the commencement of caseous 
change at the centre. The lungs feel full of little lumps when handled 
before cutting; sometimes reminding one of ft bag of shot. The lumpi- 
nesB appears on the cut surface also, and may be found more distinct 
by oblique light. The nodules can be removed with the knife-point. 

In a few oases, one lung, or even but one lobe, is aflected; but usually 
both sides are involved. 

We usually note, in addition, symptoms of consumptive dis 
traction; frequently emphysematous change; recent pneumonia; uedemti | 
of the lungs; bronchial catarrh. I 

Miliary tubercle of the pleura is probably always associated with that 
of the lung; inflammation readily sets in, causing tuberculous pleurisy. 

In the neaH, the disease may affect the pericardial sac, the muscle, 
or the endocardium. Of the pericardium we may repeat what was said 
of the pleura. Miliary tubercle in the heart is most frequently seen 
beneath the endocardium of the right ventricle. 

Miliary tubercles may be seen on the tunica adventitia, as well aa on I 
the intima of the blood-vessels; most commonly on the veins. Miliary I 
tubercle of the thoracic duct was first described by Ponflck. 

The spleen is usually enlarged, and often full of countless nodnlea, ' 
many of which are cheesy in the centre. If few in number and trans- I 
parent gray, they may ou«ily be confounded with the Malpigbian bodies I 



810 TUBEBOULOeiS. 

bnt they are more prominent and can be raised with the knife-point 
without damage, which we cannot do to the Malpighian bodies. In 
doubtful cases, the microscope decides, showing in tne Malpighian body 
a peculiar central blood-vessel, and in the tuoercle, bacilli. The cap- 
sule of the spleen may also contain miliary tubercles, often associated 
with inflammatory changes. 

In the kidney, miliary tubercles are chiefly found in the cortex; 
while in the medulla they may be wholly wanting. They often form rows 
like strings of beads. They are most easily recognized on the surface 
of the kidney^ where they distinctly project above the smooth surface. 
They are very often surrounded by a little ring of injected vessels. 
They are sometimes distributed along the ramifications of one branch of 
the renal artery. 

The peritoneum is an extremely common site; especially the greater 
omentum. Peritonitis or ascites is very frequent^ as a consequence 
of the tubercular deposit. The greater omeutum is often thickened, 
dense, rolled up, and wrinkled. 

Miliary tubercle in the mucous membrane of the stomach is rare. 
Strassmann and Ghiari have discovered it in the tonsils and thyroid 
body. 

The liver is often affected; the tubercles are found sometimcis 
in the interlobular connective tissue, sometimes in the interior of the 
lobules, and form gray transparent nodules, or yellowish opaque bodies 
with indistinct boundaries. Increase of the interlobular connective 
tissue is a very frequent accompaniment. 

The meninges, especially the soft ones, are often the seat of extensive 
miliary tuberculosis or tuberculous meningitis. 

The bacilli are always found with the microscope in fresh miliarv tubercle, 
and more especially in the giant cells, which are numerous. They become in- 
frequent in proportion to the extent to which decay of the cells, necrosis, and 
caseous change occur; probably the spores alone remain in the cheesy detritus, 
and impart to it infectious properties. Koch has repeatedly shown the bacilli 
within blood-vessels. 

An exact histogenesis of miliary tubercle cannot be given here: it has long 
be^'n noticed that it first appears in the neighborhood of blood-vesselK and 
lymphatics, and, according to trustworthy authors, often begins in the adventi- 
tial lymph-sheath. 

General miliary tuberculosis has been a subject for many experimental re- 
searches, owing to the ease with which it may be produced in many animals by 
infection with cheesy tubercle. The first thorough experiments were by ViUe- 
min (1865). 

III. Symptoms. — General and local symptoms must be carefully 
separated; the former being the consequence of general infection, the 
latter depending on the predominant affection of certain organs. 

There is usually considerable fever; non-febrile cases are rare, but 
Lange mentions one. The type is variable, being sometimes continuous, 
sometimes remittent, sometimes intermittent. Brfinniche has shown 
that an inverted type is common, with exacerbations in the morning and 
remissions in the evening. 

The pulse deserves great attention; contrary to what occurs in 
typhoid fever, with which it is easily confounded, the pulse is usually 
rapid, being not rarely as high as 120-130. 

Profuse continued sweating often occurs, causing sudamina. Herpes 
labialis is also seen. I have repeatedly seen unquestionable roseola on 
the abdomen and breast; Waller has seen the same. 





TCBEBCCLOSie. 

' Aibaminnria is ver^ common, and peptonuria ia not rare. 
Thfi coneciousuess IS often obscured at an early period; the patient 
pays no attention to things, or is furiousiy deliriouB. 

Aa in acate septic endocarditis, so in general miliary tuberculoeis, we 
can distinguish two chief types, the typhoid and the intermittent, cor- 
responding to the fevers of those names. In the case of a man who had 

had a dry, fissured, red tongue, swollen belly, roseola, large spk 

tnmor, and diarrhcea, I found at the autopsygeneral miliary tnoerculosis, 
old circnmseribed foci in the lungs, splenic tumor, and old tuberculous 
ulcers of the intestine; and such cases are quite common in Zurich. 

The diagnosis being sometimeB very difficult, much value may be 
assigned to an observation of Weichselbaum, which has been con£rnied, 
by Meisel, Lustig, Ulacaris, and Doutrelepont, showing that tubercle 
bacilli circulate in the blood, and can be demonstrated in blood taken 
from living patients. The bacilli are few and scattered, and they re- 
qnire close search. Ratimeyer obtained splenic juice by puncturing a 
living patient with a Pravaz syringe, and in one case found tubercle 
bacilli; this or^n is said by Weichselbaum and Lustig to be especially 
rich in the bacillus. 

The local symptoms depend on the organ chiefly attacked. In many 
caaes (especially when the lungs are affected), we have little else except 
severe conghing, continuing day and night, uncontrolled by narcotics, 
and soon followed by violent pains in the muscles of the breast and ab- 
domen in conseauent of the violent exertion. 

There may do symptoms of bronchial catarrh — extensive sonoroua 
and sibilant riles, rough, interrupted, or weakened vesicular respiration, 
and mucous expectoration. The sputum sometimes contains streaks of 
blood, or may be colored rusty brown, so aa to resemble tbe sputa of 
fibrinous pneumonia. The disease began with spitting blood, in a case 
of Litten s. 

Dyspnmft ia often prominent; breathing is excessively accelemted, 
and often orthopnosic. while physical examination shows no cause for | 
the acceleration. (Irritation of vagus fibres by miliary tulwrcle?) 
There are sometimes attacks of rapid breathing, having a superficial re- 
semblance to asthma. 

Cough and difficulty of breathing may be associated with great j 
cyanosis, and this symptom becomes of especial importance when dis- \ 
ease of the bronchi and alveolar spaces cannot bo demonstrated. 

There may bo a total absence of local thoracic symptoms. The pcr- 
cuasion sound is sometimes tympanitic, a sign that the tension of the 
lung-tissne is diminished, and in correspondeuce with this we may hear J 
the cracked-pot sound, usually in the suuclavian fossa. ' 

The symptoms of old consumptive disease may be so prominent that j 
we overlook general miliary tubercle of the lung. In this case, we find 1 
tubercle bacilli in the sputa, which would not do the fact in uncompH- , 
cated miliary tuberculosis, as bacilli are not expectorated nntil the 
nodules are softened and break into the airpassages. I 

In miliary tubercle of the pleura, Jurgeusen has heard peculiar crepi> ■ 
tant sounds, distinguished from pleuritic friction murmurs by their soft 
character. In other cases, there is pleurisy of one side or both, and the 
general appearance of the disease is entirely that of exudative pleuriay: ' 
in this case the discovery of bacilli in the exudation would be of espeoiu j 
diagnostic value. The exudation is often hemorrhagic, ' 



^ 



TUBBaOUhOUB. 

Ueneral miliary tuberculosis may be concealed behind the symptoms 
if perioarditia, neritonitiB, or meniugitis. 

Traces of albumiu in the urine do not necessarily point to miliaiT 
tabercle in the kidney, for tbisBymptom is often- found where there u 
only general infection and fever. Neither does the existence of tuber- 
clii baoillt in the urine allow us to assume miliary tubercle in tlie kid- 
ney; on the contmry, it would joint to chronic tubercle with ulcerative 
dcntruotion. Roiwnsteiu refers many cases of anuria in chiidren to 
miliary tubercle in the kidneys. 

Prociuoly the same holds good in regard to tubercle bacilli in the 
■tooli. 

Prominent imiwrtance most be attached, not only to the bacilli as 




4 



UaehoniU. AftMjMav. 



d»DOBrttst«<l is tb« Uood, Iwt to those of th« choroid, for the l«tt«r 
can cmUj bs raconaod daring life with th« ophthalmoecope aa yellow 
vwibed-OBt spots (m* Fix. M). The nsptom is not, nnfortDDstely, a 
CMUtftBt one. uA eta wj bo eo«&tod on wta«ii the dia —s p extends to a 
gnat mukjorgtm^ 



« ■howMMTMr* Ik tew 

IummI ittor-t«* te oa* caw »l iho ■ 
Lik«v (MM) teT* mcfcrta mtwte 
AwMabakkT* emaadad 
KteMM Mlu. UnmoM 



Hp, Th» f Nth amt (•• GtmUs aad 
te«ttk«Wkl»to£aphdHliBO- 
iko iMH > C Mil pimcat. -— ' — " 
dtha nKHaliaoor»ctat 



TUBERCULOSIS. 313 

depresBioD, which at the autopsy corresponded to a central destruction of the 
choroid tubercle. 

The course of general miliary tuberculosis is almost always unfavor- 
able, and usually acute. Death does not commonly occur before the end 
of the second week. Wunderlich^s case of death on the twelfth day, and 
Bressi^s of death on the third day, are exceptions. From four to eight 
weeks is an average, though cases lasting several months occur. 

Death may be preceded by symptoms of collapse, or excessive dis- 
turbance of breathing, or excessively high temperature, or meningitic 
symptoms, or symptoms of dissolution of the blood (uncontrollable 
epistaxis, bleeding from the gums), or by accidental complications, such 
as sudden rupture of the spleen (case by Aufrecht). 

IV. Diagnosis. — We cannot usually be certain unless tubercle 
bacilli are demonstrated in the blood, or tubercles in the choroid. In 
the absence of both of these, we can only reach a certain degree of 
probability. 

When caseous tabercle and ulcerative changes are visible in peri- 
pheral organs — ^lymphatic glands, tongue, pharynx, or larynx — we may 
have strong suspicions of general miliary tuberculosis. 

The dii^ase is most frequently confounded with: 

a. Acute bronchial catarrh. 

Play attention to the severity of the general symptoms and the loss of 
•trengtb, which is usually rapid. 

b. Intermittent fever. 

Notice the history. In the tubercular disease, the periodicity is apt to be less 
marked, and splenic tumor is oftm wanting, while in intermittent fever quinia 
produces rapidT effects. 

c. Typhoid fever. 

In tubercular disease, the temperature is usually less elevated: distinct stages 
of the complaint are not seen; meteorism, roseola, and diarrhoea are usually 
absent; bronchitio symptoms at the beginning are more prominent. 

d. XJr»mia. 

The mistake is easily made when the tubercular disease supervenes on neph- 
ritis. Rigal describes such a case. 

e. Miliary carcinosis of the liver. 

The differential diagnosis depends on the proof of a cancerous tumor of the 
liver, and the fact that the two diseases rarely exist together. 

V. Prognosis. — This is unfavorable. Many think recovery possi- 
ble, others deny it; it would certainly be a rarity. Periods of apparent 
improvement must not deceive us, for they are usually followed by a 
rapid return to the worse, and increased eruption of tubercle. 

VI. Treatment.— This is purely symptomatic; we are often limited 
to antipyretics and narcotics. 



;S 1 I TUBERCULOSIS. 

'. I'tiWfiuU^tiS l\fi^y'i**ut:t\'n uf the Cerebral Membra fus. Meningitis 

Tubrrculosa, 

I. KiioioMX. — rulvrv'ulous meningitis is simply a distinct variety 
of iiiiliai> iulvr\niU>«i::i. h may be a conseqaence of general miliary 
tiitiiiivuU»itks. or cho iiitL::irv tiiberolo mav be mainly confined to the soft 
i luotnal luoiubi-H'.ios; the lacter is the more unusual case. 

Tlioiv j*iv i^fcv» vt*ry vi:*t:!u'i sta^s in the development of the disease. 
\\\ I ho ilrsi, m.*:;4r\ tutvrv'Ies A'jjvarnpiT'n the meninges without excit- 
ing mtlaiuiiuHioi'v s>:ui«;ocr.s« wnile in the second the disease develops 
1 11 1 v» I u Iv IV II !oi: s Mi^ir. v.^:*: : s by t he su p-erven t ion of inflammatory pro- 
v-odM^v Moibiit *.l:>ii:r5>a::^v mav be ab^n: in the former case. 

V\w oAus^-s .ir\» \ie:*-::oal wiiV. those r-f general miliary tuberculosis; 
M\\ iu*.v:vn'.oi;s ^he^'sv deposii may leao :o general infection, and, in 
^onMs^uoiuv, :o m\ oufbrvsik of general iU^«rr:::Ioeis orto mDiary tuber- 
V u'A»*iji oi iho >*.*f: meninges. A very freoi:r": cause, especially in chil- 
li ivn. '.* :ho :ubfrc::l'.»u5 cheesy change in IrcirhAac glsoids; most fre- 
vjuoiit!\ :h^««>^ ^f :he tra.:hed and brc^ncL:. " Doutrelepont recently 
Jojjk : ;^^\l :he v.'u:br>?8ik cf rj^«tTcular menir.giTis after lupus; an observa- 
lu'ii oi ii'-va: imivnanc^. as jtreseniing a k:i.i -:f asto-inoculation, since 
the '.'.ilvivlf l^v*illi:s is fouL-J in lupus. There *r* a few cases in which 
vio jo,;ivtr of \\\iir.v.^j^ .c uld be shown, s-j i2:a: :; 5«irm3 as if in some cir- 
^■u•.ll^:a!Kv^ the* mr:::Lges. like the fancvs, larynx. ir.:escine, and kidney, 
wv.^'w. \.h: piimirily affecte^l. Cvmj»&re riivl.-^ in the preceding 
^'hai'tvr. 

C hilJrei: atv i::-oh :he m:ir. fr«::ri.i'.y ftf5»::cd. especiallT from the 
>^v.*...l \^' :hc s:x:h \r^ri af'.rr :h:i: *r-rrl:«i. :if iisekse ^rows more and 

V:.: '.v.ilt six is fT'f-^rr ifei-.-ei :"r.ii. :if' ff^nile. The disease is 



!:. AN\r^x::Ai Chax ~-iV.— As .~. y-m'f-: nfzingitis. the bones 
.: : -. >\.:'.". .-. :::.i::: .s rr-.i: :r;il :i rl.oi. alI :!i-f i:ira mater is very 
:i . -, . N •.■..■.■-.> . i :v. ...jrv ".- >: r.".i r.i- ?.;-.-. ::z:f^ \^ ^etz. on the surface 



.: ': . .'.:::■. rs>.::.-.'.v 7. :":.r :.:.::"l :•.::..•;•■. :. :!if niidle meningeal 
-..".;.». ,v...i. *'.>, .V. ::.-. : i^s.. ; .f :lf lira \'s*z\i. i-f si nnses usually 
..•..:.*•.. V. ...:. :......*. ■... y^r' ...iwr-.i^c-i. ILi-s:zr :i.r inra. we find its 

: • - . . : : .-i >. .: • . . :.'■ \ : i'.-r. I . : :c* i ^■' i '.'r.'.i f n r^fc^iksi;:: ns of blood . 

. . .. . ';v >.-::.■: :' :' t :f:_ ?: r.rrr-* :f fTrf.Trl" rr^jrr.inent, the 

_ >.» •• ... w 

."; . :. ::;.::■ f ..- •." ■:'; \:;. i: : \;f: -tt - l:is:r?. I:s blood- 
^ :?.!■»-..> i. •-. '":-. '*..' .'." •.-.*;■ :-iv :»f TTi.v'. t; :r-f l~es: ramifications. 
N :-• : : V.'.'. s-.c!-. ■ : •« .:> : :.. *»7-:'.: r i- :•: 5»ff~ rf:« ani there on 
- , ■.%>!..*. : , ■ JL": v.. '-. ■ »: - . ■ i*:". v::~ Tir } lA IS sTrippcil off 
. .- , . . 'O . >: ; . .:. : ^ ;•*-:• i.> ; -i IlT: sern :- S:-:*! sides of 



-■ . . r ::■, > -. », A. ". ::. >. .in.-^. -. ;" ::.?^.r i:r« r.snallv well 

.V.V. .'. \ '.-..■ .' . >. ;>.•.». I- ? 7 i s-TJi:c of .Viiemato- 

' •• . ", . .• "^ : :■; j .i-' k-Ttr!^ :nr inberoular 

; . • ' -^ . I--. > <." :" . ".r!'; ■:-.>««i: :his region 

.V . . \ . V* •. ■.»■- ■ .••.i>*:s ■ :.fc: i^v ■.■■;•' 'v-i'.. marked. The 

-Vi;. ;.i , . vv- .:> >. i ■ '?.*■.' i- :••" rTi.r -y :n--f-7 character; 

v<.v> .-. V. .'. . / . :. . ^ \ >;.■•.- -•:■.: * :' : " •-■. in-fi:. The ruber- 

» Ao I \ ..... ,11. H > i:.-\ . . :. I : :.i •; Az .'--Ui-f Centre, and 



TUBERCHLOStB. ol^fl 

othera are undergoing cheesy metamorphoaiB. Diffuse cheesy tntercu- ^ 
lous thiokeniug aud deposits ia the pia are also sometimes seen. 

The ventricles are often widely dilated, hut not always with fluid, and 
not always in equal degrees. The fluid is usually serons, or serous aud 
flocculent, eeidom purulent. Gadareroua softening is frequent in the 
ependyma and neighboring cerebral substance, and single tubercles have 
been seen in the ependyma. ■ 

In the choroid plexus, purulent infiltration may accompany tuber- | 

On the upper surface of the cerebellum, tubercles and gelaliuo-puru- 1 
lent infiltration of the pia are usually very marked. I 

Schultze notes the important fact that tuberculosis of the meninges, | 
or tubercular spinal meningitis is usually found if that part is ex- i 
aroined. 

The substance of the brain and cord may bo inTolved. Hemorrhage 
occurs; foci of inflammation and necrotic softening are found. The lat- 
ter may be caused by tubercle compressing the blood-vessels and inter- 
rupting the circulation in a portion of the brain. A few tubercles also • 
are found in the brain-substance. ] 

In most cases, the disease is diffuse, though the base is usually more I 
affected, and the convexity may be preferred. Local tuberculosis of the I 
meninges is rarer. Such cases prefer the region of the arteria fosste I 
Sylrii; when the left artery is affected and the circulation ia interrupted, I 
they cause aphasia, alexia, agraphia, and hemiplegia of the right aide. ] 
We would add that the left half of the brain seems especially predisposed 
to tubercular meningitis. 

Fraentzel has reported a case of local tuberculosis in which the ves- 
sels of the choroid plexus alone were involved, the rest of the pia being 
nnaftected. There was hydrocephalus. Death occurred withiu thirty J 
hours, with attacks of lose of consciousness and twitchings of the face. I 

We do not enter on a microscopic deacription ot tubercle in this place. Host 
antborB state that it origiDate!!i in tlie adventitial lymph-alieaths of tlie vesseU of 
(be pia, espt^ialty those of the veins, the endothelium being the part first in- 
volveil. An it grows, it contracts the vessels proper. The internal and niiUUIe 
costs are often infiltrated in places with round cells. The tubercle may grow 
through the wall proper of the Tes»el; or in other spots it raaj contract the v««wel 
and thus lead to ihromboeis bj compresBJon. The true path ognomonio sign isal- I 
ways, not the giaut-oell, about which there has been so much dispute, but the tu- I 
bercle bacillus of Koch. 

Tubercle has often been seen in the walls of the blood-vessel, especially In the 
inoer coat. Ziegler states that the older view, of which Rindfleisch is the chief 
repreeentative. ot the genesis of tubercle from the endothelium of the adventitial 
lymph-sheaths, rests on a false interpretation, making the tubercle cells to be 
migrating blood-cells and proliferating connective -tissue cells. 

A microscopic examinntion of the substance of the brain and cord shows that 
the tuberculous deposit often extends along the sheaths of pia mater into the I 
brsln and cord, producing diffuse infiltration, and often foci of softening in the I 
vicinity. I 

The frequent preponderance of the basal affection lias given rise to the terra I 
basal or basilar meningitis, BB contradistinguished from the purulent meningitis I 
of the convexity, but it is better to avoid these terms, as exceptions are too numer- 
ous to the suppiraed rule. 

Tuberculous meningitis ia also called acute hydrocephalus — a name which ia 
unsuitable, because dropsy of the ventrielee is sonietimea absent in the disease 
In question, and is by no means exclusively confined to it. 



Ill, Symptoms.— The clinical phi 



are essentially like those 



816 TUBEBCULOBIS. 

of the purulent form, depending as they do upon inflammatory nisns in 
the blood-vessels^ and increased intracranial pressure caused by the exu- 
dation. Symptoms of local lesion may be added, caused by necrotic or 
inflammatory softening of the substance of the brain. But purulent 
meningitis often advances as far in a few hours or days as the tubercu- 
lous form does in many weeks; the latter also may have remissions 
which resemble convalescence, but are almost invariably followed by ex- 
acerbations. 

Premonitory symptoms are a marked feature, especially in children. 
They become cross, freakish, timid, and inclined to cry, sleep badly, 
dream a good deal, occasionally twitch, gnash the teeth or squint, lose 
appetite, and are costive. 

I have often treated children that suffered from these rather unde- 
cided symptoms for several weeks before the flrst unqu^ionable menin- 
gitic symptoms appeared. I remember a case in which the only child of 
parentis who married late in life was presented for my treatment; I was 
uncertain for weeks, until I saw yellow spots of tubercle in the fundus of 
the eye, and in a week the symptoms of stiff neck, high fever, and exces- 
sively rapid pulse had appeared and the child was dead. 

Among tne manifest symptoms, stiff neck, headache, giddiness, 
growing stupor, retraction of the abdomen (referred by Henoch to irrita- 
tion of the splanchnic nerve and consequent contraction of the intestinal 
wall), and constipation are the chief. Add vomiting, which sometimes 
occurs onl^ at the beginning, but in other cases is repeated many times 
a day dunng the entire sickness. Gases with meteorism and diarrhooa 
are rare. The hydrocephalic cry is rarer than in the purulent form. 
The pulse varies greatly in its rate, either spontaneously or after bodily 
emotion. The breathing is often very irregular in rhythm and depth. 
Sighing or sobbing breath often occurs. Tne Gheyne-Stokes phenom- 
enon is more common than in purulent meningitis. The variations in 
temperature are numberless; there may be no fever at all^-or fever onlv 
near the close — or only just before death — or feverish and typhoid condi- 
tions during the whole course of the disease. Temperature beneath the 
normal range has also been described repeatedly. On&ndinger reports 
several cases: in one, the rectal temperature fell to 28.6® C. before death. 
Sise of temperature after death also occurs. 

As complications, we mention paralysis of the eye-muscles, pupil, 
face, and extremities. Twitchings are not uncommon. I have repeat- 
edly seen paralysis disappear and return. Gon jugate forced positions of 
the head or eye occur; also continued lateral decubitus with flexed hip 
and knee joints. Soporose patients not uncommonly make repeated 
motions of seizing or grasping with the same extremity. In three recent 
patients of mine, I found the patellar tendon reflex absent^ and in two 
other observations, it was normal in the one and weakened in the other. 
The pulse is often retarded and unequal in force; afterward it usually 
becomes so fast that it can hardly be counted (irritation and paralysis of the 
vagns). The skin may display unusual irritability of the vaso-motors, 
so that slight irritation is enough to cause protracted redness. Boseola 
and herpes facialis also occur, and (in case of heavy sweating) sudamina. 
Icterus has been seen. The urine often contains albumin and peptones. 
Changes in the fundus oculi (choroid tubercle) and tubercle bacilli in the 
blood (Vol. IV. p. 212) are of great diagnostic importance. Neuritis and 
neuroretinitis occur simultaneously or independently; also apoplexy of 
the retina. 



TUBEHOtftOBIS. 



8^ 



^H[It is fsahionft'bld to divide this disease into etaffes — that of irritatioail 

^Irincreasec cerebral pressure, and of paralysis. We tliink this incorreotl 

and artificial; the symptoms of different stages almaet always run side I 

by side, and symptoms of paralysis and irritation frequently alternate io I 

the same organ, as is seen m the pulse. I 

There are some eingnlar cases, as when the disease opens with para- 
lysis, or one or several attacks ot aphasia, followed by paralysis of the 
face and extremities. 

IV. Diagnosis. — The close resemblance between purulent and tnber- 
lar meningitis iDTolves the danger of confusing them in diagnosis. 
Notice that the tuberculous disease develops more slowly, is more insidi- 
OQs in its progress, often has less fever or even none at all; addtheevi- 
dence of hereditary tendency and previous scrofulosis, or tuberculous 
inflamtnations of the skin, bones, or joints. Some coses must remain j 
doubtful, e. g., tuberculous disease ot the petrous bone is not necessarily 1 
followed by tubercular meningitis, for the purulent form may occur. 

It is easy to confound the disease with typhoid fever, especially when, 
oontrary to the rule, there is meteorism and diarrhoaa, or roseola and en- 
larged spleen, for the rigidity of the neck may be found very fully 
developed in typhoid fever as a consequenco of cedema of the pia mater. 
In this case, as in that of purulent meningitis, the diagnosis depends on 
the recognition of choroid tubercles, tubercle bacilli in the blood, and j 
bacilli in the stoole. I 

If the disease opens with paralysis or enoephalitic symptoms, we may I 
be inclined to infer embolism or thrombosis of the cerebral arteries ratlier I 
than meningitis; here the important points are: rigidity of the nucha, I 
and the state of the fundus oculi and the blood. I 

V. Prognosis. — The disease probably always ends in death. Be- I 
coveries are reported, but are doubtful. Dujardin-Beaumetz reports a I 
recovery after choroid tubercle had been seen. I 

VI. — Tbeatuent as in purulent meningitis. Holm recommends I 
benzoate of sodium {1 part : 10 of water; tablespoonful every two hours) | 
as a remedy (!). I 

9. Tubercular Peritonitis. I 

I. Etiology AND Pathoi-ooical Anatomy. — Of thecausesof tuber- I 
culoua inflammation, or of general tuberculosis of the peritoneum, we I 
may repeat what was said under general miliary tuberculosis and tuber- I 
culous meningitis. The disease may develop as an independent dis- I 
ease, or may be the consequence of a widely diffused general miliary I 
taberculosis. I 

Miliary or submiliary gray nodules, rather than cheesy or partly 
calcified masses, are usunliy found. Inflammatory changes are often as- 
sociated, many adhesions netween the Intestines and the abdominal 
viscera {constituting the so-called adhesive tuberculous peritonitiB)and 
eausioua, seroua, or more commonly hemorrhagic, very rarely purulent. 
Extravasations occur in the peritoneum, so that the individual nodulea 
are seen surrounded by a hemorrhagio area, or at a later stage (when the 
ooloring matter of the blood has been altered), by black pigment. Bam- 
berger mentions a case in which large clots of blood were found in the 
peritoneal cavity. Ascites is said to be common, but this has often been 
mistaken for serous peritonitis. If the tubercles are few, the 

Mlook carefully at the omentum. In chronic cases, thickening and 



^^nld 



tit. Bam- I 

id in the ^^^H 

ften been ^^^H 

ningand ^^^| 



318 TUBEB0UL06IB. 

crampIiDg of the omentum and mesentery occnr^ the omnium often* 
forming a roUed-up cord which crosaes the abdomen from right to left 

Localized milary taberculoeis of the peritoneum most be distinguished from the 

general or disseminated form; it is found close to cheesy tubercles of the ab- 
ominal viscera, most frequentljr over tuberculous intestinal ulcers, in which 
case it often foUows the lymphatics for long distanoes. The tacb has no clinical 
importance. 

II. Symptoms and Diaqkosis. — Our diagnosis depends on our 
power^ in the presence of peritoneal dropsy, to assign a tuberculous 
origin to such dropsy; and m doing this we chiefly lean on the facts of 
etiology, and on the discovery of tubercle bacilli in the blood and the 
peritoneal fluid. Vallin is wrong in supposing inflammation in the 
neighborhood of the navel to be characteristic of this disease. 

The course is usually chronic, though at times it majr become acute. 
There is pain, swelling of tlie belly, diarrhoaa or constipation, loss of 
appetite, vomiting, and continued loss of strength. Fever may be pres- 
ent or absent, the contracted omentum ma^r be felt as a tumor; even 
the adherent coils of intestine may give a similar impression. 

There is especial danger of confounding this condition with cirrhosis 
of the liver and thrombosis of the portal vein, and errors cannot alwavs 
be avoided in spite of all care, if the demonstration of the bacilli fails. 
The diagnosis of cirrhosis is favored bv alcoholic excesses, enlargement 
of the spleen, alterations in size of the liver, and jaundice; that of peri- 
toneal tuberculosis, by finding hemorrhagic fluid in exploratory tapping 
of the abdomen. 

The curability of the disease is assumed by a few authors; I have 
just discharged a patient as comparatively cured, with a wrinkled and 
thickened omentum. The disease is usually chronic. Death usuallv 
comes as a consequence of progressive marasmus, or of asphyxia througn 
increase of dropsy. 

III. Pkogxosis. Treatment. — The prognosis is almost always 
unfavorable. The treatment is purely symptomatic. The above-men- 
tioned patient from the Zurich clinic owed his cure to the long-continued 
use of sweat-cures and preparations of iron. 

Appendix. — For tuoerculous pericarditis and pleurisy see Vol. I., 
pp. 33 and 389. 

10. Scrophulosis. 

(Scrofulosis.) 

I. Etiology. — The numerous clinical points of contact between this 
disease and tuberculosis have often been noticed, but Koch first proved 
that scrofulosis is but a special clinical form of the other, and owes its 
origin and development to the tubercle-bacillus. We are inclined to 
consider it as a cnronic tuberculosis of the lymphatic glands, strongly 
predisposing the system to inflammations wliich are liable to become 
tuberculous. 

Scrofulosis is especially a disease of childhood. It most frequently 
begins towards the end of" the first dentition, or the end of the second 
year of life, and ends at the completion of puberty. Some of its con- 
sequences may persist through life. 

This disease is rare in adults. U baa b^ea seen in prisoners living in gloomy. 



TCBEKCCLOSB. 

narrow cells, forced to spend a long time in & Bedentarr way —the so-called prison 
■crofula. It is much commoner to find it bu^innio); with the first dentition 
(about the ninth month), and sometimes earlier. Chaussier described a con- 
geoital form, in which a child was bom with suppurating lymphatic glands (?). 

The constitution is very important, as in the cbbg of conauniption. 
Faults may be inherited, congenital, or acquired. There are scrofulous, 
m there are consumptive families; many inherit hoth tendencies. 

As regards congenital faults of constitution, we know that children 
are especially liable whose parents were old at the time of the 
birth of the former; or diSered widely m age; or who were in a state of 
marasmus from consumption, cancer, tertiary syphitie, etc. ; or were in a 
condition of wretched poverty; or were blood relations. Drunkenness of 
the father is said by many phvBicians to cause scrofula in the children. 
Thesa facts are paralleled in tne etiology of consumption. 

Among the acquired faults of constitution which predispose to 
scrofula we would first name those which result from improper nourish- 
ment. This includes the case of children who have never had the breast, 
or good cow's milk, but have been brought up from the first on meal 
porridge and such indigestible foods. When children begin too suddenly 
to use adults' food, consuming abundance of potutoesf bread, and pud- 
dingti with too little meal, scrofula easily occurs. 

Bad diet and unwholesome surroundings greatly assist the develop- 
ment of the disease; hence it is frequent amon^ the lower classes of 
laborers, whose children spend their drst years in dark, dank, close 
cellars or attics, and seldom get into the fresh air. 

Children of the better classes are not rarely attacked by scrofula 
when they are over-taxed with school work and mental tasks which in- 
terfere with the care of their health and with play in the open a' 

There are several reporU of endemic scrofula in 
deaf-mute«. hut which diminished when the pupiU 
walks in the fresh air. 

Certain diseases of childhood, especially measles and whooping-J 
cough, less frequently scarlatina and diphtheria, German measles and 
flmaU-pox, have a bad reputation for causing scrofulosis. It has appeared 
subsequent to vaccination — a fact which has been quickly used to repre- 
sent vaccination as the means of implanting diseases in well children. 
Of course, all these influences only convey a predisposition to scrofu- 
losis; the infection with tubercle bacilH is needed to produce the dis- 
ease, and in regard to the manner of communication in scrofula hardly 
anything is known. 

We must further note that in cold, damp countries scrofulosis is 
especially common, and is frequent among persons (even adults) who J 
remove from the tropics to temperate climates. 1 

II. .STMPT0M3. — yerofulosis is to be specially feared for children who I 
are predisposed by inheritance, or whose elder brothers or sisters have I 
hiwl It. It is also stated that children who have it often have had pre- 
mature eruption of teeth (the normal date being being the ninth month). 

Two forms were correctly distinguished by the older authorities— the 
torpid and the erethistic. 

The torpid cases have a thick coat of fat and look spongy; the lips 
tn thick and turned up, the lower part of the nose Is thick and shape- 
leas, or pear-shaped, and as it were pendulous. The patients are las^s 



320 TUBEBCXTLOSIS. 

have a stupid, clumsy/ almost vulgar oxpression, and are usoallv not 
remarkably lively. 

The eret hi stic cases have a delicate, soft, pale skin, irith bluish veins 
winding over the forehead and breast. The hair is usually blond and 
soft, the eves large, with bluish sclerotica, and {possessing a peculiar 
swimming lustre. The teeth are long, bluish-white, and translucent. 
The mind is lively, sparkling, and quick to grasp. The face easily 
blushes with passing emotion. 

The symptoms of scrofulosis vary greatly; surgery or ophthalmic or 
aural science mav be more required than internal medicine. We ahadl 
refer only to such symptoms as belong to the latter domain; we cannot 
even enumerate the others. 

Scrofulous (tuberculous) changes of the Ivmphatic glands are first 
betrayed by swelling, but not every swollen l^mph gland is primarily 
tuberculous; for example, primary scrofulous inflammations of the ddn 
may often be accompanied by secondary sympathetic non-tuberculous 
buboes. 

Those most frequently affected specifically are the cervical and the 
submaxillary glands, which may become as larse as a pigeon's egg, and 
by uniting may make bunches that protrude under the skin of the neck, 
producing deformity and causing a mechanical obstacle to movement of 
the head. As long as no further complications exist, the skin over them 
is natural and fiexible. The glanas are fiattened, and not tender. 
Thei^ sometimes form a row of swellings along the sides of the neck, 
making a sort of chain. 

Careful observation will often discover enlargement of the inguinal, 
occipital, and cubital lymphatic glands (the latter above the internal con- 
dyle of the ulna), which shows how erroneous it is to take the two latter 
as a sure sign of syphilis. 

The internal Ivmphatic glands may become enlarged in precisely the 
same way, though this is rather unusual. The bronchial glands form 
examples. This is recognized by dulness over the manubrium stemi, 
sometimes even by slight swelling at that pointy or symptoms of bronchial 
stenosis or paralysis of the recurrent nerve from pressure. Obstructions 
of the veins of the neck are sometimes noticeable (swelling of the veins 
and even slight oedema). Scrofulous (tuberculous) changes of the mesen- 
teric glands are connected with symptoms of tabes mesenterica: the 
children usually suffer from uncomfortable diarrhoea with disgustingly 
offensive discharges, the belly is distended like a frog's, the mesenteric 
glands are often recognizable on deep pressure, the hunger is unappeas- 
able, and yet the child emaciates day by day, becoming pale, hollow- 
eyed and hollow-cheeked, losing the hair, acquiring a withered, lean, 
and pendulous skin and a peculiar old look. Death often follows after 
progressive emaciation. 

Scrofulous swelling of glands is usually slow in developing; but there 
are exceptions. I once treated a boy of six, in whom acute swelling of 
bronchial glands came on, and in five days produced severe disturbances; 
there had been no perceptible tumor previously. 

The swellings of glands may recede spontaneously, or may soften and 
suppurate, usually beginning at the centre; the pus may break directly, 
or may form long fistulous passages. Redness and swelling of the cov- 
ering skin, adhesion of the skin to the gland from periglandular infiam- 
mation, are external signs of this condition. Suppuration may be pro- 
tr»cted, the fistulas do not close, but form ulcers with undermined 



TUBEBCUI«S18. 



3S1 



^H^llen edges; and at laet learedisfiguring cicatrices with radiating puck- 
ers, which may by their contraction cause deformity of the neck and 
impede its motion. 

The tonsils are glands of this class which are often found in a state 
of chronic hyperplasia in scrofulous persons. This may cause a tendency 
to obstinate catarrh of the throat and follicular inflammation, disturb- 
ance of speech and breathing, and even asthmatic attacks. 

Scrofulous disease of the skin most commonly takes the form of im- 
petiginous eczema, affecting the face or the hairy scalp with eefjecial 
irequency, and very often accompanied by inflammatory swelling of the 
nearest lymphatic glands — secondary or sympathetic hubo. There is 
little to distingnieh this from eczema innon-scrofnlouB persons, unless it 
be its great obstinacy and great tendency to relapses. Eczema of the 
akin often attacks the neighboring mucous membranes, espectallv i 
those of the nose aad ear, where they become still more obstinate, and 
give rise to discharges and further inflammations. The converse also 
occurs: eczema of the skin caused by irritating discharges from the ear , 
or nose. 

Obstinate acne is often connected with scrof ulosis. Lichen hardly ever 
occurs except in scrofulous persons; lupus is closely related to scrofula, ' 
as it is a form of tuberculosis of the skin. Lupus is a sort of late form 
of scrofulosis, usually developing after puberty. The tendency to chil- i 
blains is another instance of the great vulnerability of tbeskin of scrofu- I 
lous persons. 

AbscesseB often form in the subcutaneous cellular tissue, which 
keep recurring, and may cause dangerous loss of strengtli. If they 
break outwards, ulcers that are hard to cure often form, sometimes 
crater-like, and resembling syphilitic ulcers of the skin. A part of 
theso formations is tubei-culons. 

The mucous membrane of the nose is often affected, causing obstinate 
inflammation, frequently relapsing, and at last permanent. Many cases 
of obstinate cold in the head are connected with scrofulosis. Ulceration 
ia not uncommon, and may extend to the bones of the nose. Impeti- 
ginous eczema also occurs, frequently forming the basis of relapsing 
erysipelas of the face. Obstinate angina and pharyngitis are also fre- 
quently due to scrofulosis. Bronchial and gastro-intestinal catarrhs 
are known to be frequent: a less commonly known complication is a sero- 
purnlent discharge from the vagina, which very obstinately resists treat- 
ment, and often causes inflammation and swelling of the labia, resulting 
in abscess or gangrene. 

Scrofulous disease of the bones causes necrosis and caries, which may I 
be duo to tuberculous deposits. The vertebral column is very often i 
attacked, causing kyphosis, gravity-abscess, (wrha^s peripachymenin- 
gitis, compression myelitis, etc. Or tuberculous inflammatory swell- 
mps appear on the bones of the flngers aud toes (spina ventosa), or in 
other parts, as the ribs, stenium, or bones of the limbs. These are 
surgical diseases; so are the tuberculous affections of the joints which 
are known as fungus of the joint, tumor albus, or arthrocace. 

The eyes are often affected in scrofula, though not in a specific way. 
There may be impotiginons eczema of the eyelids, ciliary blepharitis, 
catarrhal and phlyctenular conjunctivitis, keratitis, and often several 
of these in combination. These may cause trouble for the whole of life; 
aa (macity of the cornea (tencoma), or adhesion between the cornea and 
■Afaynechia anterior). HornerasBociatestamellaTC.Q>t&T%'^'«\'Oa«i&T«&N£a>. 



995 



TTBESCruieis. 



^ 



The external meatoa of the e&r ts sometimes inflamed and disc 
Bometimea the middle ear is iuflamed in connection with 
catarrh; and sometimes the petrous bone is tnberciiIoDB, which doetroya 
the organ of hearing permanently or leads to tbrombosiH of the sinuses 
or inflammation of the meninges and the brain. 

Scrofula is a chronic disease, often laeting many years. The changea 
often hegin in one organ, and extend to others snceessively. In pro- 
tracted eaaes. Icucocytoais has been observed; Hontnd statoa that he ban 
aeea the red corpuscles of the blood lessened in size. RemiEsions and 
exacerbations are comjuon; the patient is often worse in winter when 
shut up in the house, and better in summer. 

Among the complications, miliary tuberculosis ie the most dreaded; 
this, or tuberculous meningitis, may suddenly appear after apparent 
recovery, and at the autopsy the bronchial glands are apt to be in the 
cheesy- tuberculous state. 

In case of protracted suppuration, amyloid degeneration of the great 
glanda of the abdomen may occur, known by the hard swelling ot the 
liver and spleen, albuminuria, and o?dema. Fatty liver also occurs. 

III. Anatomical Changes. — These are composed of rariouB ela- 
ments, some specific, others not. We do not here describe the latter. 
The specific inflammation of the lymphatic glands is essentially based on 
the development of the tuberculous foci containing the bacillus, often in 
the interior of giant cells; in cheesy foci, the bacUlua is uaaaUy want- 
ing. The bacillus is usually in small numbers, and this may aid in 
giving a local character to the affection. The recently attacked glands 
are gray and hypenemic, but in older ones the cheesy process beiximes 
prominent. 

IV. DiAGNoais, — This is uauatly easy if we regard the totality of the 
syinptoms rather than any single one. or if we discover the bacilO, 

V. PuooNOSis. — This is comparatively good. Most patients escape 
with life, but we must remember that disfiguring scars, deformities of 
the bones and joints, severe spinal diseases, or irreparable injury of spe- 
cial aenses may occur, and that general miliary tuberculosis is a threaten- 
ing posai bill ty. 

VI. Tbeatment. — The etiology shows ua what to do f or prophylaiia. 
Blood- relationa should not be encouraged to marry; marastic or con- 
sumptive or tertiarily STphilitic patients should not get children. The 
physician should forbid women of scrofulous or consumptive families 

I to nurae their own children, especially when they themselves show ejgus 
of these diseases, or when they are younger than eighteen, or are ansmic. 
Let wet-nurses or good cow's milk be then substituted. The food of 
children must bo strictly cared for, and plenty of exercise in the open 
air allowed. 
After the disease has appeared, general and local treatment will usu- 
ally be required. 
The general treatment concsrna the nutrition and occupation of the 
patient, the diet, and exercise in the open air. In summer, let the patient 
live in the mountains, or better, by the sea;- in winter, in Sleran, Kioe, or 
other mild climates. Mental overwork should be forbidden. 
Cod-liveroilisa very important remedy. Give about a deesert-spoon- 
ful, half an hour after the first breakfast, and the same amount after sup- 
per; to older children, from this amount to twice as much. A pepper- 
mint losenge may be taken directly afterwards. The remedy neeus to be 
taken for months or years; it should be suspended for a week oi|i ' 



^ 



^^^P TVBKSouwais. 39tH 

^^Hkry fonror six weeks, to prevent ancouqucrable disgust. In the hotS 
^^^ammer months, it will bo best to leave it oS, as it is liable to injare thAS 
appetite. The ferrated oil ia desirable for pale children; the iodated nUM 
seems to us to have no special value. ■ 

It ia not known what pivea its peculiar value to cod-liver oil. Many^ 
have incorrectly ascribed it to the very small amount of iodine contained. 
The secret is probably in the fact that the oil is very easily absorbed and 
digested. It is commonly supposed to be useful only in the erethistio 

im. but we do not accept this unconditionally. 
The preparations of iodine and iron, and iodine and iron baths, araj 
[t on the list. fl 

For the frequent combination of scrofnloeis with rachitic, we prefwl 
' ponder given at p. 04, Vol. IV. Otherwise we advise I 

ij Syr. ferri iodati , fl. 3 ij. I 

Syr. simp fl. 3 ss. I 

U. S. One teaspoonful three times a day after eating, M 

f{ Ferri iodati sacchar^iti gr, ^ "9 

Sacchari albi gr. viij. I 

H. f. pil. no. X. I 

S. One pill, three times a day. I 

I have lately made trial of Fowler's solution, and am well pleased; I J 
give it mixed with equal parts of bitter almond-water, three to Sve drops I 
of mixture three times a day, after meals. I 

For brine baths, dissolve two to five pounds of sea-salt or common I 
Mlt in a full bath at 28° R., and let the patient remain in it twenty orv 
thirty minutes daily; after which he should rest an hour in bed or on aM 
aofa. In poor families the bath can be used several times by addingl 
boiling water and some more salt when used. ^ 

Natural brine hatha are preferable, and the sea-bath is the best. 
Seaside hospitals have long been in use in Italy, France, and England, 
for poor children, with excellent results. Bergeron states that gniiiular 
swellings, cold abscesses, scrofulous ulcers, and joint-diaeases are much 
improved by a residence at the sea, while bone- tuberculosis is not iaflu- I 
enoed, and eczema and blepliaritis are mode worse. I 

There is no lack of briue-batba (■'soolbader "). Wg mention the befltil 
known: Arnstadt (Thuringen), Bex. (Switzerland), C'anustadt (Wurtem- 1 
berg). Diirkheim (PfalzJ, Frankenhausen {Schwarzburg-Rudolatadt), 
Gandersheim (Brunswick), Gmunden (Austria), Uall (Tyrol), Hamburg 

(Prussia), Juliushall (Brunswick), Ischl ( Salzkanimerxut), Kensington 
Bavaria), Konigsdorff-Jostrczemb (Silesia), Eosen (Thilnngen), Kos- 
tritE (Gera), Kreuznach and Miinster a. Stein (Rhenish Province), 
Nauheim (Hesse- Darmstadt), Keuhaua (Bavaria), Rhemo-Oeynhausen 
^Westphalia), Reichenhall (Bavaria), Rheinfelden ( Aargau). Bothenfelde 
(Hanover), Salzdetforth (Uanover), Salzhemmendorf (Ilauover), Salz- 
schlirff(Hesae), Sulznfein (Lippe), Salzungen (Thuringen), Schweizer- 
balle near Basic, Sodeu a. Taunus (Prussia), Soden n. d, Werra (Hease- 
Cassel), Sodenthal (Rhenish Bavaria), Suiza (Thurinnen), Salzbad 
(Alsace), Snlzbrunn (Bavaria), Weisbudon (Nassau), Wittekind (Prusaian 
Saxony). 

Among the iodine-springs wo name T61z and Adelheidaqnelle, both. 

iu 



.»• 1. '- . - ..:ai>:>aru wiii-ruuot*H 

;,- : -^i-i!.-.! off with water. 
: V "l-Iiver oil, decoction 

:.: 1 ::ki%:-ar:Ila. 



w?r i: :!:e end of tlie vear 
:• • :> of Charles Vlll.. 
- • ■■. :ravelle<i thence t<» 
Li i.dve believed that 
\ '• oriirin from Hoods. 

■ ■ -' tract ed rains, and 
A "h their glandered 

. -' u by the sailors of 

• • sj. None of these 

■ •: :hat syphilis was 
: I : -^ rliarle* VIII. 'd 

. ->v vAs the means of 
%:; . in-.! iven secluded 

• :*; suppose that the 

.:'.'■>. :: fTirnished differ- 
ft ^rm-.xkl thrust, a^s the 
-^ UM.. 1:0.. show. The 



and prodiiceil syphilitic diseoee; of course, the caae must have been one ' 
of maakcd n^hancre in the urethra. Aithongh Beujamiu Bell (1793) took 
Balfour's nide, it was reserved for Eicord (1831) to give to gonorrhma its 
true position. 

Ricord's scheme, however, identified the soft chHncre aud syphilis. 
Two of hi^ pupils, Bassereau aud Oiei'c, separated them, giving to soft 
chaucre a place with gonorrhoea as a local disease. These views are not 
yet universally adopted. The "unicista" still believe that general 
eymptoms sometimes follow soft chancre. 

Uollet eicplaiued a part of the difficulty by the "mixed chancre " — a . 
soft ulcer, which in a subsequent coitus is infected with syphilitiu 1 
ririH. It seems to heal within u short time, but after some weeks symp* a 
toms of syphilis follow, J 

The symptoms of syphilis have been divided into those of tb^j 
primary, secondary, and tertiary perimis (Ricord). The exceptions tol 
this arrangement are frequent, as is the case with other diseasti^ that i 
have u typical course; but the scheme la of great use in pnuitiee. 
While the primary period is essentially confined to the development ot a 
hard chancre, the secondary includes a great variety, mostlv of superfi- 
cial affections, on the skin and mucous membrane; while tlie tertiary ia 
sienalized by gummata, which also develop in the interior of viscera— 
whence the term visceral syphilis. 

There is also an hereditary form of syphilis. 

1. Acquired Si/p/iili« in Ike First and Second Stages. 

I, Etiology. — Syphilis is a highly contagious disease. It cannot ba ' 
doubted that the poison exists in ttiu olood of the patient, fur when such J 
blood is placed under the skin of well persons, intentionally or other- J 
wise, they become ayjihilitic, almost invariably. One source of contagion, I 
therefore, may be the passage of blood directly from abrasions of tha n 
genitals of one party to similar abrasions in the other, during coitus. 

The secretions of all cutaneous syphilitic alterations of Uke first and 
second stages are contagious. Contagion by products of the third 
or summons stage does not seem to occur, though views are not united on 
this point. During coitus, the secretionof condylomata lata may pene- 
trate into wounds of the well person; and in kissing, a similar disease o£ { 
the lips may infect a crack in the lips of the well person. 

The physiological secretions of syphilitic persons, us tears, nasal or I 
bronchial mucus, sweat, saliva, milk, and urine, are not infectious oC 1 
themselves, but may accidentally acquire infections properties. If, fori 
example, the secretion of broad condylomata of the fauces mingles with, f 
thesaJiva, the mi.\tnre is not free from danger. I 

/ Two physiological products are exceptions tir this statement— the I 
\tiemeu and the ovum. Both are almost always infected in syphilitic per- ' 
sons; it ia matter of experience that such persons have uo liealthy coil- 
dreu while they ai-e under the infiuence of the disease. 

Sexual intercourse is the most frequent, though not the only external 1 
means of contagion. In many cases it occurs by accident. I 

Among these accidents are kisses; the use of vessels for drinking and' 1 
eating, of pipesand cit^urs previously employed by syphilitic persons, may , 
also communicate the disease. Surgical instrumentaused unawares upoa 
syphilitic patients and afterwards, without disinfection, upou well per- 
il may communicate it. It lias repeatedly occurreil in catheteriara. oC, 



^jms, a 



326 8YPUILI8. 

tbe Eustachian tabe, and also after the use of the lancet or the cupping 
knives. The use of razors preyionsly employed b? syphilitica has re- 
peatedly communicated the disease. In Jewish children it has occurred 
after circumcision, if the operator was syphilitic, and after operating 
applied his lips (fringed with syphilitic growths) to the woand to check 
the bleeding. Bites and scratciies from syphilitic persons have trans- 
mitted the disease. In glass factories, a sort of epiaemic has repeatedly 
occurred, owing to the passage of the blow-pipe from mouth to mouth* 
This does not nearly exnaust the list of accidents. 

Physicians and nurses are liable to accidental infection. There are 
many sad cases in which physicians have examined patients, whose dis- 
ease they may not have been aware of, and have been infected through 
scratches or cuts on their fingers. Such cases are often not understood 
for a long time. 

Midwives also are often infected while conducting cases of labor, and 
themselves become sources of wide-sproad infection. 

Bardinet reported that in 1874,in the town of Brive, a midwife became infected in 
this way, and in eight months communicated the disease not only to her huslMiad, 
but to all the women (more than one hundred) whom she attended in labor. 
Jean Beyer described a similar epidemic in 1705; forty women were infected in 
four months, and communicatee! disease to their husbands and children — in all 
eighty persons. Bleynio gives a like case from the arrondissement Rochechou- 
art about 1850-60; the origin of the trouble was a syphilitic midwife's practice of 
touching the navel of the new*born child with her saliva. 

Vaccine syphilis is deserving of special mention. The opponents of 
compulsory vaccination speak of the danger of infecting children with 
the Ivmph taken from a syphilitic child. The pure contents of such a 
vesicle, however, do not infect; they do not acquire infectious properties 
until enough blood is mingled to be visible with the naked eye. It is 
against well-known rules to vaccinate with lymph which has a tinge of 
bloody color. A number of physicians who have been charged with 
communicating syphilis in this way have, in self-defence, asseH;ed that 
they had observed the rules; this has led to a doubt whether the pure 
lymph is always free from danger. Microscopic examination of the con- 
tents of vaccine vesicles always shows single blood-corpuscles, but that 
does no harm as long as blooa cannot be detected by the naked eye. 

No prudent physician wiU use a child to vaccinate from, if there is the slight- 
est suspicion of hereditary syphilis, even though the danger of spreading be very 
sU^ht. This danger can be much diminished by forbidding the use of healthy 
children under six months old as vaccinifers, for the first symptoms of syphilis 
may appear later than the third, but hardly later than the sixth month. 

With the exception of the hereditary form, syphilis mostly affects 
adults. If children have it, the causes are inheritance, or accidental in- 
fection, or violation, or exceptionally, carelessness in vaccination. Men 
have it of teuer than women, not only because society allows men greater 
laxity of morals, but because one infected woman may communicate it 
to many men. Climate and geographical position have no influence: 
the poison nourishes wherever it is carried and has access to the vessels 
conveying the fluids of the body. 

The nature of the poison is unknown, but of late years more and more believe 
it to be due to sohizomycetes. Kieba observed in the juice of the tissne of a hard 



c)unCT«. besidM founil cella. eertain rods, 8 tn fi ii(\ h=0.001 mm.) long; I 
moving bIowIv, which he cultivated nlih success and transplanted to ape*. ' 
Baumann, and Martineau and Hamonie have described something similar, while 
Pisarewaki and Aufrecht report round uchizomycetes. micrococci. By a compli- 
cated procees. Luat^uvton has lately shown the regularpreaenceof syphUiabficiJIi 
in aypnititicsclerusH. condyloma, ^oiiina, and syphilitic excreta; experimeals in 
culture and inoculatipn are wanting. His atateinent? are ooniirme<l hy 
Doutrelepont and Sl^hDtzand DeQiacomi, who give simpler methoda, Doutrele- 
pont a tales that he has lately found tliem in the blood and preputial sebum ol 
patients. Alvarez, Oomil, nnd Tarvel pay they have found them in the HmeRma 
of well men also. Ltistgarten found his syphilis hacilli always inclosed in round 
cells, never tree. The aubjact is not yet in a condition tor decision. 

Bdulc and Scheel found nyphilitic material active when diluted with one hun- ■ 
dred partsof water; with Rve hundred parts it had loHt itt activity. When pr»- 1 
served in lyniph-tubeH it loses its power in a week. Culd does not chan^ It. but 1 
a temperature of 40° R. destroys it. 1 

It seems uncertain whether ayphilis occurs in animals. It is said to have been J 
observed in hares, and to have been produced artificially in apes. Some claim to ^ 
have produced it in other animals by inoculation (7). 1 

After one attack, a person is protected against another, but cases are J 
known in which reinfection occurred after some years. 1 

Syphilis and other infectious diseases (typhoid, pneumonia, eryeipelBa, I 
etc.) do not exclude one another. It is often noticed that the sj'tnptomH . 
of syphilis recede, while those of other infectious diseases are prominent, 
and in a few cases they do not reappear. A relapse of syphilis during 
erysipelas has been known to spare the parts where the latter disease 
existed. 

Syphilis is endemic in many regions, as the const of Jutland, Hol-i 
steiu, Fomerania, and also in the interior. This state is promoted by I 
crowded quarters, lax morals, and indifference to disease. In large i 
cities, especially seaports, it is especially common, as sensuality and ex- I 
trav^ance are rifest there. I 

IL Symptoms.— SyphilisisesBentially chronic. Cases that Imve a short | 
course, and sometimes cause death soon, arc exceptional. Relapses are . 
common, sometimes returning at intervala durinff life. 

The following is an outline of the course of the disease. Directly 
after infection, notliing is perceived for some weeks (the so-called stage 
of incubation); after which a hard Icnot or nicer with cartilaginouB 
edges appears at the point of infection — the ulcus durum. The neigh- 
boritig lymph glands swell at the same time. Then some weeks more 
pass without further changes; many call this a second stage of incuba- 
tion, but it is only the time required for the spreading of the poison io , 
the general circulation. A series of exanthemata now appear, usually ■ 
called svphilides, and forming Ricord's secondary stage; tne first stage f 
being tfiat of the development of the hard chancre. 

A tertiary period often occurs, especially in neglected oases. While 
the broad condyloma is the chief and the commonest affection of the 
skin nud mucous membrane in the secondary stage (called the condylo- 
matouB stage), the gnmmous tumor of theekin and nincoue membrane, 
often found in internal viscera, belongs to the tertiary, and by its break- 
ing-down causes dangerous symptoms. 

A stage of marasmus and Beqiielte sometimes follows. 

The stage of incubation is on the average from three to four weeks; 
a longer time is known: a shorter is less common. The duration is most 
accurately known in cases where syphilis is intentionally produced by ia- 



I 



ocnlation'. the shortest time waa ten days, the longest forty-foo« 
Sigmund haa observed as long us fifty-six days. 1 

The hard chancre (ulcus durum), also called primary or inItU 
sclerosis, or Hunterian cnancre, is the first manifest alteration. It k 
most commonly seated on the sexual parts; in men on the outer or innfr 
surface of the prepuce, the anterior border of the prepuce, the skin 
of the penis, Ihe point of junction between the inner lamella of the 
prepuce and the coronary sulcus; lesBfreauentlyon the fnenum, meatus, 
or in the urethra. In the latter case it is called masked or urethral 
chancre. In women, it is most frequent on the labia majora or posterior 
oommissnre, rarely on the prepuce of the clitoris, the moos, or vaginal 
part of the uterus. 

As the hard chancre merely shows where the poison first entered ami 
began to act, there is no difficulty in understanding how it is fonnd tin 
ench spots as the lips, etc. American physicians (Taylor, Knight) have 
lately spoken of chancre of the tonsils as not very rare. 

In typical coses, there is n single hard lump, usually of longish t 
resembung cartilage in consistency, and quite sharply defined. "" 





RinK'tbapeil hsri) <:biumn 

may exceed that of a bean. In hard ulcers on the inner lamella of the 
prepuce, we can usually feel the hard lump plainly by pressing betweeu 
two fingers. The skin over tho lump grows thinner and redder, ami 
gets a peculiar glazed look. A slight secretion is sometimes found on 
the surface of the lump, which ia serous and dries to a thin scab (see 
Fig. 60). Under pressure, the lump is not sensitive or very slightly so; 
no bleeding occurs, as in soft chancre. 

Sometimes coarser processes occur; deep and ereii crater-shaped loss 
of substance, with the edge retaining its cartilaginous hiirducss; or gan- 
grene or phagedena, which may cause the loss of considerable portions 
of tissue. 

The fact that hard chancre is almost always single is very important 
as distinguishing it from soft chancre. 

Deviations from theform described occur. Ifrbagadeschangetohsrd 
chancres, the shape is longish and fiattish. On theglans we often see Hat- 
tened chancres. They seem of the hardness of parchment, thin Iike-pa{>ei'. 
and may easily be overlooked (ulcus durum foliaceum, s. papyrnceum, s. 
pergamentarium). Hard chancre often developsin a hair follicle. oft*« 
taking a papulous form, easily confounded with acne by the inexperienced. 

Hard chancre, left to itself, may last many mouths i 



When it begins to disappear, the centre becomes more and moi-e deproBsoU, J 
like a pit or a navel. Absorption often is complete and leavea nothing ' 
behiud. but white cicatrices snrroanded by a brownish ring of pigment 
may arise if nlceration was present. 

Absorption is often imperfect, leaving a red thickened place, less 
haj-d tbau before, which may at times Hwell and harden again — a change i 
which may precede other relapses on the ^kin and mucous mombrane. | 
The hard ulcer may have relapses like other symptoms of syphilis— I 
nlcus dumm redus. " 

Among the complications we name phimosis, balanitis, [losthitis, bal- 
ano-posthitis, and paraphimosis, which easily occur when the hani ulcer is 
seated on the anterior or posterior point of attachment of the inner 
lamella, in the coronary sulcus, or on the glans. In phimosis and para- 
phimosis, these complications often have to be relieved by cold applica- 
tions and injections into the preputial sac, before the nicer ia seen. I 
When a hard ulcer is seated ut the point of junction between glans and ' 
prepuce, internally, we may, by drawing back the prepuce, easily 
see how paraphimosis originates: the ulcer often snaps back like a 
valve, as the cartilage of an upper eyelid will do when we evert it. 
Hard ulcers on the meatus cause tickling and pain, and sometimes 
mechanical interference with urination. Ulcers in the urethra cause a 
purulent discharge which mav ho mistaken for clap, but pressure on the I 
urethra commonly detects a hard knot. In women, the chancre often I 
loses its speciflc character in a short time, changing to a broad ooudyloma, 1 
BO that we then have general syphilis, and the primary symptoms seem I 
wanting. I 

The histology of the initial acleroeia <b explained by Biesiadecki, Auspitz, and 
Dntia. Thu blcwd-veaaele of llie cutis are to a certaiu ojctent the poini of origin. 
An accumulation of round cells Hrst forms In the mlveaiitia. Some at theui pass 
into the sucroundingcannective tissue and infiltrate it. In the meantime tbiuk- 
eniag and sclerosie of the connective-tissue SbrKe. and proliferation of the cells, 
take place. By degreee. thickeniag- and nuclear proliferation attack the middle 
and inner coats of the arteries. The endotholiuia swells, projects into the vascu- 
lar cavity and contracts it. and acute endarteritis obliterans results. The 
lymphatics are attacked later, showing multiplication of nuclei in their adventitial 
tissue, but retaining their wideopen passage. These changes begin in the upper 
vascular reclons and gradually extend deeper. 

TheepideriDlsiH not untouched. The uapillee are first observed to extfiid 
deeper into the skiii than is normal. The cutis-tissue beoonies increasingly 
infiltriiteil with round cells, and the individual papllte are laterally conipreaaed 
anil iitteiiuated. Single round cells pass into the deeper layers of the epiderniis, 
anil at la->i nests of round cells form. The syphilis bacilli may form an especislly 
liuiwrCsiit component i,Bee Fig, 01). 

While the hard chancre is developing, very remarkable changes also 
occur in the nearest lymphatic glands, and often in the vessels. In chan- 
cre of Che penis, the lymphatics of the dorsum penis are often changed 
into liard, round, often knobby cords, not especially sensitive to pressure 
between the fingers. In very unfavorable cases, they may suppurate. 

The inguinal glands swell; not one or a few, but a considerable num- 
ber of them. One side is often more affected than the other, or one 
gland much more than another. Often, only that side is affected which 
corresponds with the location of the chancre. Single glands often grow 
to the size of a walnut and larger, forming in combination large lumpy 
bundles which can be felt through the skin. They are not sensitive to 
pfewore; the skin above them is neither hot nor red. This is tho 




flwolleu, either bvliiiid the angle of one jaw. or (as Jii three caseti '/I mine) uudet 
the chia, foriuinK a pnijectioii tike u pigeon's egg. In the ca«e of the fingers, the 
corresponding cubital or miliary glanila ewell, etc. These points must be applied 
_■_. j_.. .., .. 1^ j^j. ^1^^ diagnosis or hard chancre. 



n doubtful a 



After the formiitiou of the hard ulcer and adjticent indolent buboee. 
a period of repoae ("Becom! period of incu!»ation") Beems to follow, not 
at all fixed in length, but averaging six or seven weeks; bo that new 
symptoms may be looked for from the ninth to the eleventh week after 
impure coitus. lu a few fortuaate cases, the disease seems to endj "' 



STPRILI8, 331 

the firtt symptoms. Other patients have undergone some change during 
tlie secoud period of iaciiDfition ; they are pale and depressed, often 
seem hypochondriacal, and, in a general indennite way, (eel sick. 

The secondary i)eriod often begins with an eruptiTC fever, which 
may even be preceded by a chill, or several slight chilly sensations. The 
fever may last longer than n week, is usually remittent, and sometimes 
is almost typhoid. Enlarged spleen and red spots (roseola syphilitica) 
are not uncommon, and may lead to the diagnosis of typhoid. Abund- 
ant roseola, with erythema, may be mistaken for scarlatina or measles. 
Albuminuria occurs in twelve per cent of the cases (Fiirbringer); tube 
casts, round cells, and red blood -corpuscles are found in the urine. 
Mercurials generally put the symptoms quickly to flight. Acute cases 
are known, of the kind called "syphilis maligna acutissima" bv Guibot; 
the symptoms come in hasty succession, are very marked, and involve 
great danger to life. Weakly constitutions and external misery favor 
the development of this form. Balz has reported hemorrhagic syphilis, 
with bleeding on the skin, from the nose, air-passages, stomach, intes- 
tine, and kidney. One patient died with such symptoms in ten days. 

In the secondary period, indolent swellings of the lymphatic glands 
become more general, often including almost all the peripheral glands. 
In other cases, the swelling is confined to definite parts of the body. 
depending on chance — but parts exposed to pressure or irritation by 
the clothing, or in the neighborhood of accidental wounds, are more 
liable to be affected. In scrofulous patients, the swelling may bo enorm- 
008 — the so-called strumous bubo. Internal lymphatic glands seem to be 
also subject to swelling. 

It was once thou^t that swelling of lymphatic glands of certain 
regions occurred only m syphilis, and was, therefore, ofdiagnostic value; 
this includes the enlargement of occipital and cubital glands; but the 
point is not sustained. 

The bjatotogical changes oC indolent buboes cosaist of thickenintc of the trabec- 
ular connective tissue nnd increase of the cellulur element". In the lymph 
einUBea the endothelium i» swollen, and itH nudei are increased. The adveatitia 
and media (if the vessels are ioflltrated with round cells. The capaule of tlie 
lymph gliinda is usually thickened. 

Al>90rption (spontaneous or under treatment) implies fattv change of the celli 
and grxdiiA) absorption of the detritus. Tlie cheesy and chalky changes of tea 
«xisl, and even suppuration may occur sooner or later. 

The sncondary stage is further marked by alterations of the skin and 
mucouH membranes, to the former of which the term syphilides is 
(unjuHlU) restricted, although the changes are fundamentally the same 
in both.* 

The cutaneous disorders include erj"thematous, papular, vesicular, 
and pustular exanthemata. 

Of the erythemata (which usually form the first eruption) roseola is 
the commonest. It is composed of red-brown spots, rrom the size of 
lentils to that of the joint of a finger, and most numerous on the skin 
of the trunk. They are found also on the extremities; on the face, 
scarcely except ai the edge of the hair. At first they become white when 
pressed with the glass pleiimeter; but as they grow older, the color seen 
on pressure is yellowish or yellowish-brown, showing that there is exuda- 
tion in the cutis and not merely hyperemia. The number of spots varies 
jjpBfttly. The same is true of the duration; under specific treatm&u^ 



I 

J 



882 flTPKiLta. 

they aometimeB disappear in a few days. Vet I have often seen the 
roseola become more distinct in the first days of treatment by intmction. 
disappearing very quic^kly afterwardH. Sligbt desqaamatiOQ may follow 
their disappearance. 

In eiamininK'o'' roseola, let the patient strip and stand for a minute or two: 
the effect of ibe sir is to contract the bloo J- vessels of the sound parte of the skin, 
and bring the eruption into relief. Do not confound the common veaooe mot 
tlinf^ with syphilitic roseola. 

Diffiiae syphilitic erythema is much rarer than the circumscribed 
roseola, and usually lastg but a few days. 

Coudyloma latum is the chief of the papular syphilides, and the 
most important for diagnosis. It is so regularly met with that Bicord 
gave its name to the secondary stage of syphilis. 

In men, it is moEt frequent on the penis and acrotnm, more rarely on 
the glans and inner lamella. In women, it is especially frequent on the labia 
majors. In both sexes, it is freouent on the arms, the inner surface of 
the thighs, the inguinal flexure, tiie navel, the folds of the breast, axilla. 
angle of the mouth, noso-Iabial groove, eyelids, and even the ean^. 
They also appear in the bed of the nails, and between Augers und toet 
(nioera between fingers and toes may always be suspected as syphilitic). 

Where skin lies against akin, we often tind broad condyloma dapli- 
Gated on tlie two opposing surfaces, We sometimes can show that 
such a sore began on one surface and thence infected the other. The 
same is the case, esjwcially, on the labia majora. the inner Burface 
of the thig^h and labia or scrotum, the anus and the mammary folds. 
The secretion is highly contagious; when inoculated upon a uealthy 
person it causes a hard chancre followed by general sypnilis, but on a 
syphilitic person it causes pustules and afterwards ulcers that are unmis- 
takably like soft chancre. 

Broad condyloma, fully developed, presents a flat elevation of the 
skin, covered with a greasy, gray coat, often having a disagreeable rancid 
smell. It sometimes covers mrge surfaces. It frequently causes itching 
and burning of the scrotum, pain in the anus on defecation, with itching 
and heat, etc. 

Broad condyloma often transmits the disease accidentally. On the 
lips, it may communicate it by a kiss, or the nse of drinking or eating 
vessels, or pipes. On the nipple, it may infect a nursling. 

This eruption does not appear as such at once, but originates by de- 
grees from broad papular elevations of the skin, of a reddish or brown- 
ish color, originally covered with moist epidermis. The change to con- 
dyloma is due to the influence of the position in which they are found, 
wnich keei)8 them warm and moist, and macerates and throws off the epi- 
dermis. When a cure occurs, the greasy secretion disappears, the surface 
becomes smooth, and brown-red elevations appear, which gradually dis- 
appear, often leaving brownish or bluish discolorations, colored by rem- 
nants of pigment from extravasatcd blood, and not parting with the 
color when pressed. 

Tike liiBtolOKT of broad condyloma includes ioSltration of the cutis with round 
cells, dilatation of the blood-vessels, penetration of the adventitia with round 
cells, and proliferatiou of the papillEe of the cutis; also the epithelial papillfe of 
tite reto Molpiiihii press farther forward, and the epidermis disapp«ais. 
Kht Bud Xustgarten claim to have found micrococci. Aufrecht describes 



Syphilitic liclicTi iiiid iisoriasis iire also includoii in the papular 
era pt ions. 

Syphilitic lichen preaeata grnupa of small, brown-red knots, of the 
size of lentils; syphilitic psoriasis, large flat knots, covered with thin 
Rcales of epidermis. Thi'^k scales with the luatre of mother-of-pearl or 
nebestos, as iu psoriasis vulgaris, are rarely seen. The syphilitic form of 
psoriasis (contrary to the non-syphititic) [laually avoids the favorite spots 
of the latter, extensor side of elbow and knee, and prefers the palmar 
and plantar surfaces and the volar aspect of the fingers. Some even say 
that psoriasis in the palm and sole is always syphilitic. 

Psoriasis on tlie'palms and soles often departs from the usual type. We 
first see red spots shining th.-ough the epiaennis; these continue to risv, 
tlie epidermis grows thin, and at last falls out in the region of the papule 
almost as if cut whh a pniich, while the latter shows a surface at first 
shining, afterwards scaly. In other cases, psoriasis has the form of ex- 
tensive horny thickening nf the epidermis, which has been called psoriasis 
cornea. 

Veaiculiir eyphilides are not very freqnent iu acquired syphilis; they 
are known as varicella syphilitica ana pemphigus syphiliticus. The 
former presents vesicles, more or less numerous and scattered, of the 
average size of a lentil or pea, and usually surrounded by a reddened 
areola; in the latter, the vesicles are larger, aud often contain a clearer 
and more serous flnid. They are found rather often between the fingers 
and on the palms and soles, 

The pustular syphilidea include acue and impetigo or ecthyma. In 
syphilitic acne, there is inflammation of the sebaceons follicles of the 
skin; in impetigo and ecthyma (pedantically separated from each other) 
there are large pustules, which leave cicatrices when they heal. The 
latter afterwards become white, and leave a mark on the forehead which 
daring the remainder of life reveals to the experienced eye the previous 
occnrrenco of syphilis. 

The syphilitic afTections of the mucous merabraue closely resemble 
thoee of the skin. The earliest and most constant is angina of the 
fauces. We usually find the fauces of a dark-red or livid tint, with 
swelling and increased secretion, which is often bounded very exactly by 
the line of the hard palate. The latter point has been suggested as a 
diagnostic mark of syphilis. I have often seen well developed roseola on 
the mucous membrane of the fauces and mouth, consisting of red spots 
and circumscribed hyperteraia, like that of the outer skin. The broad 
condyloma is important; it is most coram inly found on the tonsils, but 
occurs also on the soft palate, tongue, and inside of the cheek and lips. 
In smokers, it is often found on the lipa and tougiie. People with bad 
teeth often have it no the tongue, inside of the cheek, etc. It consists 
of elevations of the mucous membrane, glistening like mother-of-pearl, 
grayish or bluish white — termed plaques opalines. Others call them 
mucous patches. Continued destruction of the superficial layers may 
lead to loss of substance and bleeding; the former may cause deep sinuous 
ulcers nf the touails, with subsequent cicatrization, and may even cut off 
the uvnln. 

The above affections do not by any means complete the list. There 
^tber cutaneous diseases. In many cases the skin loses its usual 



^ueptbe 



334 SYPHILIS. 

brilliancy and fulness and becomes brittle, with a tendency to crack 
and scale off. 

The hair often drops off, so that in a short time, not only the head, 
but the parts around tne eyes, the chin, lips, and pubis, become nearly 
bald— defluvium capillitii sive alopecia syphilitica. It is a popular 
notion that early baldness is a sign of sexual excesses. Specific altera- 
tions also occur in the nails; sometimes inflammation of the fold and 
bed of the nail (paronychia s. paronyxis syphilitica), sometimes an affec- 
tion of the substance of the nail (onychia s. onyxis syph.). The former 
are broad condylomata or pustular syphilides of the fold, extending to 
the bed and loosening its connection with the nail, and impairing the 
nutrition of the latter. Oummata may form on the periosteum beneath 
the bed, by which the bed and nail are raised up; if tne gummous tumor 
breaks down, the ulceration readily extends to the bed and substance of 
the nail. 

1'he f ascisd and tendons are often the seat of pain or of tenderness oa 
pressure, especially if any eruptive fever attacks the patient. Severe 
pain sometimes occurs in the bursas mucosae and tendinous sheaths 
with which, in a few cases, inflammatory swelling is associated. Mus- 
cular and articular pains are also frequent; the latter sometimes associ- 
ated with swelling, and closely resembling acute articular rheumatism. 

Many patients suffer much in their bones, especially the tibia and 
skull. Sometimes there is deep-seated pain, hard to localize; sometimes 
there are well-deflned snots of sensitiveness to pressure. There may be 
no further perceptible alteration; but in some cases there is inflammatory 
swelling of the perisosteum, easily detected by passing the finger lightly 
over the skin, or visible to the eyes as prominences, over which the skin 
may be slightly reddened, swollen, and hot. Many patients are plagued 
with boring pains (dolores osteocopi s. terebrantes), coming in tne early 
part of the night and passing away with a gentle perspiration in the 
early morning hours. 

The mucous membranes of the nose and the larynx are subject to 
erythematous, roseolar, and condylomatous disease. In the nose, the 
symptoms are a burning and itching, a feeling of dryness and pain, 
sometimes a bloody and fetid discharge; in the larynx, tickling and 
inclination to cough, and hoarseness. The exact nature of the altera- 
tions in each case can only be learned by rhinoscopio and laryngoscopic 
examination. 

Syphilitic catarrh of the fauces may cause inflammation of the Eusta- 
chian tube, and injury to the hearing. Moos and Boosa have shown 
that internal periostitis of the petrous bone and disease of the labyrinth 
may also occur, and may weaken or destroy the power of hearing. 

Disease of the eye often occurs at the end of the second stage, or as a 
transition to the third stage. Iritis is the most frequent affection; it is 
sometimes the ordinary form, without special peculiarities, and some- 
times is gummous. In the latter case there are a number of small tumors 
on the iris, especially in the neighborhood of the pupil; sometimes 
yellowish, sometimes brownish in color. Next in frequency are affec- 
tions of the choroid in various forms, including irido-choroiaitis, serous 
choroiditis, and excessive development of pigment in patches (choroiditis 
pigmentosa disseminata, Hock). Many authorities refer disseminated 
choroiditis to syphilis, and regard it as a certain sign. Inflammation of 
the retina and optic nerve (retinitis, neuritis) also occur. InflAmmatoiy 



;b of the corueu somotime's ocuur, tuking the form of gray spots of 
e of pina' heads, and c^lod keratitis punctata by Maiichner. 
Severe nervoua disturhiuices occur in toaiiy coaeB. Fouruier showed. 
that circumecribed aiuBBthesia is common, especially on the hands ao^^ 
forearms. Many complain of violent neuralgia. Facial palsy has boes^ 
Been. In a case of my own, chorea appeared soon after an eruption ot 
syphilitic roseola, but disappeared under a course of meroory. Many 
suffer from obstinate eleeplessness; others are greatly depressed. 

If a rational treatment is pursued, tertiary symptoms may often he 
avoided, but not always. Mituy of the older authorities state that 
syphilis has no tertiary symptoms, but thut what are called such aro 
merely consequences of tlio use of mercury. But it not infrequently 
happens that patients present only the tertiary symptoms, showing no 
traces of the secondary ones, and never having had a course of mercury. 
They are often ignorant of any infection. Such patients sometimes evi- 
dently have no wish to deceive the physician. It follows that primary 
and secondary symptoms may give so little trouble that they are over- 
looked by the patient. No syphilitic person is sure, in spite of the best 
treatment, that he will not have tertiary symptoms; many have married, 
have bad healthy children, have felt in good health for ten, twenty, even, 
thirty years, but suddenly the stealthy foe bursts out from his ambush, 
and brings tertiary symptoms at a time when all seemed safe. 

The broad condyloma being the characteristic form in secondary I 
symptoms, the gumma or syphiloma leads among the tertiaries; whence f 
Bicord proposed the name of gummous period. Special detail of symp. J 
toma will begin later on. 1 

All tertiary symptoms lead to a protracted course, and often last for ' 
many years. One organic svstem after another may be attacked; scarcely 
are tne symptoms conquered in one place when they break out anew in 
another. Injuries or bad habits sometimes determine the attack to a 
special organ: thu^, persons who overstrain the roiud are more liable to 
cerebral typliilis; drinkers, to that of the liver, and so on. 

A Rnaf stage of marasmus is especially apt to come in neglected cases. 
In order to produce it. it is not necessary that there should have beea 
tertiary symptoms, with suppuration and loss of fluids. The patient I 
becomes pale, loses strength. Keeps his bed, and at last dies of weakness, 
if help is not obtained in time. 

Among the sequelfe are amyloid degeneration of almost any of the I 
organs (which need not be preceded by suppuration), consumption, 
chronic nephritis, aneurisms, and psychopathies. Pigment-syphilis is 
described by Schwimmer as a formation of brown spots on the skin. 
Syphilitic leucoderma is u sort of contrast to this, appearing chiefly in 
women, on parts of the neck where there had been roseola or papules; it 
presents white patches, explained by Riehl by the fact that the pigment 
IB carried from the deeper layers of epidermis into the cutis by wandering 
cells. I once saw hypertropny of the entire skin, a sort of ichtliyosis, in 
n man — keratosis syphilitica; it is not rare on the palms of the hands 
Mid soles of the feet, often combined with painful rhagades. I 

The most dreadful thing about this disease is that we can never bo | 
sure against relapses. They are often preceded by febrile movement and 
renewed enlargement of the spleen. Sometimes they are brought on by 
injuries. It is u fact that wounds often heal badly in persons with Intent 
Bir|)ijilia. and do not begin to cicatrize until antisyphilitic treatment has 
^Jfapp adopted. Relapses after a thorough treatment, adopted perhaps at 



336 SYPHILIS. 

the time of the first secondary symptoms, are almost the rule. They most 
frequently occur as mucous patches on the mucous membrane of the 
mouth and fauces. The relapse's may occur at first every six or eight 
weeks, but by degrees they grow rarer and slighter, and in the second 
year usually cease entirely. 

A question often put is that of marriage. Marriage should never be 
contracted previous to the end of the second year ; it is best to postpone 
Until the end of the third year, and even then it must not be permitted 
unless relapses have been absent for at least six months past. Married 
men must look to their health, must be examined, if possible, by a good 
physician every fortnight or month, and must begin a specific treatment 
as soon as symptoms appear. 

III. Diagnosis. — ^This may offer serious difficulties in all stages. 

The soft chancre appears very soon after impure coitus — is often mul- 
tiple, is painful to pressure and bleeds easily, suppurates freely, has no 
fiharply defined hard base- and causes sympathetic buboes, usually of 
one side only; while the hard chancre is painful, and causes tenderness 
and infiammation of one, or a few only, of the lymphatic glands. 

Manv chancres begin as a distinct soft ulcer, and afterwards turn to 
the hard kind (mixed chancre). Patients with soft chancre must there- 
fore be kept under observation for some time after their sore is healed. 

An unusual situation — on the lips, fingers, eyelids, lobe of the ear, 
nipple, rectum — may mislead us as to the nature of a chancre. We 
should entertain suspicion if a source of infection has existed, and if 
subsequent wounds have been very hard to heal. Add the hard, well- 
defined base, sometimes raised like a wall, and above all the indolent 
multiple swelling of neighboring lymphatic glands, e, g.y under the chin, 
in lip chancre; above the internal condyle or in the axilla, in finger 
chancre; in the side of the thorax or axilla, in nipple chancre, etc. I 
know several instances of colleagues who contracted specific infection in 
their practice, and whose disease was long doubted, even when distinct 
secondary symptoms were present. 

The recognition of secondary symptoms is especially hard when the 
primaries have disappeared, and when it is doubtea, for instance, whether 
a certain exanthema is syphilitic or not. 

Syphilitic exanthemata possess the following marks, as distinguished 
from the non-syphilitic: 

a. They cause no itching. 

b. They have a brown-red, coppery color, which is connected with 
the fact that many red blood-corpuscles leave the vessels per diapedesin 
at the affected parts of the skin, remain a long time, and undergo a 
gradual change of the coloring matter. 

c. They often display polymorphism, that is, many kinds in combina- 
tion; maculae, papules, pustules, and squamse succeed each other or stand 
side by side. 

d. They tend to form groups; clusters, circles, or serpentine lines, 
rather than irregular arrangements. 

e. They choose certain regions, as the boundary between forehead 
and hairy scalp, the soles and palms. Those on the front edge of the 
hairy scalp are called corona veneris, whatever their special character 
may be. 

/. The action of remedies often gives a clue. Syphilitic exanthemata 
usually recede (quickly when iodine and mercurials are given. 

The syphilitic nature of chronic inflammation of the fauces, larynx. 



STPHius. 88T' 

_i nose 13 often miaanderstood, and reaista all trefttment nntil mercury 
.j iodine relieves the patient. We very, often have occaeion to decide 
whether whitish or grayish spots on the nmcons membrane of the nurath 
and fauces are syphilitic relapses or not. Smokers and persons with de- 
fective orpointed teeth often have such spots; persons who have had the 
mercnrial inunction for syphilis, and irritated their months by frequent 
wsBbing wiuh chlorate of potash, may have similar appearances, not 
speciGo in their nature. 

The diagnostic difficulties become almost icanperable when tertiary 
symptoms appear, and no previous history of sypnilis can be obtained. 
The severest affections of the nervous system — chronic heart disease, 
psendo- phthisical affections of the air paasages, stricture of the cesopha- 
gns and rectum, disease of the liver and kidney, eto, — or chronic diseasd 
of bones, mnEcles, and joints, may be produced b^ tertiary syphilis. The- 
importance of correct diagnosis in such cases is immense. After many 
years of fniitless treatment, a course of mercury or iodide of potassium 
may accomgdish most brilliant results; in doubtful cases, these remediea 
should at least be tried. 

Certain coarse anomalies may lead onr attention to syphilis — thickly 
clustered white pigmented cicatrices on the forehead, sunken bridge of 
the nose, holes in the hard palate, cicatrices in the fauces, cicatrices and 
deformities of the epiglottis, or cicatrices on the legs, genitals, and anus. 
Mydriasis of one eye, and paralysis of the eye muscles, originating with- 
out demonstrable injury, may excite suspicions of syphilis. 

Repeated abortions of married women may be held to be suspicious; 
syphilis is generally the cause, usually that of the father. 

IV. Proonosib. — In acquired syphilis, tbis is so far favorable, ae that 
surprisingly favorable results are obtained more quickly and surely than 
in most other diseases, if we understand the nature of the complaint. 
Neglect, however, may result in irremediable damage. 

But we can never be sure that the disease is permanently cured. Re- 
lapses are verj' frenuent; tertiary disease of internal organs may prove 
fatal, in spite of all care. 

Accidentally acquired syphilis is, in general, very obstinate and 
malignant, as physicians have often found to their sorrow. This may 
be due to the fact that the disease is overlooked, and not treated until a 
late period. 

Cases acquired by coitus with foreign races are considered especially 
dangerons; the Chinese form is dreaded by sailors. The stage in which 
the disease is has its weight in the prognosis; all tertiary symptoms are 
the most dangerous, as they compromise vitaJ organs. 

V. Tbbatment. — In respect to prophylaxis, the principles stated 
under gonorrhcea (Vol. IV., p. 349) apply. To prevent accidental con- 
tagion, disinfect instrnments carefully; examine wet-nurses for marks of 
syphilis, and always about the arms and genitals; use for the supply of 
lymph in vaccination only well children older than six months; employ 
Irmph that has no tint of blood, etc. After an impure connection, 
there ia little use in washing with carbolic acid, vioe^r, and the like. 
Even deep cauterization of a fresh erosion with nitrate of silver or caustic 
potash has been found incompetent to prevent the development of in- 
duration and further symptoms of syphilis. 

For existing syphilis, every physician has his own treatment; we will 
'e tho plan which has been serviceable to us in a very large number of 



^H^ 



888 BTPHILI8. 

For hArd chancre^ order two and a half draehms of emplaBtnim mercori- 
ale> to be spread on the sticky §ide of adhesive pkster in a layer as thick 
as the back of a knife, reserving a border all around for the pliELster to ad- 
here by. A light bandage may be added. The plaster is to be of a 
shape and size to cover the sore and extend a little beyond the edges. In 
ulcers on the glans or inner surface of the prepuce, insert the dressing, 
with the ointment towards the sore, inside of the prepuce. The plaster 
must be renewed morning and evening, and continued until the ulcer has 
become completely soft. Open ulcers do not contra-indicate this treat- 
ment; they heal remarkably quickly under it. The hard lumps usually 
«often and disappear very soon. Softening is not sufficient; there mast 
be complete disappearance to avoid the danger of relapse as far as pos- 
sible. If the spot once treated should again become hard, it must be 
treated again in the same way. 

It is much disputed whether general treatment is applicable for the 
primary symptoms. It has been said that this only retards the second- 
ary symptoms, and makes the disease a lingering one. We do not at all 
a^e with this, considering the hard chancre as by no means an exclu- 
sively local disease, but as indicating the accomplishment of general in- 
fection, since several weeks after infection are required to produce it, 
which is long enough for general infection. Hence the adoption of 
general treatment seems to us entirely justified. We have repeatedly 
observed cases in which, the treatment being carried out, no secondair 
symptoms at all occurred, or those that appeared were unusually mila. 
We advise the use of an inunction cure witn mercurial ointment (ungt. 
hydrarg. cinereum, one drachm for each daily treatment). 

If possible, a daily bath is taken, after which the above quantity of 
blue ointment is rubbed in upon the leg; on the following days the ap- 
plication is changed successively to the following parts: the thigh, then 
leg and thigh of the other side, then upper arm of one side and the 
other, breast, abdomen, and back again to the leg. The part rubbed 
must always be carefullv washed on the next day, before the new part is 
touched. If a bath is inadmissible, lukewarm water and soft soap are 
useil. When thirtv doses are used, we mav leave off, if there are no 
syphilitic symptoms. 

The manner of inunction is very important. Let the patient take 
the lump in the hollow of his hand and rub it slowly back and forth 
over the skin until the latter is no longer sticky and greasy, but is dry. 
Many health resorts, justly renowned for curing syphilis, owe their repu- 
tation, not to the waters, but to the skill of the rubbers. Hairy places 
are to be avoided, if possible: a hairy breast or abdomen, for example. 
Nesriect of this rule easilv causes inflammation of hair-follicles, which 
protrude as nodules, lumps, and pus-bladders, making the so-called 
eczema merouriale. This is no great harm, for the eruption heals spon- 
taneously in a few days. The most strict and careful directions are not 
superfluous: we must, esj^eoially at the banning, make sure by the eye 
and the touch that the rules are observed. 

While the inunction cure is in progress the patient ia to gargle after 
each meal with chlorate of potash (I : •^O). 

Patients must not smoke: they must keep the teeth clean, ©specially 
if any an> dofevnive. Pn^soribo for this purpose: ^ Ossium sepiaa pulv., 
3 iss,: Magnesia* oarK, Sapou. medic, ad 3 iiss.; 01. menth. pip., gtt. 
V. M. S. Tooth-jvwder, 

All these prtvautious an.* intended to prevent mercurial stomatitis. 



Hany pBtients complain of a disagrefable met&llic taste in th^ mouth b 
fore the stomatitia appears: then there is aalivalion; the gums swoll and 
grow soft, the teetli feel loose, and in fact they are so; epithelium ia 
thrown off and ulcers form; the breath in fetid, aud adhesions may oc- 
cur between the cheek and tongue which will be very hard to remove b_ 
a subsequent operation. The cheek is especially apt to he aoro where 
the crown of a molar tooth touches it. Many persons are so sensitive to 
mercuri^ that a much smaller dose than one drachm produces mercurial- 



la addition tn mercurial eozema, ptiralism. and atomsCitis, albuminuria ma^ I 
Insult from mercurial inunctioii. 1 have eaen this Swic« within the pMt jear lal 
wonieu; FflrlirinKer states tliat he has observed it ineight per csntof hispatieata. W 
Thp amount of albumia is usuall j smulL The sediment is often wanting. Uu^ I 
pension of treatment arrests tbe trouble more or less rapidly. Mercurial diar>l 
rhoea sometimes supervenes, and may talce a dfaeuterio form. 



In addition to the medical treatment, we must not forget diet. 
The food should be non-irritating, but strengthening; the hunger-cure 
is not needed. Excesses in wine and women must be avoided; it is not 
right to place others in danger of infection. The patient may^ out j 
daily, taking ail pains to avoid dampness and taking cold, to which the I 
mercurial treatment renders one subject. Cold bat&and douches are to I 
be avoided; woollen underclothes are to be worn in winter, to avoid colda " 
as far as possible. 

During the secondary period, the medicine and diet remain at first 
tbe same as above. Many direct tbe use of iodide of potash in addition 
to tlie inunction (five per cent solution, one tablesnoonful three times a 
day), but we do not much like this combination, liaving often seen an 
abundant and unpleasant eruption of furuncles follow it. We never 
found that the eymptoma of syphilis receded more rapidly, or were 



longer in relapsing, under this method. 
Broad condylomata of tbe skin can I 



removed very quickly by 
wdered calo- 



sprinkling with common salt, and just afterwards with powdi 
mel. Where two surfaces of skin are in apposition, insert cotton batting, 
to prevent f nctiou. Excesses of all sorts are to be avoided for some time 
after all symptoms have disappeared. The patients are to be warned 
not to think themselves permanently cured, hut to pay strict attention 
to themselves, aud seek medical assistance at once when anything sus- 
pious is noticed. They are to be expressly told that relapses are the rule 
within the first two years. 

In case of a relapse affecting both skin and mucous membrane, it is 
well to repeat the former treatment. If there are only condylomata of 
tbe moutn and throat, internal mercurial treatment usuaUy suffices. 
We prefer the yellow iodide, and, to avoid diarrhcea and pain, we like to 
combine with opium. (I^ Hydrag. iodidi fiav., gr. viij,; Opii, gr. v.; 
Pnlv. et Slice, glycyrrhizfe, q. s. ut ft. pil. no. 30. S. Three times a dayi 
one pill after eating.) 

During summer, baths of brine, iodine, and sulphur are useful. 

While mercury is one of the moat valuable remedies in primary and 

IDdary syjihilis, iodine preparations are of special use in the tertiary 
ea, eapaially iodide of potassium (five per cent solution, one table- 
infnl three times a day). Mercurials, however, are not superseded; 
' often act very quickly. Oummous ulcers of tbe skin of ten neal very 



840 STPmua. 

quickly ander the inflaence of mercurial plaster; chronic bone diseaaa 
improves surprisingly during inunction, etc. 

Iodine preparations, especially with iron, are the chief remedies for 
Sjrphilitic cachexia and amyloid degeneration: e. g.,^ Potass, iod., Ferri 
lact., afi 3 iiis.; Qaiainas hydrochl., gr. xv.; Pulv, et succ. glycyirh., q. 
s. ut f. pil. no. lOo. S. Three times a day, three pills, after eating. 

Baths of brine, iodine, sulphur, are very useful at this period. 

It may be usef al to notice some of the many treatments for syphilis. 

Excision of the hard chancre has been repeatedly tried, in the hope 
of preventing the development of further symptoms. The incision must 
be made in sound tissue, far beyond the diseased part. The results are 
reported variously, but few can claim to have successfully nipped syphilis* 
in the bud. The cicatrix is usually found to become induratea and 
form a second, but larger, hard chancre; or, if the excision seems to be 
successful, secondary symptoms nevertheless follow. In two cases of 
our own, we failed entirely; nor can we justify the operation, believing 
that hard chancre is the first evidence of general infection. 

There is much controversy about the use of quicksilver and the dif- 
ferent preparations. Subcutaneous injections, fumigations, baths, and 
suppositories have been recommended. 

For subcutaneous injection, corrosive sublimate has been much used, 
and has been supposed to give the speediest and most lasting results. 
Lewin has given it the most careful test. Charles Hunter (1856), He- 
bra (1860), and Scareno (1865) first used subcutaneous injections of mer- 
curials. A silver canula is required. The best si>ot8 are the back and 
sides of the thorax; abscesses are easily produced in other parts. The 
best care will not always prevent abscesses: the injection is very psiinfal; 
gangrene and death have once occurred. To lessen the painand intiam- 
mation, J. Mttller directed the addition of ten parts of common salt to 
one of the mercurial. Bamberger used an albuminate of mercury, and 
afterwards a peptone, for his subcutaneous injections, while Sigmund 
recommended bicyanuret of mercury; Liebreich, formamid of mercury; 
Wolff, glycocoll, alonin, and asparagin, in combination with mercury, 
and Schiitz a solution of hydrargyrochlo ride-urea. Calomel suspended 
in water has also been tried, but has caused inflammation and abscesses. 

Calomel is used for fumigation. The patient is placed on a chair, an 
alcohol lamp is put under the chair, and over the lamp a tin stand with 
powdered calomel; the patient is wrapped in blankets to the shoulders. 

Sublimate is used for baths ( 3 iiss. to a bath). 

Suppositories of blue ointment have been introduced into the rec- 
tum; but Furbringer shows that mercury is very poorly absorbed by 
that part. 

Among internal preparations, the iodide (already mentioned), chlo- 
ride, bichloride, and biniodide are used. 

Corrosire sublirnate is the basis of many undolj praised systems of treatment, 
of which Dzondis* is the best known. It irritates the stomach, cannot be fi^i ven 
in solution or powder, and must always be taken on a faU stomach. O ^dr. 
chlor. oorr., gr. iss.; Pulv. et succ. glycyrrfa., q. s. at f. pil. no. xxx. S. Three 
times a dav, one piU. after eating.) 

Calomel is unsuited for continued use, as it irritates the stomach and intes- 
tine. It may be g^ven in powder or pill, one-half grain twice ada^. The binio- 
dide also has irritating efFeot» upon tne mucous membrane of the mtestine. (9 
Hydr. iodid. rubri, gr. iss.; Pulv. et succ. glycyr., q. s. at f. pil. no. xxx. S. 
Three times a day, one pill.) 

Blue ointment and r^gulus of mercury have been given in the form of piU. 



SYPHILIS. 841 

Many physicians strenuoosly oppose the giying of quicksilver in any form f ok 
«3rphili8. Such "cranks" recommend also tne treatment by hanger, purgation^ 
aweating, and particularly decoctions of woods. Guaiac, sarsaparilla root, and sas^ 
saf ras are nsed this way. Sarsaparilla forms a chief component of Zittmann's de- 
•coction, which is made of two strengths, the patient takmg one-half to one pint 
of the stronger in bed in the morning, and as much in the evening of the weaker; 
the diet to be small in amount and poor in albumen. 

Many attempts have been maae to replace mercury by other metals — ^gold, 
silver, platinum, copper, arsenic. 

Iodide of sodium or ammonium have been proposed instead of iodide of potas- 
sium, but we are not satisfied of their superior effect. 

Many other remedial measures are required at different times, which 
may in part be found in text-books on surgery, ophthalmology, and 9ural 
diseases. 

2. Tertiary Syphilis of the Skin, Muscles , Fascice, Joints, and Bones. 

I. Symptoms and Diagnosis. — Gummata of the skin and subcuta- 
neous tissue are either felt or seen as lumpy projections, from the size of 
a pea to that of an apple. The skin over them is often blue-red, shiny, 
and thin. They are especially common on the leg below the knee. 
They often soften and burst outward. The fluid contents usually dry 
into brow-n or gray-green crusts on the surface. Successive portions 
thus dry up, forming a sort of layers, the lower ones being broader than 
those above them, and forming crusts like an oyster-shell. The form 
has also been compared to that of cows' dung. The name of rupia 
^or rhypia) syphilitica has been given to it. On raising these crusts, we 
nnd an ulcer of considerable depth, with step ed^es, and a greasy, tal- 
lowy coating — striking points which can be of use in distinguishing these 
from similar non-syphilitic eruptions. The ulcers often heal at one 
point and spread at another. This finally gives rise to peculiar shapes 
like that of a kidney or horse-shoe; the cicatrices which follow are col- 
ored brown-red, and when old are white with a brown edge — appearances 
partially characteristic of syphilis. Cutaneous gumata sometimes lie so 
close together that when they heal the skin is traversed by numerous 
cicatrices which may contract and cause distortion. UlceratiTig gum- 
mata may also cause deformity of the alae nasi, ears, lips, etc. Gummous 
tumors seldom become carcinomatous. They often undergo slow spon- 
taneous absorption, leaving places where the skin is sunken and tliin. 
Gummata of many other organs are often associated with those of tlie 
skin; the process often lasts many years. Many years have usually 
elapsed from the first infection to the development of gummata of the 
skin. 

The muscles may undergo important changes— sometimes diffuse 
syphilitic infiltration of the interstitial connective tissue, with fatty 
change, and disappearance of the muscular substance proper, sometimes 
the development of circumscribed nodes of gumma, wnich at times sup- 
purate or become absorbed and leave cicatrices of connective tissue, or 
adhesions to neighboring organs. Gummata often consist of deposits in- 
side of diffuse infiltrations. The clinical signs are stiffness, pain, and 
contracture of the muscles affected; the lumps and scars may be felt 
and sometimes seen. Over-exertion of certain groups of muscles, or 
injuries, may cause the local development of syphilis. One muscle 
alone may be affected or several at once. 

Keyes mentions the not infrequent swelling of bursae mucossB, as a 



^ 



cause of which he aastimes cuninious tumore, thongfa vithont aapport- 
ing his view by autopsies. Slight injuries Dft«Q form the starting-point 
of the affection. 

The sheaths of tendona have been the seat of inflammatory swelling 
or circumscribed swellings — hygromata syphilitica — iua few cases. The 
fasoiie may also become the seal of gummata. 

Joint disease is oftea counectea with svphilis. Gammous and in- 
flammato'-y processes near the articulur ends of bones may involro the 
joJDta in the affection; or else gummons knots may develop in the snb- 
serou 3 tissue of joints, causing pnin, swelling, impairment of fnnction, 
or even euppiiratioo and ankylosis. Symptoms of chronic hydarthroais 
may appear; in other cases, symptoms resembling those of iioate rhea- 
matistu may occur very early. 

The bones are oftea aSected by tertiary syphilis, but the affection 




may oocarso early as to form part of the first symptoms. Gummata 
form upon them, proceeding from the periosteum or the medulla. In 
the former case, there are 6rm soft prominences, selecting as their chief 
seat the bones nearest to the skin, as the skull, clavicle, breast-bone, ribs, 
shoulder-blade, anterior edge of the tibia, fibula, ulna, etc. These 
gummata follow the course of the blood-vessels into the bones, where 
they form polypoid and root-shaped processes. The portions between 
them disappear by degrees till patches of bone are completely gone. 
Onmmata proceeding from the medulla may in like manner cause gradual 
thinning of the bone -substance, bo that very slight external causes some- 
times produce fractnre, Gummata of the bones sometimes soften and 
burst externally, causing further destruction of the bone-substance. The 
scalp sometimes seema punched out, as in Fig. 62, laying bare the white 
carious worm-eaten bones of the skull. Thick pieces of the bone are 
even separated, and the pnleating meninges are seen, Caseona aod 
calcareous alterations sometimes occurs in gummata. If gumm 



caused to diaeppear by antisypliilitic treatment, depressions of the b 
often remain in their place, to which the thinned skin seems to be 
herent. 

Ostitis and periostitis sometimes occur in syphilitic patients, i 
originating in the breaking down of ^umma nodes, but of a more genera , 
character. Periostitis usuiiily begins in the inner layers of the periosteum," 
and forms at first an infiltration which may be pitted by presaare, but 
afterwards ossifies and forma a hard prominence— tophus syphiliticus. 
It is doubtful whether the latter may originate in the ossification of 
gummata. The attachments, or even whole muscles, may be ossified, 
canaing myositis deformans. 

In other cases, periostitis causes the formation of pus, abscesses, or 
fietulce; or gradual abaorptiou takes place. Dactylitis syphilitica, a disease 
of the phalanges of the nngers, often causes considerable swellings— spina 
ventosa syphilitica. 

Spontaneous fracture has often been seen in syphilitic patients: 
sypliilis, like many chronic diseases, leading to atrophy and fragility of 
bone — osteopsatyroais. 

Bone syphilis is one of the most dreaded forms. It tortures the 
patient with pain, sometimes lastsduring tho whole of life, causes marked ' 
and permanent deformity, and often renders n patient unable to labor. T 
Danger to life is less imminent; bnt long suppuration of the bones maW 
lead to amyloidosis, and extensive sypriilis may involve the craniun 
meninges, and brain. It is nut always easy to recognize the disease; 
is liable to be confounded, for instance, with tuberculous processes. 

Bone syphilis is one of those diseases which have often been said to bal 
due, not to syphilis, but to mercurials. This view is refuted by the faof 
that the disease occurs in patients who have never used mercurials. Yei 
this drug certainly has great influence on the bonv system. Trustworthy 
authorities have rejiorted the finding of globules of mercury in the bones lail 
patients treated with the remedy; and congestive changes in the medulla^ 
of bones are known to occur under the influence of mercurials. Nor can 
it be denied that the long-continued actiou of mercury may cause necrosis 
of the jaw and great brittleness of bones. 

II. Treatment. — Among the internal remedies, we have prepara- 
tions of iodine; and among the external, ointments of iodine and mer-^J 
cury, mercurial plaster, baths of iodine, brine, and sulphur. Ulcerativav 
processes are often found to disappear with surprising rapidity under thfr 
mfluence of the plaster. Surgical interference maybe needed: necro- 
tomy or trepanation; and in general, syphilitic disease of bone or joint 1 
belongs to surgery rather than to internal medicine. 



*3. Syphilh of the Xose, 
I, STMPTOMa AND DiAaHDgis. — The hard ulcer on the outside of the | 
nose is usually on the tip or the alse, but is rare. 

The mucous membrane very often shares in the changes of the second I 

Eeriod. There may be diffuse erythema, or hyperemia in patches, or-I 
road condylomata, which break down, and sometimes lead to necrosis J 
and loss of substance in the mucous membrane, cartilage, and bone. I 
Burning, dryness, heat in the nose, stopping-up of the mt^sages, abua- I 
dant, sometimes ill-amelling discharge from the nose, suojective percep* I 
tioQ of bad smells, and sometimes oKiena, often accompany the condition 1 



described; the causes for which i 



e easily diacovered with the rhjno- 



e usually belongs to the later stages; it 
flometimes proceeds from the outer skin, sometimes from the mucoua 
membrane, or from the cartilages or bones. The breaking down of gum- 
mata causes loss of skin, einsily confounded with tuberculosis of the 
ekin (lupna), sometimes with oancer, and leaving unpleasant deformities 
of the noee after cicatrization. Gammata on the mucous membrane often 
render the passage impervious, or during decay cause a stinking dis- 
charge, or involve the cartilage or bone. Guramataof the cartilages are 
not common. If they break do wn.ahole or fissure connecting the two nos- 
trils may be formed, without much subsequent damage; or, il the damage 
is extensive, the front of the end of the nose sinks id, and both nostrne 
form one hole. Gammata of the nasal bones may develop on parts of the 
bony frame of the nose. If the septum is involved, and the destruction 
is extensive, the bridge of the nose may sink in like a saddle, so that the 
existence of prolonged syphilis can be read in the face. Similar deformi- 
ties, however, occur after fracture of the bony ridge of the nose. Gnm- 
mous destruction of the ethmoid bone often causes loss of the nerve ofsmell 
and permanent anosmia. If the cribriform plate is attacked, there is 
danger of meningitis, and perhaps death. The 
Fin. fls floor of the nostrils is often attacked by ulcerous 

gummatous processes, causing destruction, and 
opening connections between mouth and nose. 
Such communications are very characteristic of 
previous syphilis, and easily lead to disturbance in 
eating or drinking, or to changes in the voice, 
which acquires a nasal and indistinct character- 
It is remarkable how slight a discomfort often 
attends these processes. I have repeatedly attended 
patients who had scarcely had any pain, yet the 
bony ridge of the nose was a yielding, crepi- 
tant mass. In case of perforation inwardly, I have seen emphy- 
eema of the skin. A bad-smellingdischarge — oziena syphilitica — is often 
kept up by ulceration of bone. The patients often blow out pieces of 
bone. Figure G3 represents a part of a thin lamella of the concha, which 
a patient of mine discharged while blowing his nose; hut the entire con- 
cha has been blown away in this manner. Gummous processes are usually 
easy to recognize rhinoscopically. Examination with the sound often 
discovers bare rough bone. 

Syphilitic oziena does not always depend on ulcerative processes of 
the nose; syphilis, independently of the latter, may lead to chronic in- 
flammation of the mucous membrane of the nose— rhinitis syph. atro- 
phica^with atrophy and retraction, which is associated with obstinate 
ozffina. 

II. Tkeatmest. — Besides the constitutional use of iodine and mer- 
cury, leal treatment ia very^ important. For ulcerations of the outer 
skin, we recommend mercurial plaster. For destruction of the inner sur- 
faces, the nasal douche: usin^ carbolic acid (two percent), sublimate (one- 
tenth per cent), or thymol, followed by pencilling with R Potassii lod., 
gr. XV,: lod., gr. iss.; glycerini. fl. 3ij'., or a snuff powder of eqnal 
parts of calomel and alum, or iodoform. Surgical ojierations are included. 
""I necrotomy, or plastic operations after the disease is arrested ai;d 
aled. 



Z'o, 



■« dl(clurf:Fd 



SYPHILIS. 845 

4. Syphilis of the Larynx. 

I. Etiology. — The larynx is often affected in syphilis. A frequent 
use of the laryngoscope^ not confined to periods when it seems to be de- 
manded by active symptoms^ will show the presence of slight affections 
oftener than is usually stated to be the case. 

A yery variable period may elapse between the initial symptoms of 
syphilis and those of the laryngeal trouble. The latter may appear 
among the first of the secondary symptoms— from six to eight weeks after 
the hard chancre — but years may elapse (according to Turck, thirty 
years) before the larynx is attacked. 

The outbreak of syphilitic changes may be favored by accidental in- 

J'uries to the larynx, mcludinff colds, or very loud speaking. I have 
ound syphilitic symptoms of the larynx frequent in great smokers. 

During childhood, the disease is rare; it occurs in new-born infants, 
however. Rauchf uss says that there is no distinction between hereditary 
and acquired syphilis in the form of the laryngeal disease. It is said, 
however, that laryngeal syphilis has a more rapid course, with a greater 
tendency to ulceration, in children than in adults. 

II. Symptoms and Anatomical Changes. — The chief symptoms 
are recognized by the aid of the laryngoscope, which enables us to study 
the living anatomy. 

Distinguish strictly between primary and consecutive changes. The 
primary include syphilitic catarrh, broad condylomata of the mucous 
membrane, and ^ummata. 

Many refer chorditis vocalis hypertrophica inferior (see Vol. I., p. 
181) to syphilis. 

In many cases, the above-named primary changes cause ulcerations, 
which may lead to very extensive destruction in the larynx, or to tsdema 
and laryngeal perichondritis, or to adhesions, cicatrices, and stenosis of 
the larynx. The great danger usually lies in the consecutive, rather than 
in the primary disease. 

Sypnilitic catarrh of the larynx has no peculiarities to distinguish it 
from the non-syphilitic form, when examined by the laryngoscope alone. 
Abnormal redness, swelling, and increased secretion are its chief symp- 
toms. The swelling of the mucous membrane may be so great as to pro- 
duce symptoms of stenosis. 

It may be acute or chronic; if the true vocal cords are affected, it 
causes hoarseness, which maybe of itself a suspicious fact. If the catarrh 
does not impair the vocal vibrations, the voice is not injured; and the 
disease is not recognized unless we make a rule to use the laryngoscope, 
even when no symptoms seem to require it. Subjective troubles may be 
entirely absent; there is often complaint of tickling, slight burning in 
the larynx, and disposition to cough. 

Manv syphilitics, especially those of the anxious type, complain of these symp- 
toms, although not the least change can be discovered by external or internal 
examination. There is here a sort of hypersBsthesia of the mucous membrane, 
maintained by a hypochondriacal disposition. 

If syphilitic catarrh of the larynx appears at the very beginning of 
the secondary stage of syphilis, it may be placed side by side with 
angina; it often seems to be but an extension of the latter downwards. 
In other cases^ it occurs much later^ or accompanies a relapse, or, rfurely. 



II fonm the onljr reUpM of lyphilit. If the iiaei»itr s an nr lat 
dumliou k>a|r, it cauiea nlcermtion. The nloen «re -tanMih- nnii; ad 
niuet conuaobly sitiut«d od the true tocsI cariM sad KrieniBfl aD<- 
tillKM. 

Brvftd (MtuijrloRU of the macoiu membnne of tbe Ibthz witHriar rf 
wlitU' cUrvatioiui, mu«t fre^juetitlj-aeated on tbe tra« TDoaif oardK. ^ssi n 
thi- arxteuoid cartiUffua, posterior wkII of the lairnx. Kitd An^-egiu^ 
tidNtu fuldi. Tilt! (.'Itintioru look like the broM oandflmiiiiti liiht 
pliitrrti|ce«l mucoua membrane. 

il i^roper treatment ii not givea, the saitact nlnniwtiii, and 1^ 
ulceration luiy Kpread. 

UMtMTili wul IbHh have Kivan tb« firat tboroaxfa rtaari ifcinai 
liut iarfiiK""' it»'<''<<u« iiioTubrane. Some (Letrin. WaldeatMi;^' ' 
lb* vKUiMMM of tiriMil uindjrluma in the Imrrni. 

I'Qrck kIviw iwii oaaw In which pointed condyloni 
UUtm^mnit ul tha iaryri « at aypliilittc (Mients and dii . 
VHfiMUy, liuMgit th» (filniMl oondrlotna has nv direct n 

(■Ml, ■tiKiinilini'a ((>rin«il on ihe edge ol ijplulitac « 
iidnl Willi iH^nted condylomata. 




<ii<ii>iii.>ii» fV|iliiliH iif ilio Inrvnx in a late symptom. The tumors are 
I'KK liiiKF .iiriiiii'i mill I'ii-ciiniiuTibdl, and have the eise of a pin's head, 
ri |,>tt. 'ii tii'iii . u\ .iilii'i' liiiii'M iIk'v form a ditliise nodular inmtration of 

(I.I n ri.i iiiliriiiii' iHi<<> Fig.' i;4). In cither case they mar caoae 

e..i.|ii.,ii.i' id >ii'riii.--iH. Tli<< fiivorilc seat is the epiglottis; the disease 
'fii.. |.u»acf ilin-c'il^ fnim lln' riiiiooH to tlio opifflottis. This organ is 
. tit... I •.i.kf rli-il iiiiii nil irn>giilnr f^lobnlar or roller-shaped masa which 
j.:.ta .... tn.iiifli-, itml iimv I'vi-n In* diwovercd accidentally at the larrn- 
f -.-.yU- (iiiiiiiiiriiKiM. iiH I liiivc twice found in men vhb applied for a 
.'.Ml' .lit- foi life iiii-iiniiiiv. OiimmatA may occnr on the vocal corda 
i...| . !i..-, |.:iiIf ijf ilu' iiiiK'OiiK nipmlinine of the larynx. 

>t-rr.-il I'ltiiit'iil nijijK's mnv In* distinguished. Schech samce fonr: 
(i.j.i :{ ijitiliniiioii. nf Hoflcninf:. of destruction, and of aheorptioo. 
Wl.u. a f.'iniiijiii iH^sin!" ti) iileonitp. grt';tt doTaetation may occnr; cic»- 

ii:.:;.i:.>ii iii,i\ i:iki> |<liit n iiiii> siito while ulceration eiten da on another, 

1. ii..;i.t> ii Mri.ifriiic.ii!. iiU'iT. The ulcerative process is uBually chronic, 
i ul Fi,ii,hl ]>:!> iliKiriiied Ihe cnse nf a new-born child in whom barely 
ii.i.. w.-. ke i-lii|i.-'til fntm the first hereditary symptoms in the larynx to 

I'lii' iliK'f dan^tir lion in the eonsecntire changes, and increaaee with 



every delay in treatment. The flrBt consecntire changes aro the 
tire process and its resultB. 

DangerooB bleeding is rarely caused by ulceration, though Tiirck haa' 
published & case. 

In many cases, tilceration causes (edema of the glottis; or extends to 
the perichondrium and involves daoger of perichondritis laryngea. Loss 
of some of the parts of the larynx — for instance, the entire epiglottis — 
may occur. 

Loss of the epiglottis does not always cause trouble in swallowing. The 
false cords may lie so close together during the act as to prevent food 
from entering; and the stylo-gTossus may draw the tongue backward so 
as to cover the entrance to the larynx. 

Danger is not always past, even when the ulcers are cured; for 
neighboring parts often adhere, and may lie over the glottis like a 
diaphragm, causing progressive stenosis (sec Fig. G5). Or, the increasing 
retraction of the cicatru may lead to such dislocation and impairment 
of movement as to cause permanent injury to function. The several 
parts can sometimes hardly be recognized with the laryngoscope. 

III. DiAGNOSiB. — If the patient is known to have had sypnilis, or if] 
he bears the marks of it on other parts of the body, the diagnosis is easy. 
The points to notice are eruptions, swelling of the lymphatics, cicatrices 
of the genitals, recent or cicatrized disease of the pharynx, etc. 

If patients deny syjihilitic infection (and mendacia syphilitica is 
almost proverbidl), and if indications are absent, the diagnosis may be 
difficult in case of ulcerative processes. It may be impossible to distiu' 

faish tuberculous ulceration, unless the bacilli of tubercle can be shown, 
osset-Monre has paid special attention to this point of diagnosis. It is 
a very important fact that syphilitio affections of the larynx are mostly 
painless, and are usually associated with swelling of the cervical lympha- 
tic glands, which is not the case in phthisis. Disease of the lungs is 
also an important element to consider. In lupus and lepra, there is 
nsually the same affection of the skin present at the same time. Cancer 
of the larynx offers more difficulties, but the breaking down of the tumor- 
takes place more rapidly, and causes great pain. I 
Phthisis and Hyplulia of the larynx are sometimes combined, in which.i 
case it ia impossible to draw a line between the two. 

IV. pRooNOais. — This is always serious, for, though it is often pos- 
sible to control the processes, yet the residua are often not free frorn. 
considerable danger. The result will be bett«r, in proportion as the dis- 
ease is treated in season. Stenosis is especially serious, because it is hard . 
to reach by treatment, and is inclined to grow worse; it often compeU 
the patient to wear a-cannia in the trachea alt his life. 

V. TttEATHJiKT. — This includes prophylactic, the general, and the 
local remedies. 

FatientB must be as careful as possible of their larynx, avoiding colds, 
continued loud speaking, and excessive smoking. 

If the laryngeal disease is recognized as syphilitic, general specifio 
treatment must no ordered at once. 

The local treatment may include (for catarrh) inhalations of a weak 
solution of sublimate (gr. i-4 '■ % '■■)■ ^°^ condylomata of the mncoug 
membrane, insnfHation of calomel into the larynx (Calomel, gr. ixx.; 
Pulveris acacisB, 3 ij., once a day). For gummata and ulcerous processes, 
ptuat the interior ouoe a day with iodide of potash, gr. xv. ; iodiae, gr. 



« 



4 



848 SYPHILIS. 

188.; glycerin, fl. 3ij.; or with dilute tincture of iodine; or let dilute 
solution of iodide of potash be inhaled (gr. viij.-xv. : fl. | vi.). 

Complications and sequelad are partly subjects for surgical treatment. 

5. Syphilis of the TVachea and Bronchi. 

I. Symptoms and Diagnosis.— Syphilis of the bronchi and trachea 
is much rarer than that of the larynx, but is otherwise identical. The 
larynx is sometimes affected at the same time, the process having 
extended thence to the upper part of the trachea; or the latter may have 
been originally attacked and tnc disease spread into the bronchi; or the 
disease extends through the entire course of the air passages. 

At an early period in general syphilis, catarrhal (erythematous) alter- 
ations of the mucous membrane may occur; at least, we often hear 
syphilitic patients complain of tickling, tendency to cough, and expec- 
toration, which are relieved remarkably soon by anti-syphilitic treat- 
ment. 

Broad condyloma of the mucous coat of the trachea was first seen by 
Seidel with the laryngoscope, and afterwards confirmed by Mackenzie. 

At later periods, knots of gumma may occur, oftener as diffused 
infiltration than as circumscribed tumors. They often come on insidi- 
ously, causing no symptoms but those of contraction of the passage; but 
in the act of breaking down and cicatrizing, they produce trouble and 
danger of many sorts. Purulent masses are expectorated with cough- 
ing. The secretion flowing downward may produce foreign-body pneu- 
monia. Wilkis and Kelly saw the aorta and pulmonary artery attacked 
by ulceration, with fatal results. In other cases, the mediastinum is 
attacked by ulceration and de.^truction. Necrosis of cartilage often 
takes place, and the pieces that are coughed up threaten suffocation in 
their passage. Cicatrization brings the danger of stenosis of the trachea 
or bronchi. But the process is not always alike; growths like septa 
sometimes form, as in the larynx; at other times there are flexions, and 
cicutriiMal wrinklings, or the trachea sinks together. In case of stenosis, 
the larynx makes sliorter excursions, not usually exceeding one centi- 
metre; and the head is usually held forward; both of which symptons 
contrast with what occurs in stenosis of the larynx. For clinical symp- 
toms of bronchial stenosis, see Vol. I., p. 244. The greater the longi- 
tudinal extent that is affected by stenosis, the more trouble and danger, 
even thoneh the stenosis may not be very considerable. 

Swellings in the neighborhood of the trachea have been found which 
recede<i when treated specifically, so that we may speak of syphilitic 
peritracheitis. The danger consists in compression of various^ organs, 
esp?(Milly the trachea, or suppuration and destruction. Perichorditis 
of the bronchi seems to be similar; and the growth of connective tissue 
may oxt(Mul into the lung-tissue. 

II. Treatment the same as in syphilis of the larynx. 

6. Syphilis of the Lungs. 

{Syphilitic phthisis.) 

I. Anatomical Changes. — It was affirmed by the older physicians 
that syphilis was the cause of certain forms of consumption. This view 



bTPHiLis. 849 

has been especially sustained by Virchow m later times. The clinical 
difficulty lies in the fact that we are often forced to make the diagnosis 
of syphilis exjuvantibus, and the diagnosis may have subsequent doubt 
thrown on it. Of late years, many new cases have been added, and 
it seems as if the obscure relations between the two diseases would be 
cleared up. 

Lung-syphilis ma^ appear anatomically in two forms, a diif use infil- 
tration or circumscribed gumma-nodes. The syphilitic infiltration of 
the lungs prefers the middle part of the lungs; in Grandidier's experi- 
ence^ tue middle lobe of the right lung is most frequently attacked. 
Among his thirty cases, twenty-seven affected that part, one the left 
lung, and three the apex. The latter circumstance is of special import- 
ance, as standing in opposition to the localization of tubercular con- 
sumption. The altered part is empty of air, feels firm, is dxj when cut, 
and has a gray or gray-yellow or gray- white color, like a lung in fibrinous 
pneumonia in the stage of gray hepatization. Lorain and Robin de- 
scribed these changes in the lungs of syphilitic new-born children as 
epithelioma; they have often been termed white hepatization. 

Greenfield found by microscopic examination that the chief process 
is interstitial proliferation in the lungs. The epithelium of the alveoli 
shows proliferation in many places, but may remain entirely unchanged 
in other respects. In other cases, it has undergone fatty or myelinic 
degeneration. Pancritius, the author of a recent monogram on lung- 
syphilis, considers the process as interstitial proliferation, always pro- 
ceeding from the hilus of the lung. Cornil describes a peculiar change 
of the lymphatics of the lungs consequent upon syphilis, in which the 
epithelial cells increase and accumulate, and the lymph-corpuscles in the 
tubes undergo cheesy metamorphosis. 

If infiltrations liquefy to pus, cavities form, and the clinical symp- 
toms closely resemble those of tuberculosis. Cicatricial or cirrhotic 
changes, however, are also possible during resorption. 

The gummous disease of the lungs differs from the above in assum- 
ing the form of circumscribed tumors. Softening may occur. Kobner 
describes a syphilitic new-born child which died with symptoms of pyo- 
pneumothorax, caused by a gummous tumor under the pulmonary 
pleura which afterwards broke down. In favorable cases, resorption and 
cicatrization may occur. 

Virchow mentions a third form of syphilitic lung disease which ex- 
ternally resembles the brown induration of the lungs, as found in heart 
disease. Many have connected such changes as those of broncho- 
pneumonia and gelatinous infiltration with syphilis. 

The pleura is usually infiltrated secondarily; it seldom appears to be 
affected independently of the lungs; cicatricial thickening and contrac- 
tion are a prominent feature (pleuritis deformans syphilitica). 

II. Symptoms. — Clinical symptoms of lung-syphilis may be absent, 
though extensive lung-disease exists. Moxon reports a case in which a 
person who had been syphilitic died suddenly in consequence of frac- 
ture of a vertebra, and at the autopsy there was found extensive infiltra- 
tion in the left lower lobe, and scattered spots in the right lung with- 
out any symptoms during life. Meschede also describes a case in which 
gummata were unexpectedly found in the lung of an adult who had been 
infected with syphilis many ^ears before. 

The disease may express itself by symptoms like those of commencing 
tnbercalous consumption. Langerhans gives the case of a young man 



250 STPHILIB. 

vbo hii/1 Bymptoms of catarrh of the right apex, with hsmoptysis; he 
bad had impure coitus some time before; there was no hereditary syphi- 
Vm in the family. A loug residence in a soathem climate did no good; 
aevcral copious bleedings occurred. A complete cure was obtained by 
treatment with injections of sublimate. I saw an oflScer some months 
itfo who had been sent to Davos^ for condensation of the lower half of 
thi; left uglier lobe, as a consumptiTe patient. There was no expectora- 
tion. Hhgnt febrile movement in the evening. Emaciation progressive. 
Hyphilitic infection some years bef<N^. Swefiing of the clavicle and the 
right elliow, in the third month of his residence at Davos. Mercurial 
inunctions cjuickly caused the bone-disease to disappear. The fever 
diMappeared in a week. Great appetite and rapid gain in weight. 
Ilettlthv complexion. Complete recovery. 

A tninl series of cases present the clinical symptoms of advanced 
couMumption; those of infiltration being sometimes prominent, those of 
cavities at other times; but the sputa contain no tubercle bacilli. 

Ill, I)iA(»NOSis, Proqnosis, TREATMENT. — The diagnosis is not 
oany ; one must have the divining power given by experience. We should 
always be on the watch if syphilitic members of healthy families have 
lung symptoms, for the prognosis is not very unfavorable if the cause is 
recognized quite early. The treatment includes the use of mercurials 
and iodine ]> reparations. 

Appendix.— DiflTuse or circumscribed gummata are seeninthemammffi, which 
arn (HhpcmhimI by |)encillin^ with iodine, rubbing in ointment of iodine or mercury, 
atid th(* internal use of iodine and mercury. 

7. Syphilis of the Digestive Tract. 

1. Hymptoms. — In the early stages of svphilis, the mucous membrane 
of tiiu mouth is often the seat of erythematous and condylomatous 
chiin^eH whi(!h often lead to ulceration and loss of substance. 

The Huino is seou on the tongue^ occasionally r^seolar spots. At a 
later (hito, gmunious nodes often appear on the tongue; as distinguished 
from canccuoiirt knots (which they resemble), they are solitary, not pain- 
ful, and do not (like cancer) cause hard swelling of the nearest lympha- 
tic; giiinds. if early and suitable vigorous treatment is given, they may 
UHiially l)u tlisporsed, otherwise they soften and suppurate for a long time. 
Langunbiifk and Hutchinson observed a transformation to cancer. 

It was formerly believed that numerous depressions and incurvations 
of the Hurfado of the tongue were due to syphilis. This view is as little 
jiititiliiul as that, that thickening of the epithelial layer of the tongue, 
giving a thick and almost homy covering (psoriasis linguae), is connected 
with Hyphiiis. Both conditions may be found in inveterate smokers. 

II mmata sometimes appear on the organs of the throat (see Vol. IV., 
p. 3;j4, for early symptoms). If they break down, the uvula may be 
destroyed; extensive destruction of the tonsils and soft palate occurs, and 
the latter may adhere to the posterior wall of the pharynx, making a sort 
of diaphragm between the naso-pharyngeal cavity and the parts below, 
forming at last complete closure. Swallowing and speech are much inter- 
fered with by this cliange, besides which, abnormal adhesions and closure 
of this region are hard to remedy. The condition is equally unpleasant 
when such a diaphragm forms in the lower fauces. Large vessels, even 
the internal carotid, or the vertebral artery, may be found, and fatal bleed- 
ing result. 



If gnmmata proceed from the gubmncoua or periosteal tissue of t 
hard palate, they are first perceived by the firm soft swelling, and eon ^ 
times by increased redness of the mucous membrane. In case of euppura- 
tion and openiug, abnormal communication between the month and nose 
IB oft«h formed, causing disturbance in eating, drinkiug, and speaking. 

Coses of gummons tumors in the salivary glands are described. 

Gummata occur in the submucous tissue of the (Esophagus and the 

Kriceeophageal connective tissue, which, by suppurating and cicatrizing, 
id to stricture. 

Gummata of the gastrie mucous membrane- occur, but are often of 
slight clinical importance. In many cases, there is ulceration, but the 
ulcers are capable of cicatrizing. 

The intestinal mucous membrane often has many gummata, which, 
if they ulcerate, leave cicatrized surfaces, and may produce perforation 
or peritonitis. Diarrhoea occurs in syphilitic persons, which is ouly 
arrested by specific remedies (syphilitic catarrhP). 

Similar changes occur in the rectum; with the ulceration and cicatri- 
zation of gummata, and stenosis, symptoms of stricture are joined to 
those of chronic diarrhtea. The stools are usually composed of purulent, 
sometimes bloody masses; the finger detects cicatrices oo the walls of the 
rectum. These things may easily be oonfonnded with chronic dysentery^ 
flspeciallr if tenesmus is present. .- ' 

Besidesgummata, broad condylomata have repeatedly been observe^ 
in the lower part of the rectum. 

II. Treatment, — Ijocal and general measures, based on tt 
principles, are often assisted by surgery. Syjnptomatic treatment is ofb 
required, as passing a sound for stricture. 

8. Syphilis of ike Liver. 

I. Anatomical Changes. — Severe disease of the liver is not rare 

it almost always belongs to the later period of acquired sypliitis, and i 

considered one of the so-called tertiary Eymptoms< But it is also found 
in children — as anile, associated with hereditary syphilis. 

The anatomical changes of hepatic syphilis are not always the s. 
they include syphilitic perihepatitis, hepatitis, and diffused interstitia 
hepatitis, gummous hepatitis, syphilitic cirrhosis, and amyloidosis. 

For cirrhosis and amyloid liver, see Vol, II., pp. SOI and 213. 

Syphilitic perihepatitis is marked by tendinous thickening of t 
serous coat of the liver and formation of adhesions of connective tisauff" 
to the neighboring organs — diaphragm, stomach, colon, wall of abdomen, 
etc. On section of the liver, it is seen that this often is connected with 
streaks of connective tissue in the interior of the parenchyma. It is 
rarely found alone; in such coses, it is distinguished from common peri- 
hegmtitts only by the existence of lues in other regions, or by the exces- 
aive thickness of the affected tissue. It often causes the formation of 
deprs^sions of the surface by cicatricial contraction of the net 
especially where it extends into the interior. 

Diffuse interstitial syphilitic hepatitis, also called by E. Wagner difluiji 
syphiloma, is the commonest form of hereditary syphilis of the liver. U 
consequence of excessive interlobular proliferation of connective tissue,* 
the proper parenchyma of the liver is destroyed and replaced to a vari- 
able extent by new connective tissue. The appearance of the changed 
parts has been compared to the color of fliat (Gubler) or that of sole 



852 SYPHILIS. 

leather (Tronssean). No lobular markings are seen — a condition usually 
but little observed in the liver of new-bom children. 

A whole lobe is sometimes changed to wheal-like connective tissue 
and wrinkled. Cicatricial retractions reaching to the surface of the 
liver are common in this case. 

The microscope exhibits in syphilitic hepatitis a connective tissue very rich in 
cells, some spindle-shaped, others round. Careful examination will show that the 
portal branches are essentially involved in this process; their walls are thickened, 
and abound in round ceUs^^the endothelium is proliferated in many places, with 
retraction or closure of the vessels. Similar changes occur in the intralobular 
capillaries, the gall-ducts, and (according to Rlndfleisch, Hayem, and Baillard 
Lacombe) also in the lymph-vessels. The liver cells become fatty and granular, 
and perish. 

In ^nmmous hepatitis, we can distinguish two forms macroscopically, 
one miliary, and one in large tumors. The former easily passes into 
the latter. 

The formation of gummous nodules is usually connected with inter- 
stitial proliferation of connective tissue, and thickening of the serous 
coat 01 the liver; the microscope shows every stage of transition. 

In miliary gummous hepatitis, very fine yellow dots are scattered 
through the liver, in various numbers^ and in size from a pin's head down 
to a scarcely visible point. 

The microscope in this case shows clusters of round cells, which originate in 
the walls of the vessels, chiefly the portal vessels, but also in the gall-ducts, and 
probably the lymphatics. In some places, several small groups unite to form a 
larger one, showing how the miliary form may turn to the syphiloma with nod- 
ules. Giant cells have also been seen in the little nodules. 

Hepatic gumma in largo nodules forms a tumor from the size of a pea 
to that of an apple. It is most commonly seen near the suspensory liga- 
ment and the lower edge of the liver, which led Virchow to suspect 
that mechanical irritation might give rise to the selection of that spot. 
There is sometimes one tumor, sometimes there are from thirty to fifty, 
and more. 

The ^umma is seldom a separate, rounded body; its envelope of con- 
nective tissue usually sends out many ramified processes into the neigh- 
boring hepatic tissue. Fresh gummata have a gray-red surface of sec- 
tion; in older ones, caseation occurs in the centre, which turns dry, 
crumbly, and cheese-yellow. This material displays under the micro- 
scope a granular and fatty detritus, while the non-caseous periphery has 
accumulations of round cells. Softening, suppuration, and bursting of 
pus into gall-ducts occur exceptionally. Calcification may occur. 

Where gummata project above the surface of the liver, and there are 
at the same time penhepatitic and interstitial proliferations and cicatri- 
cial retractions, the liver seems to be composed of many globular seg- 
ments, whence the name of syphilitic lobed liver. Sometimes a protu- 
berance is so constricted by the bands that it is only connected with the 
liver by a thin, movable pedicle. 

Such of the parenchyma as remains undergoes the fatty and amyloid 
changes; the latter may extend also to the new syphilitic formations. 

The formation of the large gummata agrees with that of the miliary 

yariety. 

Schuppel describes three cases as peripylephlebitis syphilitica, in 



SYPHILIS. 353 

which the lormiftion of syphiloma was very closely connected with the 
coarse of the larger portal oranches. 

II. Symptoms. — in many cases, morbid symptoms are entirely absent 
in syphilitic disease of the liver, and the anatomical changes are dis- 
covered accidentally at the autopsy. Even when symptoms exist, they 
are usually so ambiguous that we have no right to infer syphilis of the 
liver unless the history, or affections of the sKin, bones, or mucous mem- 
branes, prove the existeuce of constitutional syphilis. 

In syphilitic perihepatitis, peritonitic friction murmurs have been felt 
and heai^; pain in the hepatic region is also mentioned; a restricted or 
suspended respiratory mobility of the organ is to be carefully looked 
for. 

In the other forms of syphilitic liver disease, we have to consider pain, 

i'aundice, and changes in the volume and superficial character of the 
iver. Sometimes there are symptoms of cirrhosis (splenic tumor, as- 
cites), especially when large branches of the portal vein are narrowed or 
occluded. 

Death may be caused by general marasmus; in excessive ascitej, by 
suffocation; iu rare cases, it is connected with symptoms of acute yellow 
•atrophy of the liver. 

III. DiAGN'osis. — Many syphilitic changes of the liver are unrecog- 
nized during life. In other cases, the nodular protuberances may lead to 
confusion with cirrhosis, adhesive pylephlebitis, abscess, echinococci, and 
carcinoma. The etiology is most important; if neglected, there is no cer- 
tainty. 

IV. Pbogkosis. — This is generally unfavorable. This is partly due 
to the fact that the patient does not usually come uader treatment till he 
has reached a condition of profound marasmus, so that nothing more 
than symptomatic treatment is possible. Gumraati of other parts are 
dispersed by iodide of potash and mercurials; we may presume the like 
in the present case. Irreparable injury may have been done already by 
cicatricial tissue closing gall-ducts and portal vein branches. 

V. Tbeatment. —If the existence of this disease is probable, use 
iodide of potash, and mercurials — tho latter always with care. The use 
of the baths and waters of Tolz or Oberheilbrunn, and brine baths, may 
be tried. If there is extreme marasmus, nothing but purely sympto- 
matic treatment may remain. 

Appendix. — Syphilitic disease of the pancreas is rare; sometimes 
diffuse connective-tissue induration, sometimes gummatous nodes; it is 
of no clinical importance. 

9. Syphilis of the Spleen. 

I. Anatomical Changes. — Splenic disease is very frequent in syphi- 
lis, and occurs in several forms. 

Acute tumor of the spleen is an early symptom (see Vol. IV., p. 

Owl ). 

It occurs, though not constantly, at the time of initial sclerosis, or 
during the appearance of the first general symptoms, and thus gives to 
the disease, in some sort, the stamp of an infectious disease. During the 
use of mereury it gradually disappears. As long as it remains, relapses 
are to be expected. There are no anatomical data, but the changes prob- 
ably consist of hyperaamia and hyperplasia of the cells of the spleen^ and 
23 



351 SYPHILIS. 

indnde the cases which Virchow called soft syphilitib tumor of the 
spleen. 

Interstitial syphilitic lienitis has a chronic development and longdnr- 
ation^ and is a late symptom. The organ is enlarged^ hardened, and a 
section shows it to be crossed by uncommonly bros^ and abundantly de- 
veloped bands of connective tissue. The capsule is thickened, and some- 
times adherent to the neighboring parts. Similar changes may also be 
found at the same time m the liver, making it doubtful whether the 
splenic disease is a consequence of that of the liver, or a co-effect. 

These conditions occur in congenital syphilis; great importance should 
be attached to that circumstance in making a diagnosis. 

Gummous lienitis belongs to the third period of syphilis. As in 
other organs, nodes form, which may become as large as a walnut, but 
may be lust the size of a pin's head. When fresh, they have a gravish 
color; aiterward they become drier, yellowish, opaque, and crumbly. 
They are rarely encapsulated in connective tissue. Thev seem to be 
capable of partial absorption, and to disappear, leaving a callosity of con- 
nective tissue, Puckerings and deformities of the spleen sometimes 
occur. 

Gold has observed with the mioroscope, endarteritis and endophlebitis oblit- 
erans, hyperplasia of the connective-tissue framework, and abundance of round 
cells scatterea through the latter. Zenker found tablets of cholesterin; pigment 
crystals occur. 

Amyloid spleen belongs rather to the marasmus which sjrphilis causes 
than to syphilis itself. 

II. Symptoms axd Treatment. — We can only recognize this dis- 
order when a syphilitic person, with demonstrable gummata in other 
organs, has an enlarged and nodular spleen. 

Treatment, iodine internally, iodide of iron, iodine baths. 



10. Sypfiilis of the Kidneys. 

Syphilis plays an important part in the etiology of disease of the kid- 
ney. We have encountered it in chronic nephritis of the parenchyma- 
tous and the interstitial sorts, and the amyloid kidney; even acute 
nephritis may be produced by syphilis. The diseases have no specific 
characters by which they can be recognized as syphilitic, but it often 
appears that" the interstitial proliferation of connective tissue is very ex- 
tended, causing deep cicatricial puckerings of the surface, which give the 
kidney almost an embryonal, *. e., a lobular form. This is always sus- 
picious, but we can hardly infer kidney-syphilis from it alone, unless 
there is syphilis of other organs. It is, of course, extremely im{>ortant to 
know wfiether a nephritis is syphilitic or not; the |>r6gno8is will be 
more favorable if we can expect to control the disease with mercury and 
ioiline. 

Gummata are developed in a few cases; but thejr remain unrecog- 
nized during life. There may be the miliary or submiliary forms, easily 
mistaken for tubercle, or nodes as large as a pea, seldom as large as a 
bean. They are quite like those of other organs, often become caseous, 
are inclosed by growths of connective tissue, are usually multiple (in an 
observation by Key there were lYiitt^ m oue kidney), may be most abun- 



SYPHILIS. 355 

dant in the cortex or the medulla, and may canse great contraction, 
leaving little of the normal kidney remaining. 
Treatment as for liver and spleen. 

Appended.— For the relation of syphilis to haemoglobinoria and albuminuria, 
aee Vol. II.; p. 253. 

11. Syphilis of ihs Sexual Organs. 

The testes are often affected with syphilitic sarcocele. There may 
be thickening of the tunica albuginea with connective tissue, or inter- 
stitial proliferation of connective tissue in the septa between the seminal 
ducts or nodes of gumma in the substance of toe testis. Gases of the 
latter sort may be confounded with cancer, but they are not painful, 
either spontaneously or on pressure, and cancerous degeneration in 
the nei^nboring lymph-glands of the groin is absent. We distinguish 
syphilitic sarcocele from tuberculosis by the fact that the latter always 
begins in the epididymis. Gummous nodes of the testis may soften and 
suppurate, the testis and scrotum adhere, and the pus is discharged ex- 
ternally. If both testes are affected, with inflammatory changes and ad- 
hesions in the vasa deferentia, impotence may result. But it is wonder- 
ful how small a remainder of a testis enables some men to be potent. 

Gummata occur in the corpus cavernosum penis, causing sometimes 
loss of substance, cicatrization, and angular deformity. 

The epididymis is rarelj attacked by syphilis independently, but may 
be associated with the testis in the affection. So with the disease in the 
vas deferens, seminal vesicles, and prostate. 

Treatment internal and local, according to rule. 

12. Syphilis of the Organs of Circulation. 

In the heart muscle, sjrphilis may cause the formation of circum- 
scribed nodes, or diffuse infiltration, and callosities; these are often 
associated with disturbance of the power and functions of the heart, but 
are partially reparable (see Vol. I., p. 64). 

In the endocardium, there may be thickenings which cause interfer- 
ence with the valvular action. 

Arterio-sclerosis of the great arteries and aneurisms have been justly 
associated with syphilis; but the most important changes of this class 
belong to the middle-sized and smaller arteries, to be described in the 
following paragraphs. 

13. Syphilis of the Brain. 

I. Etiology. — This term includes not only affections of the paren- 
chyma proper, but more especially those commoner ones of the meninges 
and arteries (some consider them the only ones), which involve the brain 
as it were secondarily. 

Morbid symptoms of the brain or cerebral nerves are often connected 
with syphilis of the skull. For example, ulcerating gummata of the 
cranial bones may cause cerebral abscess; or syphilitic growths in the bony 
canals may compress the nerves and cause paralysis. Such occurrences 
are not mentioned in this chapter. 

Intra-cranial syphilitic growths are very common indeed, more so 



356 8YFHILI8. 

than in any viscus except the liver. In the majority of oases^ percepti- 
ble changes belong to the late forms of 83r])hili8^ and mast often be 
counted with the tertiary symptoms. Sometimes more than sixteen, 
twenty, even thirty years pass before the first symptoms of intracranial 
syphilis appear, and the patient is apt to express incredulity when told 
the truth. Exceptions, however, occur; cases are described in which 
brain-symptoms appeared within the first year aftor infection; Foumier 
says that facial palsy may appear directly after the hard chancre, but a 
knowledge of the anatomical changes is wanting. 

Persons of an inherited nervous temperament are specially liable to 
brain-syphilis. Injuries to the skull often seem to have been the excit- 
ing cause. Excesses ia Baccho et Venere, mental strain, and psychical 
excitement have been found to bear a certain relation to it. Lancereaux 
observed that the learned class furnishes a larger proportion of brain- 
svphilis than the laboring class. Slight or dilatory medical treatment of 
the primary disease seems to favor its appearance. 

Broad bent says that the danger is especially great when the secondary 
symptoms were slight and the tertiary appeared very early. 

Cerebral syphilis is of course most frequent in adults, but Graefe haa 
demonstrated it in a child of two years. Virchow states that children 
.may be born with si^ns of congenital encephalitis, arising under the 
infiuence of syphilitic infection of the parents and children; bnt Jastro- 
witz^s investigations of the history of its development have thrown doubt 
upon this. 

II. Anatomical Changes. — These chiefiy affect the membranes and 
vessels of the brain. Many authorities consider the vessels as the chief 
sites, and as always forming the point of origin. It is doubtful 
whether syphilitic growths can spring from the cerebral parenchyma 
proper; tney probably in all cases spread from the meninges or blood 
vessels into the brain. 

In the meninges we find gummous tumors, often springing from the 
dura mater, and next from the subarachnoid tissue. Their origin at the 
dura is generally between the two layers, from which point they press out- 
ward towards the skull or inward towards the brain, or in both direc- 
tions. They much prefer the top of the arch of the cranium and the 
base of the skull; in the former case, often lying on the falx cerebri; in 
the latter, on the prominences of the sphenoid bone, especially near and 
along the cavernous sinuses. The latter point is of importance as show- 
ing now certain nerves, most frequently the oculomotor, and next the 
abducens, are compressed and paralyzed. 

Meningeal gummata may be circumscribed tumors like nodules or 
tubercles, or may shade in the most gradual way into the neighboring 
tissue, like inflammatory infiltration. In the former case, the size may be 
that of a hen's egg, though smaller sizes are the rule. Numerous miliary 
gummata have been found on the meninges in rare cases. The section 
presents a gelatinous consistency and a gray-red transparent look, or it 
may be dry and cheesy-yellow, or the centre may be cheesy and the peri- 
phery still succulent. There may be several cheesy spots in the central 
layers. 

The effect on the neighborhood is that of pressure and consecutive 
atrophy; infiammation and softening may be added. The latter is 
especially the case with gummata that grow deep into the brain, with 
softening and destruction not confined to the new formation, bnt impli- 
cating the surrounding parenohym«b to a greater or less extent. Very 



962 

coBsiderable disturbance of the brain may result from this. The start- 
ing-point of Buch growths may not be discoverable. The meninges are , 
often adherent, thickened, and everytliiug so mixed together that it u , 
impossible to draw distinctions. M 

When the gummons groirth is an infiltration of the meninges, thft 
latter are thickened, sometimos gelatinous and juicy, eometimes bdov- 
whitfi and of cartilaginous hardness. 

Blany believe tliat aj'philis causes real inflHmniatiOTi of ttie meninges, not dia. 
tiiigulslj&blefromurdinurj- meningitis, at least not anatomicall.T, though p 
remarkable for a tendency to chronii-ity. Most recent authorities properly dea 
this. Much has also been said of theeSectof hyperemia of the meningee a 
brain in causing many diiturbsnceH; but this is little understood. 




Petrow accounted for the (list urban (.-e of circulation in the meningeB and bmiii 
by nnHt'imical changes of the eynipatbetic nerve, but this will not stand before 
unprejudiced criticism. 

Syphilis of the cerebral arteries intolvea two processes, gummons 
formatiouB, and endarteritis, the former seated in the adventitia and 
media, the latter (corresponding with its name) in theiiitima. They have 
very close relations with each other, as Baumgarten has very well shown; 
the former may give rise to the latter. In other cases, the endarteritis 
may originato independently, 
^ Syphilitic diseases of the vessels, to whichever form they belong, Bra. , 



8TPHILI8. 350 

repeatedly found the media and adventitia uninjured when the endarteritis was 
most pronounced. The process is sometimes terminated bj the forming of a new 
endothelium on the inner surface of the growths and a new tunica fenestrata on 
the outside (Fig. 66, 2, n tf and 8, a if). 

We must not sftppose that endarteritic changes are characteristic of syphilis. 
They occur in other organs in a great Tariety of circumstances, as in the yicinity 
of inflammations and new formations. Syphilis is one of their many causes, and 
they are especially referable to syphilis when found in cerebral arteries. They 
are distinguished from arterio-sclerosis by their occurrence in youthful persons 
and by absence of fatty and calcareous changes. 

Oerebral aneurism has been connected with syphilis* Aneurism of 
the aorta, or ^mmous and thrombotic changes of tne heart muscle, may 
a£Fect the brain by thrombi or portions of ulcerous surfaces becoming 
detached and carried to the brain as emboli. 

Many authors state that encephalitis can develop directly as a conse- 
quence of syphilis; this is doubtful. 

The idea that syphilis might cause purely functional disturbance o£ 
the brain originated at a period when the affection of the arteries was not 
known. 

III. Symptoms. — They are marked by great variety. Either psychic, 
sensory, or motor disturbance may be prominent; or several groups of 
symptoms may be combined. 

rsychical symptoms are common. The patient becomes irritable, 
whimsical, indifferent, loses interest in work, and may develop a pro- 
nounced mental disorder. Progressive paralysis of the insane is often 
connected with syphilis, though this is exaggerated by many, e. g., 
. Mendel. Syphilopnobia is often present. The thought of being 
syphilitic is a constant torture; the victims spend their time going from 
one doctor to another to obtain assurance that they are free from disease; 
they neglect their family and business, and become misanthropic and 
hypochondriacal. This occurs in persons who never were infected, but 
are completely overpowered by tlie memory of an impure connection. 

Loss of energy and weakness of memory are often associated. 

Aphasia often appears very suddenly, lasts some hours (seldom days), 
and then sometimes disappears in a surprising way. Repeated attacks 
of aphasia without paralysis of extremities are characteristic of cerebral 
syphilis, and are to be associated with changes in the region of the arteria 
fossae Sylvii and temporary disturbance of circulation (stenosis of cor- 
tical arteries, with speedy restoration of collateral circulation). 

Many patients show marked somnolence, lying for hours or days in a 
half-sleep, like intoxication, either quiet or delirious. Such attacks may 
occur at very variable intervals. Awakening and clearing of conscious- 
ness usually take place very gradually. 

Sleeplessness occurs in other patients, lasting for weeks and driving 
them almost to distraction; they cannot usually tell what prevents sleep, 
as they have neither pain nor disturbing thougnts. 

Headache and neuralgiform attacks sometimes occur. The headache 
is diffuse or fixed in given spots, superficial or deep, increased or ex- 
cited by knocking, or not influenced by so doing. .Bodilv and mental 
excitement, and excesses in Baccho at Venere usually rencler it intolera- 
ble. It may be so great as to cause furious delirium. It often occurs 
chiefly at night and destroys sleep. It sometimes disappears spontane- 
ously, and so suddenly as to lead us to believe that it is due to states of 
fluxion. Neuralgia of the nerves of the brain or extremities may be both 
violent and obstinate. 



860 STTHILIS. 

Kambness, and many sorts of panesthesia, are frequent; they occur 
in mauj different nenre-districtSy sometimes distinctly circumscrioed. 

Paralysis of certain cerebral nerves deserves special attention. The 
motor oculi is most frequently affected; the abducefis next. Some- 
times both are paralyzed at once; perhaps one in one eye, the other in 
the other. 8uch paralyses may disappear spontaneously, or may be re- 
lieved very rapidly by iodide of potasn (&fter the fruitless employment 
of electricity), but they often relapse. They usually owe their origin to 
gummous affections of the dura at the base of the skull. Some branches 
of the oculomotor often remain free. 

Tho facial nerve may be the one attacked. All the branches are 
often attacked at once, indicating that the disease is peripheral; but in 
many cases there is rather a kind of weakness and laxness of the facial 
muscles. 

The nerves of sense are sometimes affected. There may be loss of 
bearing, usually on one side only; or the sense of smell or sight suffers. 
'J'ho ophthalmoscope may show the latter to be purely functional (with- 
out viMible changes of the optic papilla and retina), or associated with 
neuritis (J. Jakobson), neuro-retmitis, or atrophy of the optic papilla. 
In one case, endarteritis proliferans of the arteria centralis retinae was 
demonstrated anatomically. 

Uebreich and Fdrster report a rare form of STphilitic retinitis, comprising ez- 
travaiMtion and formation of white spots in the retina. 

Paralysis or conditions like it often occur in the extremities. They 
may be* confined to one extremity (monoplegia), or to single groups of 
nniKcles; tliey may be unilateral or bilateral (paraplegia). They often 
occur with great suddenness while a certain motion is being attempted; 
or they may come on very gradually, beginning with fatigue and weakness. 
The (condition of weakness and paresis is very often permanent. Frequent 
change in the distribution and extent of paralysis often occurs: going 
from one group of muscles, one extremity to another. The symptoms 
may last for hours, or days, or months. 

Paralysis often appears in the extremities as an apoplectiform attack. 
The i)atient suddenly falls, the consciousness may be lost, or almost 
wholly retained; hemiplegia has occurred. The latter is of ten connected 
with aphasic symptoms, and right-sided; or symptoms of disease of the 
pons occur, since the region of the arteria fossae Sylvii and the basilar 
artery are very often affected. It is very noticeable that the patient 
sometimes continues somnolent and almost in a dream for many days 
and weeks, with occasional conscious moments, followed bv relapse. Ex- 
cited states occur; tossing in bed, attempts to leave the bed and dress: 
there are false ideas, expressed in word and gesture. Death often fol- 
lows after long somnolence or coma; or the patient recovers, but is car- 
ried off after one or several relapses, sometimes at short intervals. A 
surprising improvement in the paralytic symptoms often occurs, and 
sometimes complete convalescence; but if p iralys'S remains, there may 
be contracture (secondary degeneration) and atrophy from inactivity of 
the paralyzed muscles. 

Among the motor disturbances, epilepsy is especially important. It 
may be exactly like the non-syphilitic disorder. It may differ 
in having no aura, in the very rapid succession of the attacks^ in 
co/jAriouen(/.i< l>einsr only incompletely recovered during the intervals. 



SYPHILIS. 361 

The contractions may be limited to one side or one extremity, may be 
unaccompanied by loss of consciousness, and may present the symptoms 
of so-called cortical epilepsy (see Vol. II., p. 194). 

Many patients suffer from severe and obstinate tremor; others, from 
severe giddiness. 

Chorea is often seen. I have seen it in a very severe form in a man 
and a woman, in both cases directly after the eruption of extensive 
roseola, and in both cases disappearing quicklv after the use of mercury. 

Oerebral syphilis is usually chronic, though an apoplectic attack may 
put a sudden end to life. Relapses, with different symptoms each time, 
and a great variety of combinations of symptoms, are the rule. 

IV. Diagnosis. — It is usually easy to recognize cerebral syphilis 
when, on the genitals, skin, mucous membrane, bones or hairy scalp, we 
find cicatrices, spots of pigment, bone swellings, depressions, or loss of 
hair; or the disease is known to have occurred. One must be careful not 
to accept statements implicitly, for patients are apt to call soft chancre 
and even gonorrhoea by the name of syphilis, and on the other hand, 
they are very likely to lie about the matter. 

In the case of married men, we must inquire whether their wives have 
had repeated abortions, whether they are childless, whether children have 
died early, or have had cutaneous eruptions, obstinate ozsBua, scrofulosis, 
or rachitis, for all these things are orten connected with syphilis on the 
part of the parents, especially the father. 

In default of these signs, W3 rely on practical experience. One who 
has seen, examined, and rationally treated many cases soon acquires an 
instinctive perception of what is and what is not syphilitic. A descrip- 
tion in words is not easy. Sudden paralysis of eye-muscles, transitory 
aphasia or palsy, protracted and frequently returning somnolence, a 
combination of very different groups of symptoms, none very fully 
marked, deserve careful notice. The nervous symptoms are sometimes 
so incompletely developed as to suggest hysteria— a suspicion which, as 
a rule, is justified only in women. In the case of epilepsy, consider 
whether there is a hereditarv basis for that disease or other neuroses, 
whether it originated in childhood or adult age, whether injuries of the 
head, or cystioercns of the brain, can be taken into account. Originat- 
ing in adult life, and accompanied by perversion ot consciousness in the 
intervals, it is open to the suspicion of a syphilitic origin. 

It should certainly be a rule to regard a doubtful case as syphilis and 
treat it as such; this will hardly ever do serious harm. The presence of 
disseminated or syphilitic choroiditis may sometimes enable a physician 
skilled in using the ophthalmoscope to infer cerebral syphilis. 

V. Prognosis.— Though this is always serious, yet a rational treat- 
ment may often check the symptoms, or relieve them more or less com- 
pletely. We are not masters of the situation; even in light cases, severe 
and fatal symptoms may suddenly appear. The prognosis depends on 
the symptoms, and is bad in proportion to the supposed amount of 
destruction and softening of the brain; it is worse in disease affecting 
the region of the basilar artery than in that of the arteria fossae Sylvii. 

VI. Treatment. — There^ is difference of opinion as to whether 
mercury or iodine is to be preferred. From much experience we prefer 
mercury first, and use iodine in a sort of after-treatment. When both 
are given at once, we have often seen extensive furunculosis. 

We think a daily inunction with ^ iv. of ungt. hydr. cinereum is 
the best method of administration. If coma or other severe symptoms 



362 SYPHILIS. 

threaten, wo increase the dose to 3 iiss. or more. It is rery important to 
continue the inunction for a long time after the disappearance of the 
symptoms, and to resume it from time to time as a prophylactic. A 
rag thickly spread with blue ointment may be worn permanently at that 
part of the skull below which we have reason to suspect a focos of dis- 



After an energetic inunction course^ let the patient take iodide of 
potash for weeks, or even months ( 3 iiss. : | vi., one tablespoonful three 
times a day an hour after eating). Seguin recommends as much as 1^ 
oz. of the iodide dissolved in water, one and a half hours before eating. 

I have often seen brilliant success from the waters in Tdlz and Add^ 
heidsquelle-Oberheilbrunn, and Aix-la-Ghapelle; sool-baths and indif- 
ferent warm springs (Wildbad-Gastein, Wildbad-Wiirttembergy Pf&f- 
fers, Ragaz, Teplitz, Schlangenbad) have also been praised. 

As purely symptomatic treatment, electricity is used for paralysis. 

14. Syphilis of the Spinal Cord. 

I. Etiologt. — There is no doubt that syphilis leads to diseases of 
the cord, but there is much difference of opinion as to the frequency of 
their occurrence. It is impossible to decide this question, for syphilis is 
so 'widely spread that many patients may at later periods of their life fall 
victims to purely accidental attacks of spinal trouble. The success of 
io<line or mercury is undecisive, for they are often valuable in non- 
gyphilitic cases. And finally, the anatomical changes are rarely so char- 
acteristic as to form absolute evidence of syphilis. We believe syphilis 
of the cord to be frequent, but cannot attempt to give statistics. 

The symptoms usually belong to a late period, occurring conjointly 
with tertiary symptoms or after the secondary ones have continued for 
a long time. Five, ten, fifteen years and more often elapse from the 
primary infection. The first symptoms of the secondary period are more 
ranfly iiHHociated witli spinal disease; the primary affection is said to have 
\Hii:M connected with it. The anti-mercurialists say that those syphilitic 
|/atient« who have been treated witli mercury are most liable to it. Wo- 
men are leKs liable than men, perhaps because the latter are exposed to 
(ji\ur injuries which influence the outbreak of the disease. 

II. Anatomical Changes. — Diseases of the cord may be caused by 
fcyphilitf directly or indirectly, or may be functional in their nature. The 
iiAiVi^vx affections are secondary to disease of the bones or meninges — 
Mciifiliy exostoses and carious processes of the vertebrae, or inflammation, 
ihi'rkening, orgunimata of the meninges — which affect the cord bycom- 
j;reR.«ion or l)y transference of the inflammation. The proper source of 
the <rhttn/res sometimes lies farther off; for instance, syphihtic ulcers of 
the pharynx may extend back and cause disease of the vertebras, men- 
j/;;(ei;, and Kpinal cord. These changes are almost always chronic in their 

A ri'on^ the direct affections of the cord we have to name myelitis, tabes, 
v;j<r/'/i;ii?, and many would add atrophic paralysis and progresave muscular 
atM/j/hy. There are a few cases of gumma of the cord. The syphilitic 
' a";re 'yf thr*H<.' affections cannot be determined anatomically, though 
'//♦ v-derable implication of the membranes of the cord, with extensive 
^ ' ' /v'.in/ and adhesion, must be suspicious. The myelitis which some- 
?.('.«/ '//,'in m the form of many small disseminated foci (Westphal) 






STPHIUB. 

) chiefly dne to enijaTteritic thickening with more or lees completel 
wore of the arteries, aa was deecribed ander cerebral ayphilia. I 

We eometimes have to do with purely functional disorder, as Weid- 
ner in particular has ahowu, under Gorhardt's guidance. In spite of 
severe functional disturbance during life, no change has been found in 
the cord or its surroundings at the autopsy. Acute ascending Bplnol 
paralysis has repeatedly been brought in counection with syphilis. 

III. Symptoms. — There is scarcely anything characteristic of syphilis. 
It was once thought that a predominance of motor and absence oi- slight 
development' of sensory disturbances were characteristic, but this is cer- 
'tainly mcorrect. There is sometimes compression-rayelitia, sometimes 
various forms of mvelitia or tabes, multiple sclerosis, progressive muscu- 
lar atrophy, atrophic paralysis, nnilateral lesion of the cord, or tumor of 
the cord. We must cherish a suspicion of syphilis if there is a history 
of it aFid if cicatrices are seen on the akin and mucous membranes; 
though we do not often go beyond a suspicion, as all these may be coin- 
cidences. A sort of instinct for diagnosis is acquired by practice. The 
signs of the spinal affection sometimes remain unohsorved during Ufei 
because concealed behind symptoms of cerebral syphilis. 

IV. Prognosis. — More favorable than in uon-ayphilitic cases; but tt* 
permanent and complete cure is not very common. Relapses often hap- 
pen it the treatment is broken off too early, 

V. Teeatment,— As in cerebral syphilis. Electricity with gymnas- 
tics may hasten a cure. At the beginning of mercurial inunction, the 
disease may seem to grow worse, but that should not discourage as from 
persevering, ' 

15. Sifphilis of the Peripheral Nerves. 

Peripheral nerves areaeldom the seat of gnmmata; they are more fre- \ 
qnently compressed or infected by syphilitic formations of the mening( 
or bonea, muaclea or faacias. The ayraptoma are antestheaia, pareesthf 
sia, neuralgia, spasms, aud paralysis, but it isastonishing whatcxtenslveLl 
changes ma^ occur without functional disturbance, ■ 

A functional character, rather than anything anatomically demon-l 

fible, seems to belong to the neuralgias sometimes observed at the on- 
of eeoondary symptoms or precursory of them. 
16. Jlerediiari/ Si/phiUs. 

I. Etioloot. — Since acquired syphilis is no local disease of the sex- 
ual parts, but a constitutional infection, we need not wonder that syphi- 
lis is inherited. But the transmission goes no farther than to the first 
generation. A few cases exist which prove that hereditary syphilis in 
childhood does not protect from acquiring it in later years. 

Syphihs is inherited from either parent. We cannot infer from _ 

which one it comes, from the organs aSected in the child, as von BSreu- ^^^J 
sprung once taught. ^^^H 

If the father or mother has primar;^ or secondary symptoms at the ^^^H 
time of procreation, the child will certainly have syphilis ; if both par- ^^^H 
ents have it, assurance is redoubled. If tioth have tertiary symptoms ^^^^ 
exolaaively, the child usually is not born with syjihilia, but ia apt lo be 
weak and atrophic, is liable to have scrofula, consumption, and tubercu- ' 

^^u meniQgitia at a later period, and often dies early. ^^^1 



364 8TPHILIS. 

When the father has primary or secondary syphilis^ the mother may 
remain well if no communication of syphilitic secretion takes place 
through lesions of the skin; yet she may give birth to a child affected 
with hereditary syphilis. But many think that the mother experiences 
a kind of infection shown by striking pallor, depression, and feebleness; 
and further, that she is not infected by secretion from her syphilitic 
child. The latter is not a fact; the nipple, if abraded, may receive the 
discharge of broad condylomata on the child's mouth and become syphi- 
litic. It is also stated that a foetus inheriting syphilis from the rather 
may sometimes infect the mother in utero ; this has been termed choc 
en retour. 

Special consideration is due to cases in which both parents are quite 
well at the time of procreation, but the mother in some way becomes 
syphilitic during pregnancy. Many state that if the infection occurs 
during the first half of pregnancy, the child is infected through the 
mother's blood; but not if it occurs in the second half. Others think 
that the children are sometimes healthy, sometimes not, without much 
regard to the date of infection. It is certainly easy for the child to be- 
come infected during delivery by the mother's secretions, or subse- 
quently, by suckling a breast covered with broad condylomata. 

The whole subject of hereditary syphilis is by no means so plain as might be 
inferred from the above. GiUnfeld, for example, reports a perfectly healthy 
child bom of a father who was syphilitic at the time of procreation, no anti- 
syphilitic treatment haying been given the mother. I have seen the 8ame in a 
syphilitic woman. Hutchinson rei)orts that one of a pair of twins had signs of 
hereditary syphilis and died of it, while the other remained perfectly well. Fam- 
ilies with the eldest children syphilitic and the younger ones not, are not an ex- 
ception to rules, for the transmisaibility j^rows less as time passes. Syphilitic and 
non-syphilitic children sometimes alternate: this is explained by the fact that the 
disease is usually transmitted only dnring tlie existence of active symptoms. Ex- 
ceptions to this principle, however, occur. In short, there are the most curious 
freaks, and the greatest variety of forms, iu the symptoms and the manner of 
communication of syphilis. 

II. Symptoms. — Abortion or premature birth is frequent, the foetus 
being born in a putrid and macerated state. The umbilical vessels, too, 
are often thickened, and the umbilical vein closed by thrombi. Thick- 
ening of the vascular wall affects chiefly the outer layers of the inner 
coat, and is parallel with endarteritis obliterans of the cerebral vessels 
(Vol. IV., p. 358). Interstitial proliferation of the connective tissue 
of the placenta occurs (interstitial placentitis, Oedmansson), with calci- 
fication and gummous nodes. Thus the death of the foetus is caused by 
closure or contraction of the umbilical vein, which is the channel both 
for nutrition and respiration. Hereditary syphilis is the cause of the 
majority of abortions; whence comes the practical rule, that repeated 
abortion, especially of a putrid foetus, excites suspicion of syphilis, and 
leads us to treat one of the parents specifically. The discerning phyaioian 
can thus often win the lasting gratitude of unhappy parents. 

In other cases, children are born alive, but die quickly with infantile 
athrcpsia. They are wretched creatures when born, with pale, sunken 
faces, weak, bleating voice, sleepy, and weak in suckling. The skin is 
poor in fat, leatliery, and wrinkled; the skin of the palms and soles thin 
and shining, as if pflazed; there is often erythema of the nates. The au- 
topsy shows syphilitic changes of the viscera and bones. 

In a third class of cases, the chUdren arc born well, and at first make good 



SYPHILIS. 365 

progress in development, but after a time display certain suspicious signs. 
They seem to have coryza. They snuffle, have difficulty in breathing 
through the nose, and often drop the nipple while sucking; they become 
blue; since new-born children cannot breathe through the mouth, they 
have a purulent discharge from the nose. Such things must appear 
most suspicious if they are of long continuation, in spite of care to avoid 
colds. Syphilitic disease of the mucous membrane of the nose is the 
cause. 

Rhagades of the corners of the mouth, apparently spontaneous in ori- 
gin, and very obstinate, are often nothing but broad condylomata in 
process of degeneration. 

Syphilides very soon appear — roseola or papules. As in acquired 
syphilis, the latter often assume the character of broaa condylomata in 
places where two surfaces are in contact; for this we look principallv at 
the anus, groin, scrotum, navel, arm-pit, corner of the mouth, banind 
the ear, behind the ala nasi. Bullous and pustulous eruptions also oc- 
cur. Bullous eruptions are known as pemphigus syphiliticus neonato- 
rum; they are distinguished from the non-specific pemphigus (see Vol. 
III., p. 331) by the contents of the vesicles being more purulent and 
opaque, and the wall not tense, but often in loose folds and wrinkles. 
The palms and soles are the regular seat of the syphilitic form; if pem- 
phigus is limited to those places, it may be assumed to be specific. 

In the mouth and fauces, erythematous, roseolar, and condylomatous 
disease appears. 

Many children suffer pain when the extremities are handled, perhaps 
owing to disease of the bones. They hold the extremities as quiet as 
possible. Iritis sometimes occurs, but is usually delayed for some 
months. 

Hard chancre does not appear, so that we have a sort of syphilis 
cPembUe. 

During these eruptions, the child usually loses strength; his healthy 
complexion, muscles, and fat disappear, the appetite is weak, vomiting 
and diarrhoea occur, and marasmus and death close the scene. 

Children are sometimes, though not usually, born with these symp- 
toms. They rarely appear within the first two weeks, but usually between 
the fourth and the eighth ; they are rare after the third month; and, if the 
child has been completely well for the first six months, we may inform 
the parents that, in all human probability, there is no further danger. 
Late cases are believed in by some; children are supposed to have been 
attacked between the fourteenth and the sixteenth year for the first 
time; and women at the period of pregnancy! The fact is more than 
doubtful, for the cases described as syphilis hereditaria tarda seem 
sometimes not even to have been syphilitic, but rather tuberculous 
(scrofulous); and further, secondary symptoms may have been over- 
looked in infancy. 

The disease may end with secondary symptoms in acquired as in here- 
ditary syphilis. But tertiary symptoms may appear in early childhood 
— e. g,, in the liver or lungs; or they appear first at the time of the 
second dentition (seventh year of life), or during puberty. These in- 
clude gummata, rupia, ulcers of the skin, disease of bone and joints, 
gummata with destruction of the hard palate, nose, etc. Laryngeal 
oisease, as in acquired syphilis, may lead to great contraction of the 
larynx. Such changes are found even in the trachea and bronchi. It 
18 not always easy to distinguish such disease from tubercle (scrofula). 



360 BTTHILIS. 

The disease is sometimes concealed behind unusual symptoma,^ 
ascites of doubtful ori^JD, explained after death by affections i 
li?er and portal circulation. 

Sometimes the sin of the parents is avenged by other diseases. Ter- 
tiary srphilis on the part of both parents at least predisposes childrea to 
eiic& disease aa tuberculosis, or chronic hydrocephalus, chorea, idiocy, 
epilepsy, etc. 

ril. AsatomicalChasoes.— These are of great weight in deter- 
mining the nature of the disease, especially when the parents deny pre- 
vious infection. 

Of special value aa signs are certain diseases of the epiphyseal ends of 
bones, and the ends of the costal cartilages, which appear with Bome 
re^larity, and are sometimes the only sign of syphilis. The portion of 
epiphyseal cartilage lying dose to the bone is much i)roliferated (zone of 
lime infiltration), and not bounded by a straight line, but forming 
notches and zigzags a^nst the epiphysis. This may afterwards break 
down, so that epiphysis and diaphysis arc separated, crepitation can be 
felt during life, and the child does not move the limb. In separation 
of epiphyses, cure is possible. 

In serous cavities, bloody fluid is often found, especially in putrid 
fcstiises; there are also tendinous and cicatricial thickenings, wrinklings, 
deformities, and adhesions of the serous coats. 

Great importance was attached by French authors, especially Dubois, 
to abscess in the thymus gland, which was supposed to be alono suffi- 
cient for diagnosis, but this has not proved correct. Virchow has 
expressed a reasonable doubt whether the juice of the thymus may not 
often have been taken for pus. 

Gammata and interstitial and alveolar disease have been described 
in the lungs (see Vol. IV., p. 349). The lungs and liver are most fre- 
quently attacked by hereditary syphilis. 

The spleen is often swollen. 

The liver presents perihepatitic, interstitial, and gummous changes, 
just as in acquired syphilis (see Vol. IV., p. 351). 

Birch-Hirachfeld has described interstitial proliferation of connective 
tissue in the pancreas. Forster described the like in Fever's patches. 

In the cortex of the suprarenal capsules, there are often found small 
multiple cheesy gummata. The kidneys also may contain nodnlee of 
gnoimata; also cysts. 

The bones of the skull may exhibit inflammation and necrosis, and 
the meninges may be thickened. For congenital cnoephalitis, see Vol. 
lU., p. 238. 

IV. Diagnosis. — It is often easy to recognize hereditary sypfaiiis. 
We suspect it if abortion, premature birth, and premature death by 
infantile marasmus occur repeatedly in a family. The post-mortem 
diagnosis must rest chiefly on alteration of bone. 

We must examine a living child closely when we find obstinate 
auffles, with purulent discharge, and rhagades in the corner of the 
louth. 

Hutchinson has pointed out two signs of previous hereditary syphilta 
visible in later years: a deformity of the two upper inner permanent 
oiaor teeth, and disease of the cornea. 

Deformity of the cutting teeth he refers to stomatitis, connected 
with syphilis, which makes the inner upper incisors He, not parallel to 
each other, but converging or diverging. Their free edge i - ■ ' 



lOtot^^J 



8TPHILI8. 867 

and mdnally breaks oS, forming a deep semilanar ^p. These teeth 
are shorter than the others. Tne Oermans place little faith in this 
indication. 

Of Hutchinson^s keratitis interstitialis diffusa (parenchymatosa^ s. 

Erofunda), we can only say that it is very probably referable to past 
ereditary syphilis. 

y. Pbognosis. — It is always serious. Many die of infantile marasmus, 
others have severe deformity or permanent impairment of special senses 
in tertiary attacks. Artificial feeding is almost sure to cause diarrhoea 
and loss of strength, which places the child's life in serious danger. 

VI. Treatment. — A judicious prophylaxis enables us to bring more 
relief and happiness than is the case in almost any other disease. 

Persons who have been infected with syphilis must not contract 
marriage for three years after; nor then unless they have been free from 
all relapses for six months past. They must, even then, always be on 
the watch for relapses, and avoid sexual intercourse at times when there 
are manifest signs of syphilis. 

If several abortions occur in spite of this, a vigorous specific course 
of treatment must be given to one of the couple, usually the husband. 

If a pregnant woman is infected in any way, an energetic treatment 
must be pursued during pregnancy. This holds good even if infection 
occurs in the second half of pregnancy, and a healthy child is expected — 
for infection is possible during parturition or subsequently. Inunction 
with mercurial ointment seems to us most suitable. 

We have said that a healthy mother may have a syphilitic child. 
The question arises, whether such a mother ought to suckle the child. 
It has been stated that the child does not infect the mother in this case, 
but the statement is wholly false. We ought to say to such a mother 
that she has the choice between artificial feeding, which is sure death 
for the child, and the risk of personal infection in nursing. We must, 
of course, treat the child so as to relieve its symptoms as soon as possible; 
and if there are any abrasions or cracks of the nipples, we must 
order the child removed until they are perfectly healea. We may also 
g}7e the mother iodide of notash ( 3 iiss. : 3 vi., a tablespoonful three 
times a day), less as prophylaxis than as indirect treatment of the child 
through the mother's milk. 

To tempt a poor woman with money to run the risk of infection in 
order to save the mother, is going beyond the line of a physician's duty. 
The person of one should bo as sacred as that of another. If the nurse 
were already infected, and was unobjectionable in other respects, she 
might take the mother's place. 

If both parents are well at the time of impregnation, and the mother 
is infected during pregnancy, she may have a healthy child. Such a 
mother must on no account suckle her child, lest it become affected, not 
by the milk, but by the secretion of broad condylomata on the nipple. 
The child must have the milk of a nurse or a cow. If the mother's 
gyphilii is noticed during pregnancy, she must have a course of inunction 
with blue ointment, to avert the danger of infecting the child as it 
passes through the vagina and vulva. 

For hereditary sypnilis, give internally calomel (gr. ^, three times a 
day), or hydrargyrum oxydulatum nigrum (Hahnemann's mercurius 
solubilis) in the same dose, and after every meal wash the mouth out with 
a clean soft linen rag dipped in a solution of chlorate of potash (1 : 40). 
Bathe the child daily in water at ^S"* B. {96"^ F.) in which 3 ij. of sub- 



368 LEPBoer. 

limate is dissolved. A wooden tub must be osed^ for chemical changes 
may occur in a metal one. Let no part of the bath-water enter the eyes 
or mouth. Broad condylomata on the skin are to be sprinkled thinly 
with calomel, and covered with cotton. 

For tertiary symptoms^ iodide of potash or of iron is good; for exter- 
nal use, mercurial plaster for ulcerations; for ulcerations of the mucous 
membrane, pencilling with Q lodi puri, gr. iss.; potassii iodidi^ gr. zv.; 
glycerini puri^ fl. 3 ij* M. 

PAET III. 

LEPROSY. 

Elephantiasis Cfrmcorum. 

I. Etiology. — Leprosy can be traced back to the most ancient times 
in Egypt and Jndia; it is supposed to be mentioned in the books of 
Moses. It is one of those diseases that have spread gradually from land 
to land; in the Middle Ages, there were so many lepers in Europe that 
they were collected and isolated in certain asylums called leproseries, 
leper-houses, lazar-houses. Nothing but the unsparing practice of 
this method has relieved Central Europe from this pest. Leprosy scarcely 
exists in our latitude; the cases are almost confined to persons who luive 
lived long in the tropics and have brought the disease back with 
them. In Europe it exists in Norway and Sweden (where it is called 
spedalskhed), at some points in the Baltic provinces, in Hungary and 
Kou mania, some parts of Spain, Portugal, and Italy, and in Greece and 
Turkey. It almost seems as if here and there germs of leprosy remained 
concealed. Vossius has reported two cases from the confines of Memel 
who had never left their own country. The disease usually keeps near 
the coast-line. 

There is much dispute about the causes; but there is no better way 
to arrest its spread than by the strictest seclusion — a fact which seems to 
point to communicability. Formerly ascribed to climatic influence and 
the use of spoiled fish or grain, it has of late been discovered to be an in- 
fectious disease whose germs were first seen by Hansen, and then confirmed 
by others. They are small rods, called lepra bacilli, which in many re- 
spects much resemble bacilli of tubercle, and are regularly found in 
leprous foci (see Fig. 68). Experiments in artificial implantation upon 
animals have not produced general leprosy, but Neisser, Damsch, and 
Vossius succeeded in culture of the bacilli at the infected spot. Ani- 
mals do not seem disposed to leprosy, imd spontaneous outbreaks of the 
disease are unknown among them. The hereditary nature of leprosy is 
affirmed by many authors, but it is doubtful how this can be reconciled 
with the schizomycete theory. 

Most cases occur between the twentieth and the fortieth year; rarely 
in childhood. Nothing is known of the manner of contagion. Many 
consider it safe to have intercourse with lepers, pointing to the fact that 
the attendants in leper-houses scarcely ever are affected. 

II. Symptoms. — The disease runs a very insidious course. The duration 
of the incubation cannot be stated, for the prodromata appear so gradually 
that they are not at first recognized as sucn. There is often an intermit^ 
tent fever, and the symptoms may then be mistaken for those of ma- 
Jaria. 



The skin is most frequently affected with gradual development of 
iDfiltrationa and nodular eleyatiouB — lepra cutanea (tnberosa a. tubercu- 
ioea). ill other caaee, individual nerve-trunks are first attacked with 
leprous infiltration and ganglionic swellings, producing seuBory, trophic, 
and motor distarbances — lepra-nervonim (s. anoesthettca). Many cases 
are mixed forms; the tuberculous is often the basis, with the nervous . 
supervening; the converse is rather less freqoent. The mucons membrane 
of the throat, laryns, and trachea, the blood, lymphatic glands, testes, 
liver, spleen, and especially the conjunctiva and cornea, may be tlieai 
of leprous disease. 

The prodromal eymptoma, resembling intermittent fever, often last I 
a year or two, before the first signs of tuberculous leprosy appear. At f 
first erythema appears, sometimes turning pale, again leaving brownish 
spot^. The spots by degrees become hard and infiltrated, turning al last 
to large knobs and humps. The flexibility of the skin and the propor- 
tions of the body suffer from these processes. The face aasumcB an 
indifferent expression, the eyelids, nose, and ears seem thickened aud de- 
formed, and hang down, etc, A succession of nodes usually continues 
during many years. The patient may live long, and often dies of inter- 
current disease. Leprous ulcers are often developed from the nodes, 
either spontaneously or in consequence of mechanical irritation. The 
surface of the ulcer is flaccid. Some nodes, meanwhile, may disappear 
epontaneously, and continual advance and retrogression may be observed. 
Febrile movement often precedes the outbreak of new nodes. 

Whilethese processes are going on, the mucous membranes of the nose, 
fances. laryns, and air passages may develop similar ones. The nose be- 
comes impervious, and stenosis of the larynx, from infiltration and tumors 
in the epiglottis, ary-epig!ottidean folds, true and false vocal cordg, may 
cause dangerous attacks of suffocation. 

The voice may have lost its timbre long previously. 

The lymph glands are involved; large swellings of the submaxillary, 
cervical, and inguiual glands are especially common. 

Loss of huir, especially of the brows, occurs. Leprous nodes and in- 
filtrations of the conjunctiva and cornea may occur, and finally cause loes \ 
of the eye. 

Leprous disease in the liver aud spleen has been hitherto found of no 
clinical importance. 

In lepra nervorum, the diseased peripheral nerves may be felt oa 
thickened, tender cords, knotted in places. Districts of the skiu are at 
first comparatively hypeiiesthetic, but afterwards become very antesthetio, 
and not in respect to touch and pain only. Trophic disorders are oftea i 
added. Bull^. like pemphigus, called f>emphigus leprosus, often appear; ' 
Gerhard and Mfliler have demonstrated large numbers of lepra-hacilli in 
their contents. Pigmental anomalies of the skin, white or brownishspots, 
are common. Want of secretion from the sweat and sebaceoua glands 
gives the skin a dry and lustreless look. Finally, the muscles waste and 
contract. Marked palsy is rare. Single members, as fingers, toes, or 
entire extremities, sometimes drop off-Aepra mutilans. 

The disease often lasts many years. Death is caused by marasmus, 
suffocation, putrid infection by absorption of the pus from ulcerating 
nodes, or intercurrent disease. 

III. Anatomical Changes. — ^The coarse changes consist of infiltra- j 
tioD of the skin, mucous membrane, and certain viscera, with round cells, 
^^^the formation of knots of round cells. Many of these cells are very , 

f_ 



large (eo-oaUed lepra-celle) and have vacuolea in their interior. They 
constaotly contain leprosy bacilli. These are fine rods, one-third to one- 
half a« long as red blood-corpaBcles, and extremely like the bacilli ol 
tubercle. They are rarely found free, but HBually inclosed in cells, 
where they often cluster in thick balls (see Fig. 68). 



In the fresh state they move actirely. They are easily colored with 
Aniline colors, but do not take Bismarck-brown (vesuvin). They can 
be easily demonstrated by the method of double staining which is given 
on p. 276 of Vol. IV. They are distinguished from tuoercle b»ciTli by 
the fact that they liquefy coagulated blood-serum, which the others do 
not dO) aod that tuhercnloais of the iris does not follow inoculation 




LeproBj bacilli. 

in the anterior chamber of the eye. They take aniline co1ot«3 
quickly; tubercle bacilli do not. 

Spores are often seen in them, one at each end; three or four epona 
in ouej or a rod looking as if turned into spores. The bacilli have been 
demonstrated in the skin, macons membranes, peripheral nerves, 
lymiihatic glands, testis, liver, spleen, and eyes; also in the blood, usu- 
ally incloaea in white blood-corpuscles. 

Virchow has described the spleen as swollen and filled with coantlest 
white and gray granules, shown by the microscrope to contain great 
numbers of leprosy bacilli. 

IV. DiAOirosis, Prognosis. — The diagnosis is usually easy, es- 
pecially iu persons from the tropics. In the early stages, leprosy may 
easily be confounded with malaria. , 

Cures have been reported; but the prospect is hopeless. 

V. Tee ATME. ST.— Strict confinement of the sick certainly does moat 
to restrict the disease. When it is developed, doacbes ana 



ad JTninctiniH B 



DIPHTH&BU. 

JBth mercurial, iodine, or ichthyol oiatment are most to be i 
mended. It i:^ ^aid th&t creasote Hud salicylic acid hitve been known t 
do good when given inwardly. Patienla ought, above all, to leave idj 
f ected regionfl. 

^L PAST IV. 



^■^ DIPHTHERIA. 

Diphtherifl is an infections disease which occurs most frequently 
local affection of the throat, but may also attack other mucous mem- 
branijs, as those of the laryni and nose, Attemiita have been mad« 
to demonstrate the virus, but 'as yet not with decisive certainty; 
may even be true that there are various forms of schizomyoetea wlii 
cause diphtheria. From the analogy with the other infectious diseasei, 
it seems certain that the cause must be of this nature. 

We wish to state, however, that wp are using the term diphtheria in 
its strictly etiolo^cal sense, a neglect of which has given rise to great 
confusion. For, in spite of the unity of causation, the coarse anatomi- 
cal changes in different mucous membranes may differ greatly; on that 
of the throat, the esudation is for the moat part deposited in the tissue 
itself, and cannot be removed from its surface, nor usually without 
taking away the mucous membrane itself. But in the larynx fibrinous 
exodations are common, which lie on the surface, and can be removed 
easily and without essential loss of substance. Virchow has termed th^^ 
latter class of alterations croup, restricting diphtheria to the former. 
In the etiological sense, both conditions are the same. 

It would he quite wrong to class every anatomical croup as a diph- 
theria in the etiological sense, for doubtless there are croupous inflam- 
mations without schizomycetes. The experimental proof of this state- 
raent is easily given by applying caustic ammonia, caustic potash, chromic 
acid, or substances having a similar action, or by causing the inhalation 
of hot steam, wliich produce a true croup of the larynx, in the anatomi- 
cal sense. The result is the same in man, Palloui described a case of 
croupous inflammation of the laryngeal mucous membrane caused by in- 
halation of chlorine gas; and Reimer. a similar case caused by swallowing 
muriatic acid. Laryngeal croup has occurred after extensive burns. 
Croufiona inflammation of the msophagus has been caused by swallowing 
caustic ammonia. KozIakoS and Stiicker produced croup of the gastric 
mucous membrane in rabbits by introducing dilute ammonia into the 
stomach. Croupous changes oi the gall-ducts are sometimes caused by 
the irritation of gall-stones; and croup of tlie pelvis of the kidney, 
Qreter, and bladder may be caused by stone, or the uxe of irritating 
balsamics and diuretics, Croupous disease, therefore, has two forms 
—the diphtheritic and the non-diphthentic— as regards causation. 
Primary bronchial croup ia another case of the uon-dipbtheritictorm. 

Diphtheritic processes, in the anatomical sense, are not always dipb-i 
theritic as regards causation; this seems especially tnie as regards manf ' 
affections accompanied by necrosis, developed during many infectious dii ^ 
eases, and often termed pseudo-diphtheritic. Vice versa, infection witl 
diphtherial virus occurs which does not lead to diphtheritic or cronj 
oue changes of the mucous membrane in the anatomical aenae, as wUl I 
mlaiiied under the aext heading. 



m- 

■de 1 



^exDiaiaed unu 



.872 DIPHTHEBU. 

1. Diphtheria of tfie Fauces* 

{Angina maligna. Angina membranacea. Synanches. Cynanche Con- 
tagiosa.) 

I. Etiology. — There can be no donbt that this disease is contagious 
for^ apart from its frequent occurrence in epidemics, it is often observed 
that patients coming to a place previously healthy give rise to an epi- 
demic; or that well persons acquire the disease when placed in contact 
with patients, as in nursing, in kissing, in using yessels or instruments 
that were not cleansed, bj bein^ coughed upon, etc., and even by being 
in the same room. Physicians nave often been inoculated with the virus 
through accidental scratches. Successful experiments on animals also 
show the infectious nature of the disease. Trousseau made unsuccessfal 
experiments on himself and two of his hearers; but such failures of con* 
tagion happen at times with diseases whose contagious properties are fully 
known. 

Primary and secondary diphtheria of the fauces should be strictly 
separated: the former is an independent disease; the latter develops in 
the course of other infectious diseases. 

The primary form occurs sporadically in large cities at almost all 
times, so that foci of infection do not become extinct. It may beoome 
endemic in limited circles, as asylums, schools, boarding-houses. In 
many towns, certain houses are known as diphtheria houses; a great 
many cases occur in them, or they form the starting-point of new epi« 
demies. Such houses often have a bad site, imperiect disinfection of 
privies, stagnant water, close, unclean, crowded rooms, etc. Such con- 
ditions seem suited not perhaps to generate diphtheria originally, but to 
favor its multiplication, and perhaps to make the inmates more subject 
to the influence of it. 

Epidemics are not dependent on the season of the year, climate, or 
weather. Cold weather, variable temperature, and changiuK winds 
scarcely favor the spread of the disease except by inclining the throat to 
inflammation, whereby the action of the poison is assisted. For the 
same reason, the disease is found in temperate and sub-tropical countries 
oftener than in the tropics. 

The age has great influence on primary diphtheria. Children be- 
tween the ages of two and seven are most commonly attacked, and the 
tendency diminishes every year thereafter. Nursing children seldom 
have it; mothers with dipntneria have even been allowed to continue to 
suckle their infants — though I have known of a mother infecting her 
new-bom child. 

Sex has little influence; in later childhood, boys are said to be oftener 
attacked. 

The disease occurs oftener in the lower classes; yet victims have been 
repeatedly taken from princely houses within a few years past. 

On Attack does not protect from the second; a repetition is more the 
rule than the exception. Many have a permanently or temporarily in- 
creased predisposition, while others are strikingly exempt. Hyper- 
trophy 01 the tonsils causes an increased tendency. 

The mode of infection is often unknown. Diphtheritic products 
certainly often contain the virus; but since occupancy of the same room 
is sufficient to communicate the disease, we must assume that the pa- 
tient's exhalations are contagious. Schools, boarding-houses, play- 



DIPBTHEBU. 

groTindB, etc., t&vor the spread of the disease. Lifeless objects, and ^ 
probably also interniediate persons, may carry it. Food from infected 
places, e. g., milk (Klebs), has often spread the disease. It occurs in 
Bnimala (hens), and Lutz and Limmer report its transference to men; 
Gerhardt and Seeber state the same. 

It is a much debated question whether the infection begins in the 
faaces, in a purely primary form, becoming generalized afterwards, or 
whether the reverse is the cafie. An unprejudiced clinical study shows 
that both methods occur, for severe general symptoms often precede the 
local disease of the tonsils by days, while in other cases— in my experi- J 
ence more rarely — the reverse occurs. It is not impossible that these two 1 
conrses represent different poisons. A primary generalized affection I 
may represent infection through the respiratory tract or the gastro-in* | 
testinal tract, by eating infected food or by inhaling the air of a sick- i 
room. The frequency with which the tonsils are attacked may be con- 
nected with the fact discovered by Stohn, that there are spaces in the I 
epithcliu! coat through which a continual passage of amceboid cells nor- j 
mally takes place. 

Of thenatureotthediphtlieriticpoiBon nothing MTt^nieknown. ItisBUspected 
to consist ot achizoDiycetea, wbichare certainly found in tbeproducta; but among 
the man; tornis of fungi it is verj hard to And the right ones. Klebs attempted 
to distinguiah two varieties of throat diphtheria hotanicallj', which he called the 
niicrosporineand the bacillHrv forme. They differ also clinically. Lflffler, a pro- 
found student of th» subject, ia inclined to see the fungus in certain bacilli which 
Areabout as long as tubercle bacilli, but twice as thick. They are often composed 
of several members, bent or Btraigbt. Slizht knotty tbicke in)^ are often seen at 
the iHiints of contact. The ends of the rods are stained more deeply with nlfcalina 
solution of methylene-blue than the other parts. LofiQer cultivated this fungus 
purely, and auccessfullj transplanted it to animals. 

Secondary diphtheria of the throat is a consequence of inleotiouBdia-^ 
eases. It is most frequent in scarlatina, but occurs in measles, Qer-'l 
man measles, whooping-cough, typhoid fever, small-pos. and erysipelas, 1 
LSEHer has shown that in scarlatinal diphtheria of the throat t'he same>l 
or^nisma are found as in primary diphtheriu, but it is not certain that I 
this is always so. The nature of secondary diphtheria of the fauceat 
needs further study. 

In what follows, only the primary affection is discussed. 

II. Symptoms. — The incubation period usually lasts from two lol 
seven days. A longer period than this is commoner than a shorter | 
one; many estend it three or four weeks. 

The first symptoms may be general or local, or both. In either case | 
they may begin violently or gradually and insidiously. 

In children, a very sudden high fever(over 40° C.) is not uncommon, 
with all its preliminaries and concomitante: cold, livid skin, shivering or 
rigor, vomiting, convulsions, delirium, loss of appetite, thirst, etc.; ou 
the next day. the fever is less or has gone, the d]agn(^8is of ephemera is 
made, find ascribed to errors of diet, but diphtheritic chungeAof the 
fauces appear at the same time or soon after. It is therefore a duty to 
examine the throat with great care whenever such symptoms occur. 

As a warning example of the treacherous course ot the disease, I give 
an account of a case that I lately saw in consultation. A strong boy of 
four years, ill for a week. No special complaint except slight shivering. J 
Appetite entirely gone. Pallor and loss of strength increasing. Sleeni- j 
For twenty-four hours, very feeble heart-soands, with irregular 



^Um. f 



374 DIPHTHSBIA. 

rhythm; striking want of fulness of pulse. Cause unknown. At the 
consultation^ all the throat and part of the tonrae and cheeks were seen 
covered with a thick diphtheritic layer. Deatn occurred in ten houra 
with symptoms of paralysis of the heart. Thus, in throat-diphtheria, 
local trouoles may be absent; and it is a gross error to omit examination 
of the throat when there is no pain or difficulty in swallowing. 

Among local subjective symptoms, the commonest is trouble in swal- 
lowing, usually accompanied by pain in speaking. Others have lesspaia 
in swallowing than in moving the lower jaw. The pain is located by the 
patient, not back in the throat, but lower and close behind the angles ot 
one or both jaws. It often reaches to the region of the ear. Swollen 
lymphatic glands are sometimes felt behind the angle of the lower jaw 
which are sources of pain. I have treated patients in whom a change in 
the voice to a nasal tone was the only thing noticed, and was the reason 
for calling the physician. 

Symptoms of laryngeal croup, originating in latent throat-diphthe- 
ria, sometimes take the first place. 

Among the objective symptoms, those of the throat are the chief. It 
is possible that in severe constitutional infection a patient may die be- 
fore the throat-lesions are developed; in such an event it would not be 
easy to make the diagnosis. 

The affection of the throat is not always the same. The lightest form 
is catarrh of the fauces, which differs little from the ordinary sort, and 
may be diffuse, or limited to spots. The specific nature of this catfyrrh 
is evidenced by the existence of previous exposure to contagion and the 
power of communicating diphtheritic diseases to others. In the catarrh, 
swelling may be a prominent symptom; or redness; the secretion is not 
usually prominent. In circumscribed catarrh, the pain is usually limited 
chiefly to the diseased place. I have noticed that some persons seem to 
have a sensitive spot in their throats, to which, in subsequent attacks, the 
catarrh is apt to return. The catarrh is often only the precursor of 
further changes; in other cases, it disappears. 

A second sort of throat-diphtheria consists of circumscribed superfi- 
cial diphtheritic deposits. They are yellowish or grayish spots, very 
often confined to the tonsils, but also affecting the palate, posterior wall 
of the pharynx, and uvula. I have repeatedly seen them appear first on 
the tip of tlie uvula. They often originate in the follicles. They can 
usually be wiped off easily with a brush or the finger wrapped in a cloth, 
leaving slight loss of substance, if any; the base of the excavation being 
often tallowy-gray, and the edge usually sharp and very red. The de- 
posit, under the microscope, consists chiefly of epithelial cells, schizomy- 
cetes, and a few round cells. The coating may re-form in a surprisingly 
short time. In a certain case, where I most carefully cleansed the spots 
every hour by pencilling with carbol-glycerin, I often found the deposit 
after twenty minutes as heavy as before. 

Dif^se deep throat-diphtheria usually proceeds from the preceding 
form. The spots grow in size and become confluent; at the same time 
they become thicker and are harder to remove. They may extend so 
deeply in the tissue as to pierce the soft palate, uvula, or hard palate; or 
the uvula or tonsils may become separated, perhaps causing very danger- 
ous hemorrhage. Deep scars may be left after recovery. The micro- 
scope exhibits an abundance of round cells in the diphtheritic mass, in 
adaition to the elements above named. 

The parts affected sometimes become a brownish, fetid, soft, and 



DIFHTHEBIA. 375 

palpy mass. The stench is such that the diagnosis of septic diphtheria 
can almost be made with the nose. Extensive gangrene of tne parts 
around may originate in the diphtheritic parts. 

Swelling of the submaxillary lymphatic glands is usually observed in 
all forms ox diphtheria; those behind the angle of the lower jaw are most 
constantly swollen and nainful^ forming a sympathetic bubo, i. e., one 
dne to absorption of products of diphtheritic inflammation by the lym- 
phatic vessels and the nearest glands. They prevent the motion of the 
]aw, make movements pf the head difiScult, and if confined to one side 
may cause a sort of wry-neck. Absorption is usually complete after the 
diphtheritic process is past; suppuration is exceptional. 

In many cases, all the submaxillarv lymphatic glands take part in 
the inflammatory swelling; the cervical cellular tissue may also take part, 
forming beneath the jaw a diffuse swelling, as hard as a board, and 
usually of an alabaster color. This condition is dangerous in more than 
one way. It interferes with the opening of the mouth, and is an impedi- 
ment to treatment. Compression of the air passages may cause danger 
of suffocation. There may be tedious suppuration and gangrene, ero- 
sion of large vessels and death from hemorrhage, fistulous formation 
leading into the mediastinum and serous cavities, etc. Finally, rapid 
death irom oedema of the glottis may occur. 

Diphtheritic changes have often extended to neighboring mucous 
membranes. The nose is affected rather frequently. The nostrils become 
stopped up, so that the patient has to breathe through the mouth; the 
false memorane is sometimes blown out, and may even be seen from out- 
side; but a specially characteristic feature is the discharge of a putrid, 
almost stinking, li^ht brown-red ichor from the nose, excoriating the 
upper lip and causing erythema and oedema. 

The diphtheritic change sometimes attacks the mucous membrane of 
the nasal duct and the conjunctiva* in the former case producing epi- 
phora, and in the latter being obvious to view. This complication is 
yeryserious, and may cause loss of sight. 

The Eustachian tube, tympanic cavity, and even the external meatus 
are often attacked; the symptoms are deafness, subjective noises, severe 
pain in the ear, and often increase of the bodily temperature. This may 
cause loss of hearing, extensive suppuration of bone, thrombosis of 
sinuses, meningitis, and brain-abscess. 

Extension to the respiratory passages usually causes symptoms of 
laryngeal croup. 

The oesophagus and the mucous membrane of the stomach and intes- 
tine are seldom diphtheritic; the mucous membrane of the genitals is 
sometimes affected, perhaps by auto-infection. 

Wounds easily assume a diphtheritic coating; this often occurs in 
children when the mouth has been forcibly opened, causing injury to 
the lips, gums, tongue, or hard palate. Bhagades of the lips are some- 
times covered with false membrane. Slight injuries, as leech-bites or 
blisters, may undergo the same change. ^ 

During epidemics, diphtheria of wounds may appear in persons otherwise 
unaffected; the throat-disease may appear subsequently. 

The general symptoms do not always agree with tha local. We must 
especially avoid the error of supposing that cases with slight visible local 
disease are always light. 



S76 DIPHTHEBIA. 

The bodily temperature hardly ever fails to be elevated, thongh not 
always to the same degree; in some, rising far above 40°; in others, bat 
little above 38° C. There is no special type in its course. Low temper- 
atures are not by any means a' favorable sign; the septic forms of ten have 
low temperatures, though there is severe general infection, due to ab- 
sorption of putrid diphtheritic masses, with almost always fatal 
results. The temperature of collapse is not rare, and is, of course, un- 
favorable. 

The pulse often corresponds with the temperature. Intermission, or 
unusual retardation (as low as 50) may occur, and is always a bad si^ 

There is quite often a moderate swelling of the liver and spleen, with 
sensitiveness to touch. 

Advanced leucocjtosia is sometimes found in the blood. Micrococci have been 
repeatedly found in the blood, first by Hueter and Tommasi-Crudeli. 

The course is usually acute; the matter is usually decided by the enn 
of a week, or at the furthest, two. Some cases are subacute; I naye seen 
two that lasted eight and ten weeks respectively. 

Complications are not rare. Those due to transference of diphtheria 
to other mucous membranes have been mentioned. Others may be con- 
sidered in part as metastases — the poison being carried to other organs 
by the blood and animal fluids. 

Painful swelling of the salivary glands may occur, and salivation 
remains as a sequela. 

In many cases, there is repeated vomiting, either at the beginning or 
continued through the disease. Diarrhoea sometimes occurs, hard to 
control, and increasing the danger of collapse. Peritonitis has occurred. 

Albuminuria is not unusual, often appearing during the first few 
days; its significance varies. If slight, transitory, and limited to the 
period of fever, it is simply febrile albuminuria. If independent of 
fever and marked, and associated with tube-casts and round cells, epi- 
thelium from the urinary canals, and red corpuscles, it indicates nephri- 
tis. The amount of blood in the urine is sometimes so great that its 
presence is shown by the color. HsBmoglobinuria and haematinuria 
(Salkowski) also occur. Acute nephritis may be accompanied bv a 
greater or less amount of anasarca, but this is not common — much less 
common than in scarlatinal nephritis. Anuria is sometimes associated, 
but uraemia rarely. 

Cloudy opacities have been repeatedly foimd in the urine, composed of 
Bchizomycetes — the same have been described as forming a layer on kidney- 
casts. These things should be understood, as injurious seminal losses are a possi- 
bility. 

There are sometimes very threatening heart complications. The 
sounds of the heart are soft, weak, the first sound seems muffled, the apex- 
impulse diminishes in force, the area of dulness rapidly enlarges, espe- 
cially to the right, the action of the heart becomes irregular, and often 
very slow, and at last death occurs from paralysis of the organ. 

Endocarditis, pericarditis, and pleurisy are rarer. 

Death by asphyxia may occur if the muscles of respiration become 
palsied and expectoration is insufficient. Central disturbance of inner- 
ration may make the breathing irregular and sighing. 

In many cases, sudden attacks oi iA\x\V\\i^ wi^ux, %oxiLetimes causing 



DIPHTHEBIA. 877 

death directly. They are apt to take place when the patient rises qnicklyy 
or sits up to perform the offices of nature^ while in a weak condition. 
The cause is doubtless weakness of the heart and consequent anaemia of 
the brain. 

Dangerous hemorrhage may occur, e, g., from the nose, or when 
sloughin? of the throat has opened blood-vessels. There may be symp- 
toms of dissolution of the blood — hemorrhage under the skin or in many 
of the mucous membranes. In complicating endocarditis, cutaneous 
hemorrhages may be caused by embolism. 

There are certain changes of the skin of less importance. In many 
cases, extensive erythema is one of the first symptoms, reminding us of 
scarlatina. There may be exanthemata like urticaria or (more rarely) 
papulo-pustular forms. Gangrene of the skin is much more serious. 
±SrysipeIas of the face has been seen. Erythema nodosum occurs as a 
sequela. Galimani states that he has found diphtheritic alterations of 
the bed of the nail, which he considers an absolutely unfavorable symp- 
tom. 

Swelling and paia of the joints are rare; in my own cases, the knee 
has been anected, but the small joints of the fingers and toes have also 
been attacked not infrequently. Acute articular rheumatism mav be 
fully presented. In a case of mine, acute endocarditis with mitral in- 
sufficiency followed it, and during a second attack of diphtheria a year 
later, polyarthritis occurred again. 

Complications and sequelae are not always easily separated, and may 
pass imperceptibly into each other. Ansemia, with obstinate loss of 
appetite, often remains, and in spite of all care, continued it may be for 
weeks, death from exhaustion is unavoidable. 

Acute nephritis may either form a regular sequela, or the inflamma- 
tion accompanjring diphtheria may outlast the latter disease. 

Especial attention is due to post-diphtheritic paralysis, affecting 
single viscera, or the muscles of the trunk or extremities. It usually ap- 
pears in the second or third week after the disease, or even later; it 
fipecially affects adults, children between two and six being more rarely 
attackeu. 

Paralysis of the palate is common, known by the nasal voice, immo- 
bility of the hard and soft palate during swallowing and speaking, and 
by things swallowed coming out at the nose. 

The e}e often suffers, especially as to the apparatus of accommoda- 
tion. The patient loses the power of reading oi: seeing clearly close at 
hand, and according to Jakobson's observations, hypermetropia increases. 
Both sides are almost always affected, though one eye is often worse than 
the other. Paralysis may appear quite suddenly, or may be observed 
accidentally at school in reading or writing. It is often combined with 
paralysis oi other parts, and lasts weeks or months. Gradual improve- 
ment, and at last recovery, almost always follow. 

Donders remarks that the pupil is often remarkably dilated, and reacts well to 
the stimulus of light, but slowly to chauges of accommodation. Bilateral para- 
lysis is probably of a peripheral origiu. 

Single muscles of the eye are sometimes paralyzed, and the affection 
often skips from one to the other muscle or eye. " Bilateral palsy is rare 
(Uhthoff, Mendel). 

Neuro-retinitis and atrophy of the optic nerve are said by Bouchut to 



878 DIPHTHESIA. 

oconr under the influeuce of diphtheria. Amblyopia and transitory 
amaurosis are mentioned^ probably connected with nephritis. 

Paralysis of the (Bsopbagus sometimes occurs, causing great diflScuIty 
in swallowing; the patient has to be fed through a sound. 

Paralysis of the superior and inferior laryngeal nerves is more fre- 
quent, in the case of the latter, paralysis may be restricted to distinct 
groups of muscles— as the posterior thyro-arytenoids or the aryepiglotticL 
Paralysis of the latter is easily recognized by failure of the epiglottis to 
cover the larynx in swallowing, so that food enters the larynx. If the 
mucous membrane of the larynx has lost its sensitiveness by puralysis of 
the inferior laryngeal nerve, coughing does not occur, and the foreign 
substances mav enter the lungs, causing a variety of pneumonia, with 
gangrene or abscess of the lungs. 

Sometimes only those fibres of the vagus are paralyised which preside 
over innervation of the bronchial muscles or the heart. In the former 
case, the secretions may accumulate and suffocate a patient; in the latter, 
paralysis of the heart may cause death. Heart-failure may proceed from 
changes in the heart muscle also. 

Paralysis of the phrenic nerve, if double, causes certain death by suf- 
focation. 

Paralysis of the vesical and rectal sphincters may occur. Sexual 
impotence (virile) has been described (GuiUemant). 

Paralysis of the extremities sometimes affects single muscles, some- 
times entire limbs. The facial nerve may be paralyzed. Paralysis 
often ascends from the legs to the face, and may then be accompanied 
by severe anaesthesia. Cerebral hemiplegia, sometimes associated with 
aphasia, is rare. 

The electric test for excitability often proves that the paralysis is of 
peripheral origin, but central disease may also be the cause. 

These paralyses almost always recover, though months may elapse. 
Besidual paralysis is not common, and is usually associated with atrophy. 

Loss of the patellar reflex sometimes occurs long after recovery, and 
lasts a half a year or more. It may be confined to one side. Acute 
ataxia is not rarely developed in addition, connected with anaesthesia of 
the lower extremities and tottering when the eyes are shut, and may 
copy acute tabes dorsalis so closely that it might be mistaken for it in 
adults if the history were unknown. E. Bemak properly states that re- 
flex rigidity of the pupil (see Vol. III., p. 109) is absent. It is not 
known whether this is due to changes in the posterior columns of the 
cord. 

Mania (Minot), epilepsy, chorea, and valvular lesion are rare sequelae. I do 
not know from personal ot^rvation whether kidney diseases become permanent. 

III. AKAToanoAL Changes. — Numerous hemorrhages are very often 
found in the serous membranes, and in a ^reat many other parts. 

The muscles are sometimes very pulpy in consistency and dull yellow, 
and the microscope shows granular cloudiness and advanced fatty 
change. 

Extensive changes are sometimes seen in the lymphatic glands: 
swelling, hyperaemia, and bleeding. Micrococci have repeatedly been 
found in the lymph-spaces, and Bizzozero has found small necrotic foci. 

The blood is sometimes of a brownish color, thin and fluid. Increase 
of the number of colorless corpn^e.^ and micrococci have been observed. 



OIPHTHEBIA. 

The heart Caritiee aro BometiineB much dilKted, and the tisBQe Ikx^ 
%e right auricle especially may contain thrombi ailborent to the walls, 
which may cause emholism. In spots, the heart-muGcle is dull-yellow, 
from fatty change of the fibres. With the microsc^ope, we often find 
extensive changes: groups of microcooci, fiasiiring of laiiBCular Hbrea, 
Zenker's degeneration (BoBCubach), proliferation of uuclei id the mus- 
cular fibres, and ilisappearance of muscular aiibatauce with deposit of 
pigment (Leyden), On the endocardium, fresh iailammatory cbaugee 
are sometimes seen. Klebs found interstitial changes in the lungs. 

The changes in the spleen are like those in tJie lymphatic glandi 
The liver has been found fatty. The gastro-mteatinal tract often hf 
swelling of the lymph follicles, sometimes forming small ulcers. 

The kidneys vary much according to the period, the severity of the' 
disease, and the character of the epidemic. They mav b^ of normal 
size, or swollen aud enlarged. They arc soraetimea thicKly'dotted with 
hemorrhages; at other times they are pale aud gray-yellow. In the 
lightest cases, the changes seemed con&ued to granular cloudiness of the 
epithelium cells of the convoluted tubes. If the disease progresses, inter- 
stitial changes are added. In the uriuary canals of the meduliarv sub- 
stance free desquamation of the epithelium, and in places dilatation of 
the canals occur. Hwelling and multiplication of the epithelial celts 
and nuclei of Che vascular loops in the Malpighian capsules also occur. 
Extensive fatty degeneration with increasing intersti tii^ nuclear prolifera- 
tion finally appears. 

8chiEDia;-cet«8 have been repeatedlr described in the blood-vessels, Malpi^l 
hian capsulea, and urinary cacale, and the connection between throat-dipliiheriA V 
and nephritis baa beea supposed to be that tlie kidaej, in the act of excretion of t 
the parasiteH, Bulfnred irritation of itn tigaunn. FQrbrijiser dooa not cootirm this. 

In the brain and cord, meningeal and pjrrenchymatoua bleeding is 
not rare. The microscope shows more, alebs found the adventitiouBfl 
lymph-aheaths of the vessels full of schizomycetes, while in the cord 
r)^jerine observed an accumulation of colorless corpuscles in the e 
places. This author states that in the spinal cord swelling of the gaa-J 
gliou cells of the anterior cornua, disappearance of the procesees, aum 
finally destruction of the ganglionic cells, and nuclear proliferation in tha 
neuroglia of the gray substance take place, and ore the cause of para 
lysis. 

In the majority of cases, the palsy is probably due to changes in thofl 
peripheral nerves, which may be quite extensive, as in one of Meyer'aT 
cases. Parenchymatous degeneration and atrophia appearances are^ 
sometimes associated with multiplication of nuclei, formation of fat- ' 
granule cells, and vascular dilatation in the interstitial tissue. I'. 
Meyer also described nodose thickening of the nerves — neuritis nodosa. 
Leyden showed multiplication of nuclei in the paretic muscles of the 
palate, with atrophic wasting. 

The diphtheritic deposits consist in advanced cases of a fibrinous exu- 
dation, inclosing remains of epithelial cells and schizomycetes of many 
shapes aud sorts, extending to a varying depth in the tissue beneath the 
epithelium, and set off from the sound tissue by a layer of colorless 
blood-corpuscles. There is a good deal of extravasation. LOfflor'a 
diphtheria bacilli are found arranged in little groups somewhat below 
^^kB surface of the membrane, surrounded by numeroaa cells; they never . 



nd 

B8, "r 

jee J 

m 



880 . DIPHTHBBIA. 

work into the tiasue of the mncoiis membrane^ and hare not been 
demonstrated in other organs. * 

IV. Diagnosis. — The presence of the membrane leaves no^ doubt; 
but the catarrhal form can be interpreted as diphtheria only daring epi- 
demics. 

Nephritis or specific paralysis sometimes enables as to infer previoas 
diphtheria. Membranes caused by irritants are known by the history. 
Angina herpetica (Vol. IV., p. 134) is not usually hard to distinguish. 

V. Prognosis. — We must in all cases be very cautious; in spite of 
slight local disease, the most dangerous complications may suddenly 
arise. Local and general symptoms do not always correspond; yet 
extensive local disease, and especially implication of the wall of the 
pharynx, implies severe cases. Septic and gangrenous cases are almost 
absolutely unfavorable. The jounger a person and the weaker the con- 
stitution the worse is the situation. Every complication makes the 
prognosis worse, especially croup or laryngeal diphtheria. The connec- 
tion with extensive nasal diphtheria seems equally fatal. Abundance of 
albumin in the urine is unfavorable. The prognosis is essentially de- 
pendent on the character of the epidemics, some of which give fifty per 
cent of deaths. Sporadic cases are usually lighter than epidemic cases. 

VI. Tkeatment. — The strictest isolation of patients from well per- 
sons must be carried out. In epidemics, all persons with apparently 
simple catarrhal angina must be excluded from school and from general 
intercourse, and must be considered diphtheria patients. After recovery, 
no one may resume intercourse with the worla before the clothes and 
bedclothes have been disinfected ; the sick-room must be disinfected 
also. 

Family physicians should have patients teach their children when 
quite young to let their throats be sprayed, and to gargle. I know a 
number of cases in which children were the first to discover their own 
disease, and know of others in which medical treatment was rendered al- 
most impossible by the refractory conduct of the children. Permanent 
enlargement of the tonsils ought to be relieved by excision as early as 
possible. 

Pliysicians must look out for themselves, especially if they have cuts 
on the hands. If diphtheritic material has been injected into the eye, 
they must at once wash it thoroughly with disinfectants. 

The removal of patients to wholesome and unsuspicious quarters often 
has astonishingly good and speedy results, but circumstances do not 
often allow it. 

The food should be exclusively liquid, and nourishing: lukewarm 
milk, egg, meat-soup, beer, and abundance of wine, which is the most 
trustworthy agent for relieving the general symptoms. Spray the throat 
carefully once an hour with salicylate of soda ( ? ss. : 3 vi.); if the nose 
is affected, irrigate it from in front, at the same interval. Keep the 
patient in bed, let him always use a bed-pan, and avoid quick movements 
on sitting-up. Otherwise, purely symptomatic treatment. 

There are a great many treatments and views about treatment. We mention 
the following, a. Disinfectants — carbolic acid, salicylic acid, salicylate of soda, 
benzoate of soda, permanganate of potash, creasote, iodoform, sulphur, sub- 
limate, arsenic, etc., for i)encilling, insufflation, gargling, parenchymatous in- 
jection into the tonsils, or internally, b. Caustics— sulphate of copper, muriatic 
acid, chromic acid, chloride of zinc, etc. c. Astringents — acetate of lead, sub- 
nitrate of bismuth, nitrate of silver, tanmu, «\wm, ^\*i. d. Balaams — turpentine. 



DIPHTHEBIA. 881 



cabebs, oopaiba, eucalyptus, etc. e. Antiphlogistics— bits of ice to swallow, ice- 
cravat, inunctioa of mtfrcurials, calomel, leeches, f. Bromine and iodine prepa- 
rations—their vapors for inhalation, iodide of potash mternally, tincture of iodme 
for pencilling, g. Solvents of the membrane — lime-water, lactic acid, neurin, 
pepem, trypsin, papayotin, tetramethylammonium-hydroxyl, tetramethylen-am- 
monium-hydrozyl, etc. h. Chlorate of potash internally and as a gargle, <j[uino- 
line, pilocarpine, peroxide of hydrogen, inhalation of caustic ammonia, i. 



Elmetics. 



2. Laryngeal Diphtheria. 



{Diphtheritic Croup, Angina Membrancea, A. Lartpigea. A, Polyposa, 
Cynanche Stridtua, Laryngitis Fibrinosa, L, Croupsa.) 

I. Etiology. — Croup includes every fibrinous inflammation of the 
laryngeal mucous membrane, which leads to the formation of superficial 
fibrinous membranes, usually removable without loss of substance. 
Laryngeal croup is not always diphtheritic in origin, i. e., caused by the 
diphtherial fun^s; it may be produced by chemical or thermic irrita- 
tion. The diphtheritic and the non-diphtheritic agree closely in their 
symptoms, which point to increasing stenosis of the larynx. The fol- 
lowing description relates to the diphtheritic form alone. 

The two sorts, primary and. secondary, must be distinguished^ but 
the latter is of the chief importance, and many authors even deny the 
existence of the other. 

Secondary laryngeal diphtheria is most frequently a sequel of throat 
diphtheria. The affection of the throat may be very insignificant, some- 
times involving only the posterior surface of the uvula or the higher 
part of the posterior wall of the pharynx, where it is not seen, and hence 
the disease of the larynx is conisidered as primary. The younger a child 
is that is attackea by throat diphtheria the greater the danger of 
laryngeal diphtheria as a secondary affection. 

Trendelenburg and Oertel have proved that diphtheritic poison may flourish in 
the mucous membrane of the larynx; Li6ffler found diphtheria-bacilli in the 
deposits. In man. the affection is chiefly due to transference of inflammation 
from the throat, but accident may come in play, as aspiration of diphtheritic 
membrane, or the flowing down of secretion into the larynx. 

The disease sometimes accompanies other diseases, chiefly measles; 
but it may also follow scarlatina, whooping-cough, pneumonia, typhoid 
fever, relapsing fever, varicella, variola, cholera, and pysBmia. 

The rarer, primary form, is more commonly sporadic than endemic 
or epidemic. The epidemic occurrence of primary diphtheria of the 
larynx, in the absence of throat-diphtheria, has led many to believe that 
the two diseases had different causes. Primary diphtheria of the larynx 
is said sometimes to extend to the throat; hence the distinction drawn 
between ascending and descending diphtheritic croup. 

Telluric and climatic influences often have a distinct action upon 
primary diphtheria of the larynx. Thus, its frequency increases in pro- 
portion to the distance from the poles. It is much commoner in winter 
than in summer. Great dampness of the air, and prevalence of east and 
north-east winds, favor its development. Low, marshy spots are con- 
sidered its breeding places. It is frequent in coast-lands, sea-ports, and 
river-flats. 1 1 is very common on the coasts of Scotland, England, 
France, and Holland, the Baltic sea-coast, in many towns on the Swiss 



882 DIPHTHKRIA. 

lakes^ as Ckneva^ and in certain parts of Switzerland and Savoy. Craw- 
ford aiates that it used to rage fearfully in certain marshy regions of 
Scotland^ but became much rarer after drainage was introduced. 

The primary and secondary forms are distinctly children's diseases^ 
and attack most frequently those from the second to the seventh year. 
Before thj9 end of the first year it is rare, though Bouchut has described 
a case in a child a week old. Adults are only exceptionally attacked. 
The reason for this exemption is unknown; perhaps tne epithelium cells 
of a child's larynx are less resistant. 

Boys are attacked oftener than girls; according to Buhle, in the 
ratio of 3 : 2. 

The constitution has some influence. It is not true that the healthiest 
children are of tenest attacked; but scrofulous and ricketty children— or 
children whose parents were old, or phthisical, or marastic— are often 
attacked. 

Hereditarv influences are said to have been obserred in many fami- 
lies, several children of one family being attacked within a imther long 
period of time, but this hereditary influence may be interpreted as a 
predisposition to this class of diseases. The same is true oi the state- 
ment that children with moist eruptions of the skin often bqBbt with 
croup when the exanthem is cured. 

II. Akatomical Changes. — They are almost alwavs equivalent to 
those of croup in the anatomical sense; consisting of a formation of 
coasrnlated fibrinous exudation on the surface of the mucous membrane. 

It very rarely happens that such a formation does not occur if the 
svmptoms of croup exist during life; it is assumed in such a case that 
tne mass is expectorated shortly before death. 
. The consistency of the exudation varies from that of thick, creamy 

Jius to that of a hard, firm membrane; thelatter may be four millimetres 
hick. 

At first there is usually a layer like hoar-frost, or lumps of casein, 
in spots over the mucous membrane; the spots coalesce, and form larger 
ones, which may line the interior of the whole larynx, and extend to the 
trachea and bronchi. The membranous character is wanting, and the 
consistency of thick pus prevails only in the finer bronchi. 

The process usuallv begins on the posterior lower surface of the epi- 
glottis, extends laterally over the inner surface of the ary-epiglottic folds 
and aiytenoid cartilage, and thence enters the larvnx. if the exudation 
is diffusely distributed, it is usually thickest on the posterior wall of the 
larynx. 

The exudation is usually yellowish or yellowish-gray; rarely dirty- 
gray, or greenish-gray, or brownish-black. It can almost always be easily 
removed without loss of substance, the under side often showing points 
and streaks of blood. The layers that lie next to the mucous membrane 
have the least consistency. The removal is most diflScult where per- 
manent epithelium exists, that is, on the true vocal cords. The mem- 
branes are quite loose in the air-tubes, whence they can often be with- 
drawn with the pincette in the form of long tubes. 

Chemical examination shows that the false membranes consist of an albumin- 
ous substance resembling the fibrin of the blood. Thev swell in concentrated 
acetic acid or fiuid ammonia, dissolve in solutions of alkalies or saltpetre, lime- 
water, or lactic acid, but are insoluble in mineral acids and cold or boiling 
water. 

The microscope exhibits a basement substance, partly amorphous, partly 



DIPETHEBIA. 

_Q which round celte are distributed. Thecella lie innesta or rowB, insucl 

kway as to form a sort of alternation of cell-containlag Euid cell-less layers. A fen 
red coruuBclea are seen. 

On the mucouB membrane, the epithelium Is cone, and more or leas recogni& 
able parts of it cling to the false membrane. Wagner &nt described a peculiar 
enelling and change of tbe epithelial cells, which he called croupous metamor' 
phosis. He inferred that the membranes originated chiefly from this metamor- 
phosis, and were, so te speak, an epithelial product. This view has been much 
contested, and most authors proper! v assume that the fibrjnoua mass of exudation 
comes from blood-Tessels, the fibrin being at first fluid and aft«rwards coagulating 
on the surface of the mucous membrane. 

Weigsrt's lat« researches show that the epithelial cells of the mucous membrane 
have some influence upon the processof coagulation, since that cannot take place 
onleee the epithelium first perishes and enters the coudition called coagulation- 
necrosia. A coagulated esudalion. therefore, is not formed unless chemical or 
"lerniic influences (non-diphtheritic croup) or schieomycetes (diphtheritic croup] 

ITolve the proteotmg epithelial coat and cause coagulation-uecrosia. 



^HP tb uuHcnuiug Lue HUHi:Uiuiciti prucesHes, we uave uui.i<;ipuLeu luu ttubUKi ■ 

^^conrse of events, for croupous changes in tbelarjnx do not begin aasuch, h^^ 

1 in>^^H 
con^^^l 
tbeT^H 
false ^^ 



In dGBcribing the anatomica! processes, we hare anticipated the actual 
. .mrse of events, for croupous changes in tbelarjnx do not begin aasuch, 
but always have an initt^ catarrhal stage. Redness, swelling, and in- 
creased secretion, and sometimes bleeding, are the chief signs, and they com 
tinue even after false membrane begins to form. (In the dead body tbej 
often disappear. ) These conditions tend to raise and throw oS the false 
membranes from their bed by the formation of fresh layers underneath ; 
if the latter coagulate, the result may be a Btrati6ed false membrane. 

If favorable changes occur, the deposits are sometimes expectorated 
as such, sometimes undergo gradual liquefaction, which facilitates expec- 
toration. A catarrhal after-stage remains, ending in recovery. 

Loss of substance and cicatrization of the mucous coat are very rare. 

Changes may be found in many other organs after death. The throat 
is the chief seat of diphtheritic affections. Croupous processes occur in 
other organs — as the (esophagus, and even the stomach. The lungs are 
hardly ever unchanged. Collapse, pneumonic changes, emphysema (es- 
pecially of the borders), interstitial pneumonia, sub-pleural ecchymoses, 
and oedema are variously combined. The lymphatic system is almost 
always involved; swelling and hyperaemia of the snbmaiillary, cervical, 
tracheal and bronchial glands, and in the glands of the mesentery, 
swelling of tbe intestinal follicles, and enlargement of the spleen are 
Tery often observed. 

The corpse often presents appearances found in suffocated persons. 
The right heart and all the veins are full of blood, and there is venous 
bypenemia in almost all the organs, There are also very fretjuently small 
extravasations iu many of tbe viscera, and in the serous cavities there may 
be acoumijtations of bloody transudations. 

III. Stmptous. — Tbe characteristic symptoms seldom appear sud- 
denly, but are usually preceded by warnings for some days. The child 
ia fretful, will not play or eat; there ia a little fever, sometimes repeated 
shivering; signs of conjunctivitis, or cold in the head or larynx, appear, 
the latter accompanied by cough, tickling, and hoarseness. If throat 
diphtheria precedes that of tbe larynx, the child complains of pain in 
Bwallowiiig or moving hia head, the latter owing to painful swelling of 
the submaxillary lymphatic glands; or at any rate, redness, swelling, or 
false membrane in the throat. The more extensive a throat trouble ia, 
the greater the danger of secondary affection of the larynx; if there aral 
deposits on the uvula, palate, and back of the tliroat, the case 



4 



■an ou 



I 



384 DIPHTHEBIA. 

The special characteristic of the disease is the narrowing of the laryn* 
geal passage, which does not become manifest until the gbttis is impli- 
cated; the enemy may lurk concealed until the latter occurs. The first 
symptoms of such contraction, in the primary affection, usually appear 
about eyenin^ or midnight; in the latter case the child often wakes with 
the cry that he is choking. The breath (especially the inspiration) is very 
difficult. Inspiration is very slow, and accompanied by a peculiar whin- 
ing, sawing, or whistling sound, called the stndor of croup. It can often 
be heard at a ffreat distance, and has some pathognomonic value, though 
it occurs in other forms of stenosis. Expiration is usually free, short, 
and impulsive. 

The dyspnoea is indicated in the position of the body, and implication 
of the auxihary inspiratory muscles. 

The child cannot usually lie on his back, bnt sits up. He often de* 
sires to change his position; now to be raised on the arm of the nurse; 
now to be put back in bed; or he grasps a fixed object with his arms, or 
plucks at tne tongue and neck to remove the obstacle. Just before each 
inspiration the nostrils dilate. The head is bent back at each inspiration, 
the tongue thrust out of the open mouth, and the larynx descends deeply, 
rising again during expiration. The neck muscles and extensors of the 
back contract, to aid the efforts of the chest, and the large chest-muscles 
make vigorous efforts. 

The degree of djspnoaa may be nearly estimated by the way the soft 
parts of the chest sink in during inspiration. This is due to the expan- 
sion of the thorax not being f ollowea by that of the lungs. We see the 
superior clavicular fossa and the jugular fossa sink in at each inspiration. 
The intercostal spaces sink, especially the lower ones. In like manner 
the lower costal cartilages and the lowest part of the breast-bone are 
drawn in deeply, so that the ensiform process may come within a few 
centimetres of the back-bone. This is due to traction exercised by the 
attachments of the diaphragm, which cannot contract downwards, but 
is compelled to follow the suction of the chest. A deep furrow may form 
around the lower part of the chest, corresponding to the attachment of 
the diaphragm, and most developed at the ensiform process and in the 
lateral regions of the thorax. 

The number of respirations is commonly lessened, owing to the re- 
tarded inspiration. 

The voice is rough and hoarse, and if effort is made, becomes falsetto. 
If the disease progresses, it loses resonance and sinks to a whisper, hardly 
audible when the ear is held to the patient's mouth. Being unable to 
utter a loud sound, the patient often uses gestures, and when not under- 
stood breaks into crying. 

Cough occurs at times, hoarse and barking, often called ''croupy.^' 

The pulse is usually much accelerated. Fever is almost always 
present, usually remittent, and without distinct type. 

The symptoms may be much less severe next morning; this is not to 
be taken as a favorable sign, for they soon reappear with fresh severity, 
and cause death, either at once or after several remissions. 

Laryngoscopy has been successfully performed several times. The 
results are tolerably uniform; there are great redness and swelling of the 
entire inside of the larynx, and a white coat on the mucous membrane. 
The symptoms of suffocation are explained by great swelling of the 
vocal cords, causing contraction of the glottis and respiratory immobil- 
ity. From the latter circumstance we must infer that the muscles of 



DIPUTHEBIA. 385 

the tooal cords are paretic, owing to the inflammation and serous infil 
tration of the larynx; in fact, the laryngeal muscles are usually found 
very pale, moist, and swollen. If the posterior crico-arytenoids (openers 
of the glottis) are paralyzed, it may hap{)en that the free edges of the 
Yocal cords may be drawn together by snction during a hasty inspiration, 
so as to close the opening like a yalve and threaten sutfocation. This is 
especially dangerous in the case of children, as the opening of a child's 
glottis is particularly small. A croupy child, in order to avoid complete 
closure of the glottis, must draw the inspiration carefully andslowly; 
but in spite of the precaution, the contraction can only be lessened and 
not removed. 

The state of permanent stenosis is sometimes interrupted by attacks 
of imminent danger of suffocation, usually due to mecnanical causes. 
Mucous, or fibrinous membranes, detached from the lower air-passages 
and entering the narrowed glottis, may increase the difficulty of breath- 
ing excessively; and not in regard to inspiration alone, but also to expi- 
ration. If the foreign bodies can be removed by coughing, tbe respira- 
tion becomes easier. If they cannot be removed, deatn may occur 
during the attack. In other cases, the narrowing is caused by acute 
fibrinous exudation formed near the free edge of the vocal cords; or 
membranes descend from above and partly cover the glottis. 

fi^MMm of the glottis-muscles has been thought to be a cause of these sudden 
attacks, but paresis is tbe condition of which the laryngoscope informs us. Rud- 
niol^ considers them as due to disturbed co-ordination of the breathing move- 
ments. 

In croup we must never omit to examine the other organs closely. 

In the tnroat we often find redness, swelling, and gray-white deposits, 
which make swallowing painful. The lymphatic glands under the 
lower jaw are usually swollen and sensitive to pressure. 

The respiratory murmur in the lungs is usually weakened, or concealed 
by the laryngeal sounds. The area of cardiac dulness is often less- 
ened, and the upper edge of the hepatic dulness lowered, showing acute 
inflation of the edges of the lungs. Atelectasis may be recognized by 
circumscribed dulness, which disappears as soon as the patient has 
breathed deeply, coughed, or changed position. Permanent dulness, 
broncho-vesicular murmur, and tinkling (consonant) r&les point 
to a complicating pneumonia. If emphysema of the skin of the neck 
appears, this is referable to interstitial emphysema of the lung, extending 
to the cellular tissue of the mediastinum and neckj, due to violent efforts 
at breathing. 

Elmphysema of the skin sometimes spreads from the wound after trache- 
otomy. 

The barkine cough usuaDy ejects little sputum; and as children have 
a habit of swallowing the sputa, it is hardly ever seen. 

The excretion of urine may almost entirely cease. In an epidemic 
which I observed at Jena, in which I made close study of the urine and 
its chief components, I found that not a drop of urine was sometimes 
produced during a whole day. The quantity of urea, sodium chloride, 
and phosphates is always very small. If the obstruction in the trachea 
is suddenly removed by tracheotomy^ the quantity of urine and the 
25 



386 DIFHTHSBUL. 

above components increases. Albumin is often present^ and casts, 
hyaline or dotted with fat-granules, are found in the sediment. 

Group has a great influence on the temper. Children may be ordi- 
narily obedient and auiet, but as soon as they fall ill, they become 
capricious, cross, and aisobedient. The examination requires great skill 
and patience, and tbe administration of medicine often becomes very 
diflBcult. 

The features, as a rule, are distorted, and plainly express a death- 
struggle. 

The expression is usually livid. Great cyanosis and dilatation of the 
neck-veins appear when inspiration and expiration are interfered with, 
and the venous flow to the heart is checked. 

The disease usually runs a rapid course, the result being decided be- 
tween the third and the fifth day. It seldom exceeds a week, though 
Cadet de Gassicourt mentions a case in which croup membranes were 
expectorated during sixty-one days. 

Recovery is exceptional. Among the sequelae, long-contiued hoarse- 
ness and (very rarely) laryngeal stenosis have been observed. 

D^ath occurs by suffocation in the majority of cases; it may come 
suddenly in an attack of "croup," or gradually, as the larynx gradually 
contracts. In the latter case, the skin usually becomes lead-gray or 
ashen-^ray, consciousness is impaired, the signs of suffocation become 
less violent as the child is less sensible of the need of breath, and breathes 
superficially; vomiting often occurs spontaneously, though emetics may 
previously have failed to act, twitching occurs in some of the limbs, or 
general convulsions, and life is extinguished with symptoms of carbonic- 
acid narcosis. Suffocation is assisted by the existence of extensive sec- 
ondary changes in the bronchi and lungs. 

IV. JJiAGXOSis. — The laryngoscope presents the means of making a 
certain diagnosis, bat is not likely to oe generally resorted to, under the 
circumstances. We must rely on symptoms of the stenosis of the larvnx, 
rapidly developed. The acute, non-croupous varieties of stenosis oi the 
larynx are chiefly acute catarrh of the larynx with great swelling (pseudo- 
croup), foreign bodies, oedema of the glottis, and retro-pharyngeal ab- 
scess. 

Compare Vol. I., pp. 180, 182, for the differential diagnosis of pseu- 
do-croup. The history commonly decides in regard to foreign bodies; 
also in oedema of the glottis, which is extremely rare in children. In 
retro-pharyngeal abscess, the soft fluctuating prominence on the back of 
the pharynx can usually be seen and felt. 

Stenosis of the larynx occurring in the course of throat-diphtheria is 
probably due to the same cause. The throat must always be examined. 
False membranes may be coughed up or vomited. In doubtful cases, 

Preserve the vomit, add water to it, and you often flud flbrinous mem- 
ranes floating about. 

V. Prognosis. — This is very serious. Epidemics are known (An- 
dral describes one) in which not a single child recovered. The prognosis 
depends on the following special points: 

a. The younger the child the less favorable is the prospect, owing to 
the narrowness of the larynx and the feeble power of resistance. 

h. Sporadic cases are usually more promising than epidemic ones. 

c. It is said that croup is usually less severe in summer than in win- 
ter. 

d. The presence of extensive alterations in the lungs is unfavorable. 



i, . 



DIPHTHEBIA. 

e. The prognosis, finally, depends on the correct and lieeisive actidl 
of the pjiysiciaii. for any neglected point may cause irreparable injury, 

VI, Tbbatment, — Fropnylasis IS of much value. A reasonable system 
of hardening the body may prevent a tendency to colds or eoTe-tnroat, 
At places where diphtheria prevails epidemiciilly, prophylactic gargling 
with salicylate of soda is advisable. Bed-chambera and living-roomB 
must be kept constantly aired, and in many cases carbolic spray (two per 
cent) may be thrown in once or twice a day. If diphtheria of the throat 
or laryui breaks oat in the family, the affected children must be strictly 
isolated and, if possible, placed lu another house; isolation cannot be 
considered complete unless the sick and the well members arennder dif- 
ferent systems of housekeeping. 

The treatment has two chief objects to fulfil — to relieve existing 
notic symptoms, and to conquer the inflammation — and the two ri 
together. For removing the croupous membranes we may use emetii 
or solvents. 

Emetics will fail when carbonic-acid narcosis is strongly marked; yetj 
as Steiner observes, the admixture of wine sometimes enables them to 
act; or some teaspoonfuls of brandy may be taken previously. As 
emetics, we may use sulphate of copper (1 percent), a deBsertspoonful every 
ten minutes until it acts; ipecac, gr, vliss., with tartar emetic, gr.^, 
divided into three parts, one every ten minutes till it acts; or if the child 
resists, hydrochlorate of apomorphiaby subcutaneous injection (gr. iss.: 
3 iiss,, i to ^ syringe). Emetics have a merely mechanical effect, by 
removing the membranes like foreign bodies from the air passages. A 
"revulsive and corrigent" action upon the croupous process was for- 
merly attributed to them, and the treatment of croup with emetics hae 
been practised when no mechanical indication existed. As blocking of 
the glottis may occur at any time, an emetic aiionld bo kept on hand, and 
a trained nurse directed to use it when danger of suffocation appears. 

Little can be expected of solvent remedies. Lime-water deserves 
moat confidence; it is inhaled every hour or two from Sieale's apparatus. 
Biermer warmed it to increase its effect. Inhalation of lactic acid or 
alkaline solutions are of still less use. Muriatic acid aud bromine vapors 
have been used in the same way. 

To relieve infiammution, put the patient in a room, the temperature 
of which is kept steadily at 11'' R. (63}° F.). The air of the room is kept 
moist by saucers of water sot on the stove, or u two-per-cent solution of 
carbolic acid or lime-water is sprayed about thy room ever hour or two. 
Give ubundaace of wine, milk, thin egg soup,, and wine Boup. 



4 

et, I 



The auccees of iDtemiU natlphlngiaiic treatment is small; we simply n 
the chief remedies; a. (Locally) Ice cMtrngirmseH around llie neck andleeolieaU ._ 
legion of the larynx, or bett«i', the manubrium xturni, In avoid severe bleediaB 
from cervical veina; also, derivative frictiuii, BinupiHiiiB, blisters, b. General 
blood-lettiniC' ^- Frictioa with mercuriiil ointment; calumel and sublimate mter- 
nallj-. d. Hydropathic packing, e, Enemata of vinegar water. /. Peacillintc tba ^ 
mucous membrane of the larynx with concentrate sulution of lunar causCia J 
(1.; 8) (Bretonneau), etc. " 

If dyspncBa increases in spite of our eflorta, tracheotomy is to be em- 
ployed. Do not delay too long; if extensive alterations have occurred in 
the trachea, bronchi, and lungs, the operation can do no good. The re- 
sults would be much better, and popular dread of the harmless operatioB 
iQld be much less, if the right moment were not so often passed by. 



^moD 



888 DIPHTHEBIA. 



\ 



We cannot wonder at failure when a child is already half dead before the 
oi>eration; but the public have a tendency to lay the blame on the oner- 
ating surgeon instead of the physician in charge. In spite of all this, 
large groups of statistics give a very fair result. 

Trousseau found in 222 operations 57.2^ of recoYerie& 

Sann6 " 4,663 '' 24.0j< 

Duchek " 1,678 " 25. Oj^ 

Monti *' 2,608 " 26.0j< 

Bartels and Wilms found in 330 '' 31.3^ 

Eronlein & yon Langenbeck found in 504 '' 29.0^ 

Certain symptoms may require special treatment. High fever may 
require antipyretics; the best is antipyrin (^. xxx. in enema). Bartels 
used cold baths successfully. In the narcosis of asphyxia, excitants are 
of use; in many cases, a warm bath with cold doucne will make the pa- 
tient draw deep breaths a.nd remoye obstacles to the passage of air. 

3. Nasal Diphtheria. 

I. Etiology. — This affection may be primary or seoondary. The 
primary form is rare, and may extend down to the throat and larynx. 
Secondary diphtheria of the nose most frequently occurs in connection 
with that of tne throat; and is fayored by chronic inflammation of the 
Schneiderian membrane, and by scrofula or rickets. It is not very 
rare in new-bom children as a result of puerperal infection. 

II. — Symptoms, Diagnosis, Anatomical Changes. — The mu- 
cous membrane is greatly swollen, which, with exudation, yery soon 
blocks up the nostrils. The patient snuffles, snores a good deal, and 
has to breathe with the mouth open. New-born children may suffer 
distress in breathing and become cyanotic, and the act of suckling may 
be interfered with, as they are unable to breathe except through the 
nose. 

The interior of the nostrils may be seen to be much reddened and 
swollen; sometimes there are hemorrhages, but the principal thing to 
notice are the yellowish or grayish-green deposits on the mucous mem- 
brane, or in its tissue, associated with necrosis of the tissue. The de- 
posits are most abundant at the choansd. 

The discharge is abundant, and may contain mucous, muco-purulent, 
bloody, or brownish ichorous masses, the latter often haying a sickish 
or disgusting smell. The skin of the upper lip and parts adjoining is 
often excoriated, and the places swell or are covered with diphtheritic 
membrane. Sometimes almost the entire skin of the nose is swollen and 
reddened. 

During sneezing and blowing the nose, deposits are often thrown out* 
There may be deep destruction of the mucous membrane^ bone, and 
cartilage, and obstinate bleeding. 

The submaxillary lymphatic glands are usually enlarged and sensitiye 
to pressure. 

The condition is full of danger. Death often occurs during collapse. 

III. Treatment. — Irrigate the nasal mucous membrane with the 

nasal douche four to six times a day, with carbolic acid (gr. xxx.- 3 i* : 

5iij.)> sublimate (gr. iss. : jiij.)* ^^ Hme- water; in small children, 

syringe out the nose and use weaker solutions. If there is a discharge, 

inoAPf: tK cotton plug and oil the nose and upper lip with berated or car- 



DIPHTHEBIA. 389 

bolized yaseline (5 per cent). A general stimulant treatment is yerj 
important. 

The list of remedies given on page S80 is applicable here, with special adapta- 
tions. 

4. Diphtheria of the (Esophagus. 

I. Etiology.— The primary form is very rare; Wunderlich described it, and 
Steffen reported a case m which the disease spread to the throat and larynx. Ex- 
tension to the stomach has even been mentioned ( Andral, Steffen). 

As a rule, the cases are secondary. Wagner, who has studied it closely, found 
it in typhoid fever, pyaemia, cholera, dysentery, measles, scarlatina, small-pox, 
and pneumonia. Diphtheria rarely spreads from the throat or larynx to the 
cesophagus. Cancer, tuberculosis, Bright's disease, suppuration in the joints and 
urinary passages are sometimes accompanied by secondary diphtheria of the 
<S8ophagu8. 

III. Symptoms and Diagnosis.— Symptoms are absent, or are easily overlooked, 
owing to the severity of the disease. In some cases, there are very severe pains, 
difficulty of swallowing, or inability to swallow. Neureutter and Salmon ob- 
served fatal bleeding in a child, caused by separation of a diphtheritic deposit 
from an ulcer. 

The diagnosis is established when the patients throw up fibrinous membranes. 
In Wunderlich's case, the child passed a tube-like body which presented a com- 
plete cast of the oesophagus. We should distinguish scraps of epithelium, or 
mapsecr of sprue, easily recognized by the microscope. 

III. Anatomical Changes. — They comprise fibrinous deposits, sometimes 
within, sometimes on the mucous membrane of the oesophngus; in the latter case 
they are croupous; often both exist. They usually occur in spots, and are more 
rarely spread over the whole length of the oesophagus. 

IV. Prognosis and Treatment.— Prognosis always serious. Treatment chiefly 
directed to the general affection. 

5. Diphtheria of the Stomach, 

I. Etiology. — ^This disease has more anatomical than clinical interest, for it 
is usually latent during life, and only accidentally discovered at autopsies. It is 
probably alwavs a secondary affection, most frequently following diphtheria of 
the throat or larynx. 

Many epidemics of diphtheria are remarkable for the frequent occurrence of 
this form, and for the fact that its extent and severity are not proportional to the 
process in the throat or larynx. Diphtheritic changes in the stomach occur in 
the course of scarlatina, small-pox, typhoid fever, cholera, dysentery, and pyae- 
mia. It occurs in pysemic new-born infants, whose mothers had symptoms of 
pyaemia before the labor, or who have developed symptoms of pyaemia or sep- 
ticaemia from the navel. 

II. Anatomical Changes.— The affection almost always forms patches and 
islands, chiefly located in the fundus and the main cavity. These are sometimes 
loosely connected with the mucous membrane (croupous), sometime can be 
detached from it (diphtheritic in the anatomical sense). They seldom cover a 
large tract, or the entire surface, of the mucous membrane. They sometimes 
attack the intestinal mucous membrane; in pyaemic new-born infants especially, 
the entire digestive tract has been found covered with a continuous croup mem- 
brane from the cardia to the anus (Widerhofer). 

The consistency and thickness of the deposit vary; it may be a centimetre 
thick. It is yellowish, or gray, or hemorrhagic, or brownish. The microscope 
displays nearly parallel fiorillated masses of fibrin, containing red corpuscles, 
pus-corpuscles, epithelium and gland cells, and sometimes micrococci. 

The mucous coat is usually swollen, hyperaemic, and studded with pus corpus- 
cles and hemorrhages. The glands are enlarged at their bases, and the fibrinous 
masses extend like roots into their near extremities. 

III.— Symptoms. Diagnosis, Prognosis, Treatment.— The characteristic symp- 
toms are said to be vomiting, unquenchable thirst, swelling, and pain in the 
stomach, but the ambiguity of these symptoms excuses us from discussing them. 
If croup membranes are vomited, the dia^osis may be made, if we can exclude 



390 ZOOK06E8. 

the larynx, throat, and oesophagus as sources. Prognosis absolutely unfavorable. 
Tkeatment symptomatic. 

6. Diphtheria of the Intestines. 

We rep^t all that was said of diphtheria of the stomach. When dysentery is 
termed a diphtheria of the mucous membrane of the colon, we must rememoer 
that the expression is used in its anatomical, not its etiological sense. 

7. Diphtheria of the Oall-ducts and Oall-bladder. 

All the points which bear upon diphtheria of the stomach apply here. There 
are no symptoms, or icterus is proouoed by stenosis of the gall-passages, the 
causes of which are unknown during life. 

8. Diphtheria of the Urinary Passages, 
{Diphtheritic Pyelitis et Cystitis.) 
Nothing in addition to what has been said within the three preceding topics. 



C. ZOONOSES. 

INFECTIOUS DISEASES, COMMUNICATED FBO.l ANIMALS TO MEN. 

1. Trichinosis, 

{Trichiniasis,) 

I. Etiology. — Any one who eats flesh containing trichinaB which have 
not been killed in the process of cooking, is in danger of infection by 
trichinae. The muscle trichinaB are usually inclosed in capsules; they 
enter the stomach, the capsules are dissolved bv the gastric juice, and the 
trichinae are set free. They grow rapidly in tlie upper part of the intes- 
tine, and develop into intestinal trichinc Copulation then occurs, and 
soon thousands of living trichinae are born. The parents die, and are ex- 
pelled with the faeces, but the young animals pass through the intestinal 
wall, and make their way into the muscles, where they settle, as their 
parents formerly did, become muscle-trichinje, and are encapsulated. 
Trichina disease includes the whole period from the importation of the 
maternal parasite to the settlement of the young ones in the voluntary 
muscles. 

Infection usually occurs through trichinous pork, and is commonest 
in regions where the use of raw pork is customary, as in the Harz and 
Saxony. The frequency of the disease is also affected by variations in 
trichinosis among swine. 

In Switzerland, France, and England, trichinae are very rare among men and 
animals. In Germany, Westphalia is remarkable for their rarity: the first epidemic 
there was observed in 1876 by MGller. In Wtirttemberg, Uaberlein described the 
first epidemic in 1879. 

Attention has recently been called to the fact that the infection might be aided 
by the use of American hams and bacon, although Virchow says that this has no^ 
occurred, and that the same sometimes occurs in places which are considered fre 
from trichina, as regards the domestic swine. The American way of fatting swine 



B-JOKOSKB. 

tvorthe spread ot trictiin^Lauiongtliein, it being the practice 

hlfrom the slaughter house to swine. 

Eulenberg ntates that in 18?T 3,057.273 swine were slaughtered in Russia, of 

which 701 were found triclitnoua, exactly 0.04 per cent. Billings reports exainin- 

ing 3.701 swine in Boston, in 1880, of which 154 were irichinous. or 5.7 per i-enl. 

This coincides with the percentage (4.0) found in American haniH and sides of 

bftcon (Eulenberg), 

If restrictions, or a veto, are laid on the importation of such wares, the Anit 
cans need find no fault. 



m 



The origin of trichinse in the pig has Ik'ch much discussed. Soma' 
think he is the headquarters of tnchinw, and that uninfected beasts ac- 
quire them by eating the droppings of the iufected. It is found that all 
the pigs in one pen ure often infectod together. Infection by eating flesh 
o( slaughtered beasts is rarer in this country. 

Others believe that the rat ia the original harborer of trichina. It ia 
known that rats infest the pens, aud that swine eat them; and trichinae 
occur very frequently in rata. Zenker, however, thinks the contrary, 
that ratanecome infected by eating the dnng of swine. Rogner, at Hof, 
found tricbinsB in one pig, and also in all iiie rats tliat were caught in 
the same house; while the rate in neighbor.^' Ijouses were free. Most re- 
cent authors, nevertheless, regard the rat us the source of trichina ii 
swine, but do not wholly deny the occurrcnue of infection 
swine. 

Some other small wild animals harbor trichina, as the mouse, fox. hi 
badger, etc.; cats obtain them from inice and rats. 

The esperimental infection with trichinous flesh is Buccosafnl in 

e of other animals, as the ape, cnlf, dog, rabbit, 

Qoujon infected salamanders. 

The larvie of flies, eating trichinie, digest them, but if the larrce 
eaten before the trichince are killed by digestion, they produce infcctio] 
Colin says that beasts of prev that live on small rodents become infecte 
and so do birds and fishes tnut eat excrement. The infection may ( 
tend still further, and the sources may become quite numerous. 

The flesh of wild hoars has lately been found to infect man, and i 
nianypla«es inspection is required by law fop this meat as well as for tl^ 
domestic sort. The wild animal eats some of the small creatures which wa 
have mentioned as sometimes trichinous. 

Among men the disease occurs mostly in epidemics, affecting a house, 
family, barrack (Kortum), or a large district. Several epidemics have 
sprung from the custom of making a festive occasion of slaughtering and 
sausage- making. A shop has sometimes infected almost all its customers. 
Extensive epidemics have recently occurred in Hedersloben and Hett- 
st&dt; in the former place 334 cases occurred (Eratz), In Brunswick, in 
188^, an epidemic broke out which affected 354 persons (Blasias). In 
Kmrnersleben, near Halheratadt (1883), there was an epidemic of 850 
cases (Brouardel), 

The mode of infection has been studied since about 1860 by Leuckart, Vimhow, 
and Zenker. In the human muscle, Hilton first Uescribed capaulated trichia« in 
1881, but look them for cysticerci. Paget discovered a spiral worm in the cap- 
sule, whicli Owen termed tricliiuii xpiralis. Herbst in GSttingen produoad 
muscle trichinee in dogs (1851) liy feeding them with trichinous flesh. '-' 

The diiiease waa known previously ; there is good reason to refer certain 
epidemics of rheumatoid, typhoid and sweating syiupti^ms to trichinosiB, 
was directly proved at Hamburg l>y tliK autopsy of a man wbo survived an 
■"— '- -■ - 1851, but died in 1861 (TUng^l). 



ima ] 






I cap- 
iuoed^^^J 




Mf zooxoezs. 

H. AvjiTOViCAL Al/nRATiO!n.— Trtefaiia ipirslis is a round oematode m 
'.: -r;-t.- -r: ••^:,: ntiij[««. in ttw Inwatine and miisclt^. 

-I <r.:,i trichina majibe M«n with the nskeij efeasa Torj flneyelloiK- 

K'lily curvnl or rolleil at one t!u<l. Tb« r«ina!flB iu«asim time 
i>r-!i, while Ihn maS«a onlj ivafh aboat 1.5 aim. Tbmj haTe a 

I I i<< .1 1 < ji I uQil a thicker tail-«nd. The number of the fransles is alwaji 

tfjnaUimiilj larger than thnt of the malee. They arediiita; fonnd in the befiit- 
Hint of tb* oinull intmtlno, and only few arp fonnd in th« large intestine. In ex- 
MHlllnt tlM coutCDta of ibe iDWtiae>we dilute Uieoi tre^j inth water and place 




k drvif nniltT tlM tajeroi c oy w n l f tba flae tfamda an thAiIf li 

tfc WMk pi>«iM« ara (MM (MK-IM JbuM*ent in «»iet ti> gi«r n latter BeWL 

l(inD*,-Ji<ln(-ltimKeotM-lh«M<Hnacli.and tb«lr Ckpaulp ts disralrsiJ; if Hmf 
A<>vi4i<ti and ro|<>ltat«, it b MTan da*9 fttwu tb« cMtog of tlie Desk brfom the fe- 

)m bdOA fortti H<in( txvuik. Tfi^iiirncieBaf p«rliirit*aacnatiniie*MNDrwe^3k, 

I onfi m><<hpr «i»«r hKns fnrth «» th<«ii»ttd tn tlilneMi ImiMlrBiI tmimjv^ her- 

Wlt ilj Inn ttiiO) lb» fitlb to ib» aicbth w««k uad bet&g tvjedad with the e 



„ja turaiag aside at the serons coat end t^ing b«ween the Ujers of the 
^MMa>t«ry to the retro-peritoDealcoiiDeutive tiiisue. and clienoebr theoellular tiwue 
to the Tuluntary inuBclee: at other times piercing quite througD to the peritoneal 
cavity and theDce passing to the muaclea through loose connective tissue; per- 
h&pe a i>art ia carried to the muscles in the lymphatics and blnod-Tessels, aa 
Virchow found trichinie in the mesenteric glamls! They are sometimes tound in 
the fleeh of such smHll dimensions that it seems likely that they were carried there 
At once hy the blood or lymph. 

When the young animals reach the muscles, they begin to develop intri nius- 
cle-trichinse. They pierce the sarcolemma and take up their abode inside. Inflam- 
matory proceesea in the contents of the Harcolem rua accompany this step. The 
contents become light-colored in the vicinity of the parasite, lose the transverse 
markiDg. become partly homogeneous, partly granular, and at the same time the 




aaroolemma nuclei multiply and are heaped up. The adjoining perimysium in- 
tarnuLii is also inHameU. whicii is recogoiBed by the fact liiat the luusclea become 
■ olearer at Biich places, and acquire a gray-red or uray-yellow tint. Before the 
I«I»lit*^aruencap^uUte<l. they are Qtlen found stretched out, or only parllr coiled 
up («ee Fig 69). In i-iiiUCed muscle flbres a. distinct enlargement and thickeniiig 
Of the aarcolemma-eac is present (see Fig. "Oj. 

The muscle-trioliinat leach their fuU grr>wth (0.7-1.0 mm.) within two weel~ 
&» anile, oolr one ii founl in one coiinective-tiMUB capsule, two. three, 
four leaa fr«]uentiy, TbecapsulBBareellipticorlemon-Bhaiwd, andarecompoi 
partly of a chitin'like secretion from the animal, partly of hy|«rplBsia of th» 
nrtgUboring connective lissne; the trichi nee are found mIIo.1 up spirally In them, 
ttlong with 11 granular suhntance. Bv denroee salts of lime are prec.pitatal m the 
Mpaiile, makins it opaiiue, so that we Bometimes have to dtssolf e the lima salt 
In acid Wore the loUt-l up parasite is visiblefseePiK. TH. The same prooaas may 
affect the tricbiiue, which tueu breaks iniu small pltices. At the poles of ' 




i 



cttphule*, outttide of th«ni, there is oftra an awemblage of fat-drops in old cam. 
The vacapauinted )Mrasiie Utn a sreat while. Elopach gires a caae in which a 
woman who otrUinly aufterad from triehinoab in 1642 was operated on (or oanoei 
o( Un bwait In ISM, wh«n a piece of iotercoatal muscle waa taken ont and found 
full oit oaloiAed triohini» fapantog. in which the creaturea had retained their lUi 
for fnlly twent7-foar ^eara. Vitality is recognized by the pansitea moTing when 
the mteroaeoiiio preraratioo b warmed. Holler found the capeulea oalcffied in 
two-year-okt pifa lite capsalea are eaailj seen with the naked eye, aa thejr form 
yallow kaota of tha aiaa of poppy aeeds, iprinkted in the muaoles (ae» Fig. 73). 

Tha capaiUe ia <ti«eol*«d fn the stomach t^ the gaatrlo jafoe, and the parasite 
la aet fni*; tl pvwa, and in two and ooeJialf da^ becomes matnre, t^c is, be- 
t^oiuaa an Inieslinal trichina: it copolatca, and in about five days brings forth 
Uvlnir yuuny. 

Ttu> iuuscIm that reovife theeailieet and most abundant viaitatlous are the 
llUplit«|C<i>> iutwrouatala, neck, larvogeal and eye muscles, Tlie heartia free from 
thw wutull*. lu the extientiiitv they become fewer aa the distance from the 
trunk liwnaaaa. Tliey are abundant near the insertion of the tendons, ainoe tte 
lall'M' aliucil a ttalnral ohatacle to their further progreaa. 

tlvJAw of penoas who bav« fallen victims to the diaeaae are often cedematoua 
MtU auMU^latM. The arma and legs, especially the arms, are strongly Bexed . 

lu tha hewrt, lirar, and kidney, we Bnd cloudy awelling;. Ecohymoees under 
Itw iJwtnt. a^idoaTdliim. and peritoneum aometimes occur; and more commonly 
UU iK* tt*atrio mttoooa loeiabraae. The mesenteric glanda are often swoUen and 

Ill, Symptoms. — In Bome cases, troable in 

^Ijfc ft_^ the stomach or intestine begins a tew honrs 

after eating tricliinons meat. The patient ia 

sick, perhaps vomits, is sensitive to pressure 

over toe stomach, and has diarrhcea. 

In most cases, the first days pass without 
mucli trouble, but tibout the middle of the first 
week there is depression, loss of appetite, and 
alternating heat and chills, till at the end of the 
first week the symptoms are well marked. 

Precursory symptoms are often absent. 
Thcv include local in itatioa of the gastro-intes- 
tiiiitl tract, local alterations in the muBcles in- 
vaded, and general symptoms, the latter de- 
pendent partly on the changes in the digestive 
tract and muscular system, partly perhaps on an injnrious element se- 
(iiiitcd by the parasites in the capsules, and absorbed by the stomach 
(hViwIreich). 

Nitiiseit, want of appetite, furred tongue, bad taste, and foul smelling 
hmiilh, are almost always present. Thirst is increased, from the fever 
itiiil ihe uluindaut sweating. Repeated romiting is not rare, and diar- 
rhifu in usual; iu many cjiaes, they are so prominent as to fonn a " chol- 
uiifiuni " variety of the disease. Deittli from collapse may occur within 
a U-w days, though that is not very common. The epigastrium is usu- 
ally ijuitu sensitive to pressure. 

Tlui presence of trichinte in the muscles causes severe pain, easily 
mifitakun for rheumatism, especially at the beginning of the disease- It 
icj Binmtaueoua, and ia increased by light pressure. The muscles swell 
iiinl fuel hard and elastic. Very peculiar and extremely characteristic 
liiL-iili'iiiuiire gradually assumed uy the limbs, and permanent fiesedcon- 
Inn-iiirii in ili^vulojiod. In cases treated by me in Frericha' clinic, the 
rWiiiw^ wiir« l>i<ul at iiu iii-uto angle, so that the patients were unable to 
l,'l/> liimii'ii-lsr.'t. This condition improves very slowly. If the eye 
f/iU'li t itn: (t/rrcli'd, thi' \>iit\<'»t com'o\si.\i\a l\\a.t vt ia hard to move the 




ZOONOSES. 395 

eye, and there are paretic symptoms or nystagmoid movements of the 
eyeball. Deafness has been attributed to trichinosis of the stapedius 
muscle. Trichinosis of the masseters produces a trismoid condition; 
that of the swallowing muscles^ disturbance of that function; so that 
nutrition is severely impaired in all ways. Trichinosis of the laryugeal 
muscles prodaces paralysis of the vocal cords^ with hoarseness^ want of 
vocal power, and aphonia. Dyspnoea often occurs^ due in part to dis- 
ease of the diaphragm and intercostal muscles^ partly to nervous causes. 

Fever is one of the chief general symptoms, and often exceeds 40"* 0. It 
is usually of remittent type, and often has a temperature curve like that 
of typhoid. Pulse and respiration are accelerated with the increase of 
temperature; retarded pulse, due to disturbed innervation, rarely occurs. 
(Edema of the eyelids, usually a very early symptom, is very deserving 
of attention. (Edema of the extremities is earliest and best developed 
in the lower limbs; its cause has been explained by collateral oedema due 
to inflammation of muscles, closure of many lymphatic ducts, thrombosis 
of muscular veins (Golberg); during later stages, by marasmus and ma- 
rantic thrombosis of veins. 

The abundant sweats are in a certain sense characteristic. Obstinate 
agrypnia is almost always complained of. The urine is at first scanty, 
saturated, and often gives a brick-dust sediment. Later, from the sixth 
to the seventh week. Knoll observed transitory increase of urine, with- 
out change in the quantity of the most important components. Simon 
and Wibel profess to have found lactic acid in the urine, which they 
attribute to the disturbance of the nutritive processes in the muscles. 
Albuminuria is rare, and probably occurs only as a consequence of high 
fever. 

The disease may be very protracted; the cause of death is usually 
exhaustion. 

Complications are frequent. Cutaneous hypersesthesia and anaesthe- 
sia; pain surrounding the body like a girdle (Kortum). Hemorrhage, 
urticaria, pruritus, furuncles, oed-sores, and pyaemia sometimes occur. 
Loss of consciousness and delirium may appear early, with drv, dark 
lips and tongue, as in typhoid; this has been called the typhoid form of 
trichinosis. Repeated shivering fits may occur, without special significance. 
Great oedema of the conjunctiva (chemosis) may occur. The fatty cel- 
lular tissue of the orbit may seem to be oedematous, causing protrusion 
of the globe. Kortum mentions subconjunctival hemorrhages. Kit- 
tel described one case of mydriasis whicn resisted suitable remedies. 
Pleurisy occurs rarely; pneumonia less rarely; epistaxis sometimes. Many 
complain of precordial anxiety; in my own patients I have seen palpita- 
tion. Kortum and others mention ascites in an epidemic in a barrack 
at Cologne. There is sometimes tormenting hiccup (irritation of the 
diaphragm). Hemorrhage from the female genitals has occurred. 
Menstruation is unchanged, or premature, or arrested during the disease. 
Kratz described two abortions in the Hedersleben epidemic; the fetus 
contained no trichinae. Incontinence of the bladder is mentioned. 

As sequelae, weakness, stiffness, and pain long remain in the muscles. 
The skin sometimes scales off. I once observed albuminuria lasting 
eighteen months, and then disappearing permanently. Veh once saw 
oedema of the scalp followed by profuse shedding of the hair; he also 
describes weakness of memory. 

IV. Diagnosis. — It is usually easy to determine the disease, espe- 
cially in epidemics. Prominent symptoms are gastro-enteric disurbances. 



896 ZOONOSES. 

oddema of the eyelids, sweats, sleeplessness, hoarseness, moscular pains, 
and especially continued flexion of the extremities. 

In doubtful cases, we should inquire if salt or smoked pork has 
been eaten raw, and examine the article; or excise a bit of muscle from 
the patient for examination. We prefer excision to the use of the har- 
poon, but reouire strict antiseptic precautions. The wounds h^ per- 
fectly smoothly, as I have often found. Examination of the f»ces is 
harder and less promising. 

V. Pbogkosis. — It is serious, for we hare no means of destroying the 
parasites after they enter the muscles, and many die after suffering great 
pain a long time. In the Hedersleben epidemic, 337 persons were at- 
tacked, of whom 101 died. The symptoms are severe in proportion to 
the number of the trichinsB. Persons infected from the same source are 
often affected in very different degrees. The amount eaten, the use of 
alcoholic drinks, and the occurrence of diarrhoea before or just after the 
meal, are to be considered. Nor are the animal's muscles all equally 
affected. The fertility of the trichina is also important: KrsBmer 
showed that a .person may have more trichinsB in his muscles than the 
pig from which he was infected. Children are said to be affected less. 

VI. Tbeatment. — Prophylaxis is of the highest importance; it 
includes not only compulsory inspection of the pork, but provions clean- 
liness in the care of swine. They must be kept neat, so that they can- 
not eat the dung of their companions; and rats must be exterminated. 
If trichinosis appears, the rats must, if possible, be destroyed, to prevent 
communication to subsequent inmates of the pen. Raw offal, which 
may be infected, must not be given them to eat, nor must they be fat- 
tened in places where the flesh of diseased or dend animals is used. 

Legal inspection is not a certain protection, for if an animal has only 
a few trichinae, the>' may be overlooked, even when thorough and re- 
peated teats are used. Yet Eulenberg's figures show how much evil is 
averted by the inspection. The small bit of muscle to be examined is 
mashed between two object-glasses and placed under a power of about 
fifty diameters. 

Individuals should protect themselves by never eating any pork that 
has not been legally examined; nor ever eating raw flesh. The meat 
must be thoroughly cooked, especially in the interior. Vallin shows that 
encapsulated trichinae are harder to kill by heat than free ones. The lat- 
ter commonly die at 54 to 56° C, while the former resist to 60°. He 
found that three kilos of beef did not attain the temperature of 50° in- 
ternally until after an hour's boiling; and uequired two hours more to 
reach 90° to 100''. Meat at 48'' to 51° is often eaten; in well-done roast 
beef he found a temperature of 58°; in rare-done, of 51°. Twelve 
pounds of smoked and dried ham reached in three and one-half 
hours 65°, in five hours 7<i°, in six hours 82°, and in six and three- 
fourths hours 86° in the interior. Krabbe and Fjord furnish similar 
data. 

Sausage, ham, and salt meat may also be dangerous. The process of 
treating flesh with wood vinegar does not kill the trichinae. Krabbe 
found trichinae still living aftor lying two weeks in a five-and-one-half 
per cent salt-brine. Colin and Fournient have done the same; the latter 
kept trichinae alive a year in salt-solution. 

If a person has eaten trichinous flesh, he must take a quick and pow- 
erful cathartic, e. //. , compoun»l infusion of senna; a teaspoonful hourly 
until from four to eight full discharges have occurred, and then give a 



S»7 

Meapoonful of glycerin hourly till ho has need aboat fifteen. Fiedler ob- 
nred that tricaiura qaickly die in coatact with glycerin, even if diluted 
1 two or three parts of water. The quicker the treatment the better. 

If trichinosia ia developed, nothing bnt Bymjjtomatic treatment re- 
_ una. Friedreich recommeoda I^ Ralium picfo-uitricum, gr. xxx.; (juIt. 
"tub. jalap., 3 i.; est. glycvrrh., q, s. ut f, pil, 30. Five pJilB three timea 
daily; Moalcr advises benzin (f. 3 i--iifis. : 1 pint for enema) neither of 
which can destroy the trichino. We think it most rational to try to de- 
stroy the creatures and their offspring and expel them by {^Santonin, gr. 
J: calomel, tub. j'alap., aaceh. alb., ufi gr. viij. M. f. pulv. vi. 8. One 
twice a day; but the value of this dcpeuda ou not waiting too long be- 



|d< 
ro{ 
bci 



fore applying ;t — at moat four to eight wceki 
I^et the diet be strengthening. "" 



Give dailv liikewarni baths, morning 
id evening, lasting thirty minutes, at 28* K. {95°). For sweating, 
>pia (gr. -^ij in a pill, morning and evening); for muscular pains, 
sutaneouB injections of morphia; and for sleeplessness, chloral by- 
tte ( Dij.-iv. per dose). Kortum uses salicvlic acid, and advises not tfl._ 
narcotica. Traube preferred friction witli mercurial ointment. wM 



•i. Anthn. 



Malignant Pustule. 



® • / 1 



LtiihnixlHicllJlfnimthebloi 
of B Kulnun-ply innuiiljiu 
with amhru. Uuniflvda 
* - itwrKocll, 



caught bj perforiuing 
r bloud touchmi; a cut 



Itc; 
be transferred arCificiallj or bj accident to other 
animale, evea to birds, flsheH, and frogs (Oemler, 
Gibier). OraminivorouH aaimald ate more subject to 
it than omnivom, and the latter more than caniivora. 
Id many places, it is endemic and deatrOTs many 
beasts every year; iu other places, epidemics occur 
OCcaeionBlly. 

Human beings are always infected nccidentallT; 
usually by the blood, eecretions, excretions, flesh, 
fat, urine, etc., of aSected beasts coming in contact 
with tlie skin or mucous membrane: tbe infection can 
pasB tliroueh (it is said) even if the surface is intact, 
but as a rule, a lesion of the surface is required. Those 
whi) have much to do witli animals and their dejec- 
tions, us shepherds, stablu boys, farmers, veterinari- 
ans, butchers, etc., are most liable to the disease. It i 
autopsies on the disesaed animals wilb cut fingen; 

fljiger while dressing the meat; by working in fat or hair from the animals; 
hence, it is found among leatbernlealerti. tauuers, glovers, hat workers, wi 
workers, etc. It has b^en communicated by rags in paper-mills. 

The use of meat, milk, or butter from infecteti animals has caused the di_., 
in some cases, but in others it has had no had consequences; the poison may 
destroyed by cooking, or by tbe action of the stomach; and if there are no lesio 
of tlie mucous membrane, the poison may fail, at any rate, to enter the system, 

Insecta that have been upon infected animals may convey infection. Blow- 
fliee which wet their legs and proboscis with blood have been thought especially 
dangdrous; hut other insects seem to carry contagion. The symptoms are generally 
said to begin with stinging pain, but that diies not prove that stinging insects 
convey the (loison. for the same sensation occurs in cases where such stmgs can- 
not have occurred. 

Contagion from man to man is very rare, and has been even denied, tliougb 
the blood and excrement of patients have transferred tlie disease to animals. Tno 
greatest number of cases in man occur in regions where it is endemic among 
beasts, but it is sometimes introduced from a distance, e. g., by American skins. 
One attack does not protect ngslnst another. 

The nature of the poison is known; it is connected with the bacillus anthracia, 
flnt seen by PoUender (l8S3)and Brauell (1867), correctly Interpreted by Oavaint^ 



[laev^^l 



898 ZOONOSES, 

nnd recently studied thoroughly br Koch. It is a fine, molioiiless rod, 5^0 u in 
length. t-l.d9 M broad (1 ;i = 0.001 mm.) (see Fig. 73). It is found in the blood, 
t^petrially that from the finer vessels of the Tisoera, and in the tjflammatorj pco- 
<luctii of the carbuncle and the oedema. 

II. Symptoms.— If infection has occurred, the first morbid change may oocnr 
within a few liours, but in other cases the period of incubation may last seven 
days. 

The chief visible symptoms are the carbuncle or OBdema of the skin. At the 
autoimy. we often find disease of the mucous membrane of the intestine, which is 
siinlUir to that of carbuncle. Intestinal symptoms sometimes predominate, or 
rnar (*xliit alone. The intestinal disease has oeen described as mycosis intesti- 

nail'*. 

Malignant pustule is most frequently observed on exposed parts of the akin, to 
whivli lufecHlon lias readiest access. The symptoms usually begin with stinging 
|Mihi. snd many imtients think they have been stung by an insect. The place is 
rtKl<li«n«Hl and intlllrated, and soon forms a distinct papule. In the middle a 
v«H»iol«* riMim usually not tense, fiUed with serum or a hemorrhagic fluid. It 
biirAls. and the papule becomes a nodule or knob, on the border of whicn a ring 
of fresh veeioles appears. In the middle of the nodule there is a bluish-Uadt di»> 
iH>l4>ratU>(i an<l icaugrenous destruction. The vicinity is oodematous and erystpel- 
HM»u<«« lltirti reii cords (inflamed lymphatics) sometimes run from the sptk, and 
|Ih> ii(>li(lilN»rln|c lvm|>hatio glands are often swollen and painfuL 

fly tkit* pwi in t)w second or third day, general symptoms appear; high fever, 
ta|*)«i |>iil«0, thirst, dry tongue, often hebetude, diarrhoea (sometimes witti bloody 
dkH«timM«Ni). MW«)lltug of spleen and liver, cyanosis, dyspnoea, and death by oollapee. 
'Tvi«%MM« MMiiDtiiiiDs closes the case. If the cause has been recognised in season, 
atMl ihts (tiirhuncle rendered harmless, this general infection does not occar, and 
1^ iiMliMiit i«xHivers. 

<k<li>iii4 Mitifibtiiiiss makes its flrst appearance at the eyes, and then in other 
|4ia« 'I'ht»r4f is iifteu erysipelatous redness of the skin, with vesicular elevations 
III ^t\i^'4m', hltMHl Is elTused under the skin; and gangrene occurs, and in other re- 
•l«M:i# lrh0 iKtUFMi) much ressmbles that of carbuncle, with which this oedema is 

1'hu iuii5«iiiiul iitTtH)ti(m is associated with violent bloody diarrhoea, colic, pain 
III iitti uhitiiiiieii when pressed, nausea, vomiting, chills, fever, increasing cyano- 
»iii aiiii (lv«pm45u, death by collapse. In most cases, there is also carbuncle or 

ill lUi^(4Mi*kiiii.— This is not always easy, and depends on the demonstration 
<,t .i«iliii44 k<<4uiiii ia Ihu contents of the pustule, in that of the oedema, and in th^ 
ii »',i liul titbli ahaencHd is not certain evidence against anthrax. We also neek 
«. ^ i'i.it*.ii at uiutiu^t with |K>rtions of diseased animals. Finally, rabbits or guinea- 
l<»^, : /< itcii ttidculiitiMl with the pnxiucts of the inflammation, die quickly. 

V i^u^'Ufaiofeiib. -Thert) is more hope in the cutaneous affection than in that of 
^1,'. utinaiiuts. Ill iht} former, success depends on an early and energetic treatment 
hj .^'.iai'iii ttuU liauierizatiou, before general symptoms appear; the prognosis is 
H'ui .*tn uiitiugli ut tiiiy rate. 

VI l'ub4TMKNT.— F'irst and foremost, prevention of disease among anima^liy 
on*"i> 1'^ alluudtid to; f(»r which books of veterinary surgery and public hygiene 
.;|, «,4L I iib i;uu0ulted. Great care must be exercised by those who have to do with 

i:ihii </< <leu<i uuimals who have had the disease, ana in the handling of skins, 
,*,it cti.. Thb Hubh and milk had better not be used for food, thou^ they can 
t. MfuJc hut'uilbtis by great heat. 
'li,i. lieaimbiit of the carbuncle and the oedema belong to sur^ry. For the 
^tfi,:Aihui i:(iai|jlaitit Leulie recommended quinia and carbolic acid mtemally ; we 
^ItV.^M iaafisr tmloiuel (t(r. iij., twice a day) and injections of common salt (two 
j[^^ >,iii4i. iwii:4i a day). 

3. Olanders, 

(Maliasmua.) 

^ i:.i:|.ui>iUY — (ilandnn occurs most frequently in horses, less commonly in 
<^«;c> ih^^u^Aixi^-iyiix (iia4«ui and mules). It i3 communicable to other animals (except 
;,(.j|l *,Hii\^h i^d ttii»ui<. goats, rabbits, guinea-pigs, mice, cats, dogs, etc. In 
)if^:7f\^^/'f^4 I liiiWu ibimatedty seen lions attacked with glanders after eating the 
W-'*' ^f t^Uui^€b4 UciriNss: and the same in the case of the elephant. 





„,.r and Sclifitz have lately shown that the cause resides in bacilli, whi 

-T disoovered in the inflammatory products of the disease, cultivated them art. 

lAj, and then transferred them'succeaafully to well animals. Morpliologioai^ 

thouKb Hot biological, observations of low organisms in the blood and the puru- 
lent dischargee of glanders were made at an early period. 

Man is liable to infection, though not very prominently so. Cases occur most 
freqiK^ntly amonz stable-bovs. coachmen, veterinary surgeons, knackers, (armera, 
oavalrj- soldiers, Tiorse-butcners, etc. Women are naturally leas often attacked, 
and children still less so, except in cases where it is transmitted within a family. 

The most common mode of infection seems to be by the contact of blood or 
secretions from diseased borsee*witb the skin or mucous membrane. It is also 
suppiised that the sweat, saliva, tears, and urine may contain the contagious 
material, but only in case the specific disease has attacked the mucj^us membranes 
concerned, or when infectious matter is mingled wiih their secretions. In the 
care of sick beasts, in cleaning and medical examination, and at the autopsy and 
disposal of remains, many opportunities for infection exist. 

Cases are known in which persons have been bitten, and thus infected by the 
ealiva of diseased horses. 

Eating the flesh of infected arumals may cause the diaease, especially when it 
is not cooked enough. 

Communication may take place between physicians and nurses in attendance 
on slandered men. 

It is said that infection occurs by means of the air, so that it is dangerous to 
be in the same room with infected beasts. It is also said that no injuty of skin 
or mucous membrane is necessary. 

II. Stmftdub. — The stage of incubation usually Is^ts from three to five days, 
hut Is said sometimes to extend to weeks. 

The symptoms include nodes or diffuse inflltration, consisting of round cells, 
occurring on the akin and in the muscles, in the mucous membrane of the nose, 
frontal si;iuses, throat, larynx, trachea and bronchi, and in the viscera, as the 
lungs, liver, spleen, kidneys, stomach (Wyes), and even in the central nervous 
syttem. Both nodes and infiltrations have a great tendency to caseous changes, 
suppuration, calcification, and a veryslight tendency to cicatrisation; if one spot 
betiins to cicatrize, another continues to form new knots and inRltration, with 
deatruution of tissue. Ulcers o( the skin are thus formed, which continuously 
exti'nd. so that the cutaneous disease has been popularly called the " worm." 

Tliere is an acute, a subacute, and a chronic form of glanders. While acuie 
glanders usually terminates within a week or two, the chronic fomt lasts as many 
months or years, or even longer than ten years. Acute symptoms aometitnesap- 
pear, changing a chronic into an acute disease; the converse probably does not 

Acute glanders often begins gradually. If the poison is received through n 
wound of the skin, a lump or ulcer appears, which soon becomes discolored, has 
a disposition to spread rather than heal, and discliarges thin Uemorrhugio pus, at 
an oaensive emeU. In the neigliborhood there is often inflammatory oedema or 
erysipelas, and inflammation of the lymphatics and neighboring lymulistic glands. 
Siniibir changes soon appear in other parts of the skin. Vesicles appear in 
places, or impetigo and ecthyma, which form the starting-point of new ulcers. 

ChiUs and febrile movement sometimes occur, with a feehng of weakness, and 
I»in in the muscles and joints. There may be swelling or suppurative inflamma- 
tion of joints. The appearance of the patient, with sordes on the hpsand tongue, 
delirious and unconscioua, may sometimes remind one of typhoid fever. 

If the mucous membrane of the nose is also attacked, the patient complainsof 
burning, dryness, and pain in the forehead ; thin, purulent bloody masses are dis- 
chaived. sometimes with a foul smell. The septum nariunt may be destroyed. 



lair'y 



mphatio glands swell, and sometimes form 
, ^. icous membrane and lungs are bnown by 

pain, difficulty iu swallowing, hoarseness, coush with fetid expectoration, and 
jwrhaps <edema of the glottis. Tliere is usually loss of appetite and constipation; 
in the later stages, diarrhoia. 

The liver and spleen are sensitive to pressure, and often enlarged. In the 
nrine. albumin often occurs: leucin and tyroein have been found (Ninaus). Death 
OBUully occurs from exhaustion. 

In chronic glanders, the symptoms are nearly the same, but take a slower 
mane, with frequent remissions and exaoerbations. 



^ 



m. AnATOioiUL Cbahsb.— Wa hsTs mantlaiMd them toieflr. 
HMMes an often foood in Um bodr, occapyuig tha ikin, mnxdM, m 



_._ 1 loood in Um bodr, occapTing tl 

bmiM, limn, Uv«r, aod nrieen. Htutunuaco in anj t 
nodes Taiylrom the aiae of n lentil tr -•-—-* •- -— 



Nnmerow 



in; OTSHi mar ooour. The' 

jeTaiytrom tbeaiaeofn lentil to that of ■ man's BM, aDdmnohUiger. Bone 

and cartilage are of tra involTed in the breaking down of the Inrnpe. 

IV. DuaNOSn.— There la often a difDcnlty in diattagaUiing gjandraa from 

ir infecticMi is to be moat oarefnlly inqnited into. The 
', perhaps, be made mote easily and safelf by means of IicrfBer's and 



A possible opporttinity for infec 
diagnnsia mav, perhaps, he a 
Schats'B bncilli. 

V. pROOKOSiB, in acnte glanden, almost always nnfaTorable; in the ohronie 
cases, there are flfty per cent of cures. 

TL TBtaTMBiiT.— Chiefly oonfloed to the case of extaraai disease; Incisioa of 
Bhsmsnm. carbolic dressing, and carbolic injections for tlie noeeand throat. Food 
light, bat strengthen iag; alooboUo drinks. Iodide of potash, strychnia, mercn- 
riala, etc., are not like& to be of nw. For the rest, purely ymptomatio treat* 



i. AclinomycosCa. 




Actlnomrcea gnin from s broncblote (cut leniftbiitiaei of k cow'i lune: o. ' 

t ui.i u — g ^ epilbelloli cbII« c round cellM. Ci the 

ic S30 dlaoietera. From Harehiinil. 



that can be crushed, and gives to the diseased produota a peculiar character. The 
fungus is probably one of the moulds. Actinomycosis is probably the sanie in 
man and in cattle; the fungus has been successCuUy inoculated from the former to 
tiielatter. In man, most cases producemultipIeabHoeBBesandpySBmia.butintemal 
organs, as the lungs, bronchi, intestine, pleune, peritoneum, and others, may be 
invaded. Israel has lately compiled thirty-eighi observations, and has endeav- 
ored to form a clinical outline of the disease. A fe^ cases seem to be different 
from the rest; but the majority begin at the mouLh, air-passages, and intestine. 
Actinomycosis of the bronchial mucous membrane mar cause putrid bronchitis; 
that of the lungs constitutes chronic inflltration of the lung tinue, leading to 
cavities, destruction, especially pleurisy and metastatic abscesses in Other organs. 
Peritonitis and metastatic disease often acoompanies actinomyooeis of the intes- 
tine. Death is the usual result; the disease can be recognized during life only by 
the grains, which are easily distinguished by the naked eye. Treatment purely 
aymptooiatic. 

5, Hoof -and- Mouth Disease. 



Aphtha Epizootica. 



I. Etioloqt.- 



ZOON08H8. 401 

formation of veaicles on the mucous membrane of the mouth, also between ths 
toes, and on the tc>at8; it is communicable by the contents of the vesiclee, and by 
the urine, dung, blood, and milk. 

Several caaee are reported in the human race, usuallr after eatinfc raw or in- 
sofflciently cooked milk, or in itiilkerH wlio touched the uddere of diseased ani- 
mala, covered with veaicles, with sore hands. Chance may cause infection in 
other wajs, e. g., by the slaver falliug on one. Eating butter or cheese may 
communicate the diseaae. 

II. Symptoms. — The period of incubation lasts three or four days: then fevet 
occurs, and yellow vesic lea form on the mucousmembraneof the hpsand tongue, 
more rarely on the liard and soft palate, which burst in a few daye and leaveero- 
siona of Uie mucouB membrane. Thei-eisabumingandheat in toemouth; some- 
limes great swelling audtroublein awallowing. At nearly the same time veeicles 
appear betweeu the fingers and toes, and around the nails. A vesicular erup- 
tion has been seen on the breasts; in a few cases, a general ezanthem. Signs 
of gastro-enteritis sometimes occur, wliich, in connection with fever, may destroy 
small children. In the middle of the second week, the vesicles dry up, form thin 
cruets, and fall off without scars. The disease usually ends in two or three 
weeks. 

III. DtAOKOsis, PRoaxosis, Treatu ent,— In dingnosia. tlie history in of special 
importance. Prognosis is good; death is rare. Milk from diseased animals muat 
not be used at all unless it is thoroughly boiled: cuLh must not be soiled with secre- 
tions or escreCions from diseased animals. For treatment, wash or pencil the 
mouth with chlorate of potash (1 ; SO); or lime-water, a teaapoonful every hour if 
" rrhcea is present. Vesicles on the extremities are to be rubbed with fat aud, ■ 

'ered with Hlicylated cotton. J 



^^Urrl 
^■ner 



Rabies, Hydrophobia. 



I. EtIolooT.— This disease is chiefly confined to dogs, but also occurs in cats, 
horses, oxen, sheep, asses and mules, wolves, foxes, uynnas. badgers, martens, 
and jackals. It does not occur spontaneously; it is almost always spread by the 
bite of mad animals. Saliva and blood contain tlje infectious material, while 



Sesh and milk have repeatedly been eaten without injure. 

Hydrophobia in man is usually caused by the biteof doga; lessotlen by that of 
cats, foxes, oxen, etc., or by autopsies of mad animals, or by accidental contact 
of saliva or blood with wounds. Not all persons that are bitten become hydro- 
phobic; the infecting saliva may be intercepted by the dollies. Some lesion 
(perhaps a very trifling one) appears to be always necessary to receive the ))oison. 

Aspontaneousoccurrence of the disease has been affirmed,even tor man, until 
very recently, but all the evidence is untrustworthy. Communication from man 
to nian is not certainty known, 

Klehs suspects that the poison I'esided in brown schizomycetes. which he de- 
monstrated in the salivary glands of Professor Hermann, who died of hydropho- 
bia in Prague. 

II. Syuptous. — The period of incubation varies very much, but usually laata 
from fifteen to thirty days, and oftener longer. It is said that the period luis 
been protracted, not merely to one or two years, but from ten to thirty yearn, but 
the latter belongs to the realm of fable. A period ot six months is established 

There is uauallj^ a short stage of premonitory symptoms before the outbreak 
of the disease, lasting from one to tnree days, on an average. The bite, if not 
healed, begins to give pain, to swell, bleed, and discharge more freely, or the 
cicatrix, if formed, becomes sensitive, livid, and is said to open sometimen (?), 
p^in often radiates from the wound over the whole extremity to the spine. There 
is deep dei>resBion of mind: the patient grows pale, restlesH, lose* appetite and 
sleep, and is usually tortured by unspeakable anxiety about the disease. The 
pupils are enlarged, the gaxe is fierce, and symptoms of the spasmodic stage soon 
appear. 



deep, sighing, or sobbing inspirations, during which the patient becomes cyanotic 
and is greatly distressed for iii'eath, aud feels suffocated. Spasms in the act of 
swallowing occur when the patient tries to eat or drink. TliesiKhi, or even the 
thought of drink, or the mention of it. may produce attacks of sucli spasnu. The 
^—sotient is unable to swallow his saliva, which is secreted in exceas, and has to.— 

i_ J 



Is ^t imihjpg and swallowing 

- .!-=:■. . -. -€:-=:« : uxr lei, mental excitement, 

- r.L- ---:■. ir-* •■?*-• ■ ;U 4<} '. and higher. TU«» 

; ■—.•-■ „ I — n 1^1 1 iuzar have been found 

-J ■ r — .-' =1..—:.-:. .ii>ii:;za:i^n. and distinct 

^ii. -..r-M Li.. :«:.ii:: — -Li::ia4r: rwiimg thttse about 

■^ ~- ^ia-.-ii '.r - - •r.r' -»Trp*niities, or general 

-tAst :a-.. —1 r --zi-n'^ :kt* muiw ot biting. Such 

.- — =- • issT r?- zicT^a^ ciie patient is con- 



Lvi*. — I ::i -arr :«ween one-half and 
.: •■:-: -luc- "* f^'upcoms of colia])se 

-»- 1- - ^-Ls:^ 'haracteristic. Rigor 

- ■-•■;.,. • >i^u^~ >!-sr.rj3 very soon. The 

. A. '■ -r :aa :• und the white blood- 

_■ ■ i u r:. =-r« s lauallv <£dema. and 

i — -»!::■•* : ?niin. ^ad curd, and t ho 

. • «.- L'l iir7.cu> :Y the back or the 

- :■•— . T -■*• ■-■•«:. T\^ nuo.'us membrane of 

-:- --» ■.^' —•. "■■.•? Tt'it-^Q has been noticed 

. — »."M. .:■ "'111. -li 'iru-iinrsa and fatty 

-v. :.• "r.i."ia— L ^ftruf JiiT»* been occasionally 

o.. - ^••■-■-.. •r»f«".-i*!" ▼•^■?n the hi«<t»^rv 

ft 

-.--.■ -* I ■ .r'l.r*! 'Av rxi^tencc of the 

-.-. -.t.. .* -^v-r^ '^isCj ■..:i'5 di-tirH'iion. 

.tr-:.?*.;.^? :■ r xT.- mere mental d is- 



••►-•I 



^ .i ■ :.«■'. "Ui^ should le.>3en 

■-'■•■ :■ ■.: ?* ■ iMnsiructed 

- .J ■.■-IT*, -e: all do;^d be 

- . -. IV i::::. and have it 
■...--. ' :::>s: :o destroy the 

, - • :■•.;-: ::!e beat means is 

- . --f.:!^ *■ tf*"" ^^* injection 

^ -.-.I..: '."le : Cher narcotics 

^r-^r ■. ■iciv some may be 

.^..>v ..■ ::e i-.iuiaa ii>?cies. 



INDEX. 



Abscess of spleen, 45 

Acetonaemia, 78 

Acetone, 72 

Acquired syphilis, 325 

Actinomycosia, 400 

Acute articular rheumatism, 153 

etiology, 158 

symptoms. 154 

anatomical changes, 156 

diagnosis and treatment, 157 
Adenie, 10 
Anaematosis, 19 
Angina herpetica, 184 

membranacea. 881 
Anomfdous gout, 63 
Anthrax, 897 
Aphthae epizooticie, 400 
Arthritis deformans, 96 

gonorrheal, 246 

uratica, 67 
Articular rheumatism, 

acute, 168 

chronic, 158 

muscular, 159 
Arthromeningitis crouposa, 156 
Asiatic cholera. 221 

etiology. 221 

symptoms, 224 

anatomical changes, 233 

diagnosis, 285 

treatment, 286 
Asphyctic cholera, 220 

Bacilli of anthrax, 897 
of cholera, 221 
of glanders, 399 
of leprosy, 870 
of relapsmg fever, 162 
of syphilis, 827 
of tubercle, 276 
of typhoid fever, 191 

Bleeders, 87 
Boat belly, 261 
Bones, softening of, 94 

syphilis of, 842 
Bovine lymph, 146 

humanized, 146 

primary, 147 

retro vaccination, 147 



Brain, Bolitary tubercle of, 807 

syphilis of, 855 
Buboes in soft chancre, 255 
Bubon d'erablee, 256 

Cartilages, goat of. 62 
Cerebro-spinal meningitis, 

epidemic, 268 

simple, 264 
Chancre, hard, 825 

mixed. 886 

soft, 262 
Chancroid, 252 

etiology. 252 

symptoms, 258 

diagnosis, 256 

treatment, 257 
Charcot-Neumann crystals, 4 

Chicken breast, 88 
Chicken-pox, 150 
Chlorosis, 14 

etiology, 14 

symptoms, 14 

anatomical changes, 17 

diagnosis and treatment, 18 
Cholera, Asiatic, 221 

diarrhoea, 225 

sicca. 227 
Cholerine, 226 
Chordee, 242 
Choroid, tubercle of. 812 

Clap. 239 

Cocci of erysipelas, 128 

of gonorrhoea, 241 
Coma diabeticum, 78 
Comma bacilli, 221 
Consumption, pulmonary, ^5 
Cri hydrocephalique, 261 
Craniotabes, 86 
Croup, diphtheritic, 881 

non-diphthentic, 88o 

Diabetes insipidus, 82 

etiology and symptoms, »^ 
anatomical changes and treaii- 
ment. 84 

Diabetes mellitus, 68 
etiology, 68 



404 



INDEX. 



Diabetes mellitus, STmptoiiiB, 69 

anatomical changes, 78 

diagnoeis, 79 

prognosis and treatment, 80 
Diabetic coma, 78, 77 

ocular changes, 75 
Dolichocephaly, 86 
Diphtheria. 871 

of the fauces, 372 

of the larynx. 881 

of the nose, 888 

of the oesophagus, 889 

of the stomach, 889 

of the intestines, 890 

of the gall-ducts, 890 

of the urinary passages, 390 
Diphtheritic croup, 881 

etiology, 881 

anatomical changes, 882 

symptoms, 383 

diagnosis, 386 

treatment, 887 
Dysentery, 215 

etiology, 215 

symptoms. 216 

anatomical changes, 219 

diagnosis, 220 

treatment, 221 

Elephantiasis Orsdcorum, 868 
Endocardium, syphilis of, 355 
Enlargement of the spleen, 40 
Ephemeral infectious fever, 190 
Epidemic cerebro-spinal meningitis, 
258 

parotitis, 187 
Epiaidymis, sypliilis of, 3oo 
Epididymitis, 243 
Equinola. 146 
Erysipelas, 124 

cocci, 128 
Essential pernicious anaemia, 19 
Exan thematic typhus, 118 

Febris miliaris, 135 
Fermentation test for sugar, 71 
Ferric chloride reaction of urine, 72 
Fever, ephemeral infectious, 190 

hay, 185 

herpetic, 190 

intermittent, 167 

marsh. 167 

petechial, 118 

relapsing, 159 

remittent, 175 

typhoid, 191 

typhus, 118 

yellow, 237 
Fi^vre bilieuse haematurique, 175 

Garrod's thread test, 59 
General miliary tuberculosis, 307 

etiology, 307 

anatomical changes, 309 

symptoms, 310 



General miliary tubercoloais, diagno6is» 
818 

treatment, 818 
Glanders, 898 
Glycosuria, 81 
Gonococoi, 241 
Gonorrhoea, acute, 289 

etiology, 289 

symptoms, 240 

anatomical changes, 348 

diagnosis, 248 

treatment, 249 
Gk>norrhoea, chronic, 246 
€k>ut, 57 

etiology, 57 

symptoms, 58 

anatomical changes, 64 

diagnosis, 66 

prognosis and treatment, 67 

Hssmatoblasts, 4 

HsBmatophilia, 87 

Hasmophilia, 87 

Hard chancre, 828 

Hay fever, 185 

Heart muscle, solitary tubercle of, 807 

syphilis of, 855 
Heller^s test, 71 
Hereditary syphilis, 868 
Herpes facialis, 180 

of the larynx, 135 

of the pharynx, 134 

progenitalis, 134 

zoster, 131 
Herpetic fever, 190 
Hodgkin*s disease. 10 
Hoof-and-mouth disease, 400 
Hydrophobia, 401 
Hygromata syphilitica, 342 

Idiopathic ansBmia, 19 
Infection spleen, 41 
Influenza, 184 
Inosituria, 72 
Intermittent fever, 167 

latent, 173 

pernicious, 174 
Intestinal diphtheria, 390 

phthisis, 299 

syphilis, 351 

Joints, deforming mflammation of, 96 
syphilis of, 342 

Kidney, syphilis of, 354 
tubercles of, 306 

Lactosuria, 82 
Laryngeal diphtheria, 881 

herpes, 135 

phthisis, 294 

syphilis, 345 
I^aryngitis phlvctasnulosa, 135 
Larynx, diphtheria of, 381 

phthisis of, 294 



INDBX. 



405 



[, syphilis of, 845 
Latent gout, 68 

intermittent fever, 178 
Leprosy, 868 

baoilii,870 
Leuoooythaamia, 1 
Leuktemia, 1 

etiology, 1 

symptoms, 2 

anatomical changes, 7 

diagnosis, 9 

prognoHis and treatment, 10 
Levuloee, 72 
Lipasmia, 58, 76 
Liver, solitary tubercle of, 807 

syphilis, 851 
Lues venerea, 324 
Lungs, syphilis of, 848 

tuberculosis of, 265 
Lung-stones, 279 
Lymphosarcoma, 10 

Malaria, 167 

etiology, 167 

symptoms, 169 

anatomical changes, 176 

treatment, 176 
Maliasmus, 898 
Malignant lymphoma, 10 

pustule, 897 
Malum coxsB senile, 96 
Mamma, syphilis of, 850 
Marsh fever, 167 
Measles, 99 

etiology, 99 

sy motoms and anatomical changes, 

diagpiosis, 105 

treatment, 106 
Melaneamia, 11 
Melanoleukaemia, 4 
Mellituria, 81 
Meningitis, epidemic cerebro-8pinal,258 

etiology, 258 

anatomical changes, 259 

symptoms, 260 

diagnosis and treatment, 268 
Meningitis, simple cerebro-spinal, 264 

tubercular, 814 
Meningo typhoid, 202 
Microcytes, 4 
Miliary tuberculosis, 807 
Mixed chancre, 886j 
Moore*s test, 71 

Morbus maculosus Werlhofii, 28 
Mumps, 187 

orchitis in, 189 
Muscles, syphilis of, 841 
Muscular rheumatism, 159 
Myoidema, 282 

Nasal diphtheria, 888 
Nephrophthisis, 802 
Non-diphtheritic croup, 888 
Nose, diphtheria of, 888 



Noae, syphilis of, 848 
taberooloeis of, 297 

Obesity, 51 

etiology, 51 

anatomical changes, 52 

symptoms, 68 

dliagnosis and treatment, 55 
(Esoph^sus, diphtheria of, 899 

syphilis of, 851 

tuberouloeis of, 299 
Osteomalacia, 94 
Osteopeatyrosis, 848 
Ovinola, 145 
Ozesna syphilitica, 844 
• 

Paraphimosis, 248 
Peliosis rheumatica, 27 
Perisplenitis, 45 
Peritonitis, tubercular, 817 
Pertussis, 178 
Petechial fever, 118 
Pharyngeal diphtheria, 872 

etiology, 872 

symptoms, 878 

anatomical changes, 878 

diagnosis and treatment, 880 
Pharynx, diphtheria of, 872 

syphilis of, 850 
Phimosis, 248 
Phthisis laryngea, 294 

pulmonary, 265 
etiology, 265 
symptoms, 268 
anatomical changes, 287 
diagtiosis, 289 
prognosis, 290 
treatment, 291 

enterica, 299 

pharyngea, 297 
Plague, 176 

Poeumonoconiosis anthracotica, 281 
Pneu mo typhoid, 201 
Poikilocytosis, 4, 10, 15, 22 
Polyarthritis, acute, 153 

chronic, 158 
Polysarcia, 51 
Polyuria, 82 
Progressive pernicious ansamia, 19 

etiology, 19 

symptoms, 19 

anatomical changes, 21 

diagnosis, 26 

prognosis and treatment, 27 
Prostatitis, gonorrhceal, 244 
PseudoleuksBmia, 10 
Purpura hemorrhagica, 88 

rheumatica, 27 

simplex, 27 

Rabies, 401 

Rachitis, 85 *^ 

Rectum, syohilis ait 851 
tuberculosis of, 302 
Recurrent typhus, 159 



406 



INDSX, 



Relapsing fever, 159 

etiology, 159 

anatomical changes, 161 

ffjrmptomB, 163 

oiagnoeis and treatment, 167 

spirilli of, 168 
Remittent fever, 175 
Renal phthisis, 903 
Reno^phoid, 303 
Retinitis leuksBmica, 5 
Rheumatism, acute articular, 158 

chronic articular, 158 

muscular, 159 
Rice-water stools, 336 
Rickets, 85 

etiology, 85 

symptoms, 86 

anatomical changes, 91 

diagnosis and treatment, 98 
RoBtheln, 116 
Rubeola, 116 
Russian clap, 343 

Scarlet fever, 107 

etiology, 107 

symptoms, 108 

anatomical changes, 115 

diagnosis and tr^tment, 116 
Scorbutus, 81 
Scrofula, 818 

etiology, 818 

symptoms, 819 

anatomical changes, 832 

diagnosis and treatment, 323 
Scurvy, 31 

etiology, 31 

symptoms, 33 

anatomical changes, 85 

diagnosis and treatment, 86 
Sheep-pox. 145 
Small-pox, 186 

etiology, 136 

symptoms, 137 

anatomical changes, 143 

diagnosis and treatment, 144 
Soft chancre, 252 
Softening of the bones, 94 
Solitary tubercles, 307 
Spinal cord, solitary tubercle of, 307 
SpirochaBte Oberraeieri, 163 
Spleen, diseases of, 40 

abscess, 45 

acute enlargement of, 40 

changes in position of, 49 

chronic enlargement of, 43 

hemorrhagic infarctions, 45 

inflammation of capsule, 45 

palpation, 42 

parasites, 48 

rupture, 49 

solitary tubercle, 307 

tumors, 48 

wandering, 49 

waxy degeneration, 47 

izamination of, 378 



Stomacn, diphtheria of, 889 
syphilis of, 851 
tuberculosis of, 399 
Subeultus tendinum, 310 
Sugar in the urine, tests for, 71 
Summer catarrh, 185 
Sweating sickness, 185 
SyphUis, acquired, in the fixBfe and sec- 
ond stages, 835 
etiology, 835 
symptoms, 837 
diagnofiis, 886 
progpiosis, 887 
treatment, 888 
baciUi, 837 

tertiary, of the skin, muacles, fas- 
ciss, etc., 841 
of the digestive tract, 850 
of the kidneys, 854 
of the larynx, 845 
of the liver, 851 
of the lungs, 848 
of the nose, 848 
of the spleen, 853 
of the trachea and bronchi, 848 

Tabes mesenterica, 830 
Thorax, phthisical, 370 

rachitic, 88 
Tophi, 60 
Trichina, 893 
Trichinosis, 890 

etiology. 890 

anatomical changes, 893 

symptoms, 394 

prognosis and treatment, 896 
Tronimer's test, 71 
Tubercle bacilli, 376 
Tubercular meningitis, 814 

peritonitis, 315 
Tuberculosis, 265 

miliaris disseminata, 807 
Tuberculous inflammation of cerebral 

membranes, 314 
Tussis convulsiva, 178 
Typhoid fever. 191 

etiology, 191 

anatomical changes, 194 

symptoms, 198 

diagnosis, 212 

prognosis, 213 

treatment, 213 
Typhoid fever, bacilli of, 191 
T^^phus fever, 118 

etiology, 118 

anatomical changes, 119 

sj^niptoms, 120 

diagnosis, 123 

treatment, 124 

Ulcus durum, 828 

molle, 252 
Urethritis blennorrhoica, 389 
Urinary organs, chronic tuberculosis 
of, 303 

^^Kthfiria of, 890 



INDEX. 407 

Vaccination, 145 Whooping-cough, etiology, 178 
Vaccine syphilis, 826 symptoms, 179 

Vaccinola, 146 anatomical changes, 183 

Varicella, 150 diagnosis and treatment, 188 

Variola, 186 

vlSSl'goi.i1»^ YeUow fever. 237 

Wandering spleen, 49 Zona, 181 

Whooping-cough, 178 Zoonoses, 890 



LANE MEDICAL UBRARY 



To avoid fine, this book should be returned 
on or before the date last stamped below. 



OCT aO 1990 






L46 ZichhoTSt.H.L. 657 
Z34a Handliaok of praatlaA 
1886 medicine. 1 


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