HANDBOOK 
OF 
Practical Medicine 
BY 
Dr. HERMANN EICHHORST, 
in 
PROFESSOR OF SPECIAL PATHOLOGY AND THERAPEUTICS AND DIRECTOR OF THE 
UNIVERSITY MEDICAL CLINIC IN ZURICH 
VOLUME IV. 
DISEASES OF THE BLOOD AND NUTRITION, AND INFECTIOUS 
DISEASES 
SEVENTY-FOUR WOOD ENGRAVINGS 
NEW YORK 
WILLIAM WOOD & COMPANY 
1886 Copyright by 
WILLIAM WOOD & COMPANY. 
1886. 
PRE9S OP 
8TETTINER, LAMBERT & CO., 
129 & 131 CROSBY 8T., 
NEW YORK. 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. 
PAGE 
Diseases of the Blood, ....... 1-40 
1. Leuksemia, ........ 1-10 
2. Pseudoleukaemia, ....... 10-11 
3. Melanaemia, ........ 11-14 
4. Anaemia. Chlorosis, ....... 14-19 
5. Progressive pernicious anaemia, ..... 19-27 
6. Purpura simplex, ....... 27 
7. Purpura rheumatica, ...... 27-28 
8. Purpura hemorrhagica, ...... 28-31 
9. Scurvy, ........ 31-37 
10. Haemophilia, ..... ... 37-40 
PART II. 
Diseases of the Spleen, ....... 40-50 
1. Acute enlargement of the spleen, ..... 40-43 
2. Chronic enlargement of the spleen, ..... 43-45 
3. Inflammation of the splenic capsule. Perisplenitis, . . 45 
4. Hemorrhagic infarction of the spleen and inflammation of the 
spleen. Splenitis, ....... 45-47 
5. Waxy degeneration of the spleen, ..... 47-48 
6. Tumors of the spleen, ....... 48 
7. Parasites of the spleen, ...... 48-49 
8. Rupture of the spleen, ....... 49 
• 9. Changes in position of the spleen, ..... 49-50 
SECTION IX. 
Diseases of Nutrition, ....... 51-98 
1. Obesity. Polysarcia, ...... 51-57 
2. Gout. Arthritis uratica, ...... 57-68 
3. Diabetes mellitus. ....... 68-81 
Appendix. Mellituria, ...... 81-82 
4. Diabetes insipidus, ....... 82-85 
5. Rickets, ......... 85-94 
6. Osteomalacia, ....... 94-96 
7. Arthritis deformans, ....... 96-98 IV 
TABLE OF CONTENTS. 
SECTION X. 
PAGE 
A. Infectious Diseases with Typical Localization, . . . 99-265 
PART I. 
1. Acute Infectious Exanthemata, ..... 99-152 
1. Measles, ........ 99-107 
2. Scarlatina, ........ 107-116 
3. Roetheln, ...... . . 116-118 
4. Typhus fever, . . . . . . .118-124 
5. Erysipelas, . . . . . . 124-130 
6. Herpes, ........ 130-135 
a. Herpes facialis, . . . . . 130-131 
b. Herpes zoster, ...... 131-134 
c. Herpes progenitalis, . . . . . 134 
d. Herpes pharyngis, ...... 134-135 
e. Herpes laryngis, ...... 135 
7. Febris miliaris, . . . . . . .135 
8. Small-pox, ....... 136-145 
9. Vaccination, 145-150 
10. Varicella, ........ 150-152 
PART II. 
Infectious Diseases Involving the Motor Apparatus (Joints or 
Muscles), ........ 152-159 
1. Acute articular rheumatism, ..... 152-158 
2. Chronic articular rheumatism, . 158-159 
3. Muscular rheumatism, . . . . . . 159 
PART III. 
Infectious Diseases Involving the Blood and Blood-Producing 
Organs, ........ 159-177 
1. Relapsing Fever, ....... 159-167 
2. Malaria, ......... 167-176 
3. The Plague, . . 176-177 
PART IV. 
Infectious Diseases Involving the Respiratory Apparatus, . 178-187 
1. Whooping-cough, . . . . . . . 178-184 
2. Influenza, ‘ . 184-185 
3. Hay fever, . 185-187 
PART V. 
Infectious Diseases Involving the Digestive Apparatus, . . 187-239 
1. Epidemic parotitis, ....... 187-190 
2. Ephemeral infectious fever, ...... 190-191 
3. Typhoid fever, ....... 191-215 
4. Dysentery, ........ 215-222 
5. Asiatic cholera, ...... 222-237 
6. Yellow fever, ........ 237-239 
INFECTIOUS DISEASES. TABLE OF CONTENTS. 
V 
PART VI. 
PAGE 
Infectious Diseases Involving the Sexual Apparatus, . . 239-258 
1. Gonorrhoea, ........ 239-252 
2. Soft chancre, ........ 252-258 
PART VII. 
Infectious Diseases Involving the Nervous Apparatus, . . 258-265 
1. Epidemic cerebro-spinal meningitis, .... 258-264 
2. Simple cerebro-spinal meningitis, ..... 264-265 
B. Infectious Diseases with Variable Localization, . . 265-402 
• PART I. 
Tuberculosis, ......... 265-324 
1. Pulmonary phthisis, ...... 265-294 
2. Laryngeal phthisis, ....... 294-297 
Appendix. Tuberculosis of the nose, .... 297 
3. Pharyngeal phthisis, ....... 297-299 
Appendix. Tuberculosis of the tongue, lips, mucous membrane 
of the cheeks, oesophagus, and stomach, . . . 299 
4. Intestinal phthisis, ....... 299-302 
Appendix. Tuberculosis of the rectum, . . . 302 
5. Chronic ulcerative tuberculosis of the urinary organs, . . 302-306 
6. Solitary tuberculosis of the viscera, . 307 
a. Solitary tubercle of the brain, .... 307 
b. Solitary tubercle of the spinal cord, . . . 307 
c. Solitary tubercle of the spleen, .... 307 
d. Solitary tubercle of the liver, .... 307 
e. Solitary tubercle of the heart muscle, . . . 307 
7. General miliary tuberculosis, ..... 307-313 
8. Tubercular meningitis, ...... 314-317 
9. Tubercular peritonitis, ...... 317-318 
10. Scrofula, ........ 318-324 
PART II. 
Syphilis, .......... 324-368 
1. Acquired syphilis in the primary and secondary stages, . 325-341 
2. Tertiary syphilis of the skin, muscles, fasciae, joints, and bones, . 341-343 
3. Syphilis of the nose, ...... 343-344 
4. Syphilis of the larynx, ...... 345-348 
5. Syphilis of the trachea and bronchi, .... 348 
6. Syphilis of the lungs, ....... 348-350 
Appendix. Syphilis of the mamma, .... 350 
7. Syphilis of the digestive tract, ..... 350-351 
Syphilis of the buccal cavity, ..... 350 
Syphilis of the tongue, ...... 350 
Syphilis of the pharynx, ...... 350 
Syphilis of the salivary glands, ..... 351 
Syphilis of the oesophagus, ..... 351 
Syphilis of the stomach, ...... 351 
Syphilis of the intestines, ...... 351 
Syphilis of the rectum, ...... 351 
8. Syphilis of the liver, ...... 351-353 
Appendix. Syphilis of the pancreas, .... 353 
9. Syphilis of the spleen, . . . . . . 353-354 
10. Syphilis of the kidneys, ...... 354-355 
11. Syphilis of the sexual organs, ..... 355 
Syphilis of the testes, ... .... 355 
Syphilis of the penis, ...... 355 VI 
TABLE OF CONTENTS. 
PAGE 
Syphilis of the epididymis, . . . , . 355 
Syphilis of the vas deferens, ..... 355 
Syphilis of the seminal vesicles, ..... 355 
Syphilis of the prostate, ...... 355 
12. Syphilis of the circulatory organs, ..... 355 
Syphilis of the heart muscle, ..... 355 
Syphilis of the endocardium, ..... 355 
Syphilis of the arteries, ...... 355 
13. Syphilis of the brain, ....... 355-362 
14. Syphilis of the spinal cord, ..... 362-363 
15. Syphilis of the peripheral nerves, ..... 363 
16. Hereditary syphilis, ...... 363-368 
PART III. 
# 
Leprosy, .......... 368-871 
PART IV. 
Diphtheria, . ........ 371-890 
1. Diphtheria of the pharnyx, ...... 372-381 
2. Diphtheria of the larynx, ...... 381-388 
3. Diphtheria of the nose, ...... 388-389 
4. Diphtheria of the oesophagus, ..... 389 
5. Diphtheria of the stomach, ...... 389-390 
6. Diphtheria of the intestines, ..... 390 
7. Diphtheria of the bile passages, ..... 390 
8. Diphtheria of the urinary passages, .... 390 
C. Zoonoses, ......... 390-402 
1. Trichinosis, ....... 390-397 
2. Anthrax, ........ 397-398 
3. Glanders, ....... . 398-400 
4. Actinomycosis, ....... 400 
5. Mouth-and-hoof disease, ..... 400-401 
6. Hydrophobia, ....... 401-402 HANDBOOK 
OF 
PRACTICAL MEDICINE. 
SECTION VIII. 
DISEASES OF THE BLOOD AND T1IE HEMATOPOIETIC 
ORGANS. 
PART I. 
DISEASES OF THE BLOOD. 
1. Leuhcemia. Leucocytlmmia. 
I. Etiology.—Leukaemia 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 leukaemia, 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 atfected in very different degrees. 
Behier also recognizes enteric leukaemia, 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 majority, 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. 
Leukaemia is more frequent in men (among 200 cases, 135 males, 65 
females). 
1 2 
DISEASES OF THE BLOOD. 
The disease occurs usually between the twentieth and fiftieth years, 
the maximum occurring in males in the third decennium, in females in 
the fourth decennium. 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 leukaemia 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 menstrual 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 hereditary 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 among the causes is still doubtful. Two cases 
have been reported in which this disease was converted into leukaemia. 
Hereditary influences seem to have been potent in a few cases. 
! 
Casati observed splenic leukaemia in a girl whose grandmother and father had 
suffered from the same disease. Biermer observed it in two sisters, aet. three years 
and four and one-half years, Senator in twins, aet. one and one-half years. 
The disease occurs in animals (dog, horse, cow, pig). 
II. Symptoms.—The most striking symptoms are the changes in the 
blood. All other symptoms may occur under other circumstances, par- 
ticularly in anaemic conditions. To examine the blood, the tip of the 
finger, 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 
glass. 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 wTith a whitish gray 
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 350-500 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 requisite in order 
to discover any red blood-globules. Even in less advanced cases, the mi- 
croscopic appearances are very characteristic (vide Fig. 1). 
Three principal forms of white blood-globules are visible. One form 
is smaller than the red blood-globules and contains a single nucleus sur- 
rounded by a narrow zone of protoplasm. The latter is sometimes so 
small in amount that the cell looks like a free nucleus. These white DISEASES OF THE BLOOD. 
3 
blood-globules resemble the parenchyma cells of the lymphatic glands, 
and abound in leuksemia of a predominantly lymphatic character. 
A second form of white blood-globules exceeds the red ones in size. 
They contain generally three or four nuclei, sometimes are grouped to- 
gether like a clover leaf, and often present constrictions. This form re- 
sembles the cells of the splenic pulp, are especially numerous in leuksemia 
of a predominantly splenic character, and are probably derived in great 
part from the spleen. 
Finally, Mosler called attention to white blood-globules which con- 
tain drops of fat. They are said to be derived from the medulla of the 
bones, and to be characteristic of myelogenic leukaemia. Much more 
Fig. 1. 
Blood in leukaemia (chiefly lymphatic). Enlarged 450 times. 
characteristic of the latter form, however, are the so-called transition 
cells of E. Neumann. These are imperfectly developed red blood- 
globules which still contain a large nucleus, while the zonal portion is 
homogeneous and colored. 
Various forms of white blood-globules are found even in the blood of healthy 
individuals. This should be expected d priori in leukaemia, because, as a general 
thing, we do not observe pure forms of lymphatic, splenic, or myelogenic leu- 
kaemia. Recent investigations have shown, however, that the form of the white 
blood-globules is not? a positive indication of their place of origin, and that a still 
larger variety of these cells may be distinguished by staining with aniline. 
The red blood-globules are sometimes very much diminished in num- 4 
DISEASES OF THE BLOOD. 
ber, and they may even be reduced to half a million in one cubic 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 leukaemia famish abundant mate- 
rial for examination. The blood is not infrequently cloudy, milky, or pus-like. 
It readily decomposes and becomes acid, probably as the result of the formation 
of glycerin-phosphoric acid from the lecithin contained in it. The specific gravity 
is diminished to 1.036 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 unusually large. The longer the blood is allowed to stand the more 
abundant the crystals which are deposited (Charcot-Neumann crystals). Zenker 
attributes their origin to the white blood-globules 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. Jsederholm 
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 
(melanoleukasmia). In one case, Friedreich observed 
amoeboid movements of the red blood-globules. In 
some cases, there is a large number of protoplasm 
granules (hsematoblasts), often aggregated in groups. 
Unusually small red blood-globules (microcytes) have 
been repeatedly seen. A few writers claim that 
schizomycetes are present in the blood. 
Quincke found only one-third of the normal 
amount of haemoglobin in the blood, but, accord- 
ing to Laacher, the quantity in the individual red 
blood-globules is unchanged. 
Leukaemic blood contains substances which ap- 
pear to be derived, in great part, from the blood- 
producing organs. We may mention hypoxanthin, 
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 leukaemia. The former has been found in healthy blood, but only after stand- 
ing for some time. It is probably 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. 
Next 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 much 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 pulse, 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 fiat prominences. In the 
neck, they give rise to great deformity and interfere with the mobility 
of the head and neck. Large glands are often observed in the 
axillas and inguinal folds. The cervical and submaxillary glands are 
Fig. 2. 
Leukscmic crystals from the 
blood, partly free, partly in- 
closed in white blood-globules. 
After Zenker. DISEASES OF THE BLOOD. 
5 
first attacked. As a rule, the tumors are not tender on pressure, and, 
unlike scrofulous glands, the overlying skin is not reddened or adherent; 
furthermore, the swelling is generally flatter and softer. As the disease 
advances, the consistence of the tumors not infrequently increases. 
Caseation and suppuration are extremely rare in leukasmic lymphatic 
glands. 
The spleen and glands are often enlarged long before the blood 
undergoes leukaemic 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. Some 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 follicles at 
the base of the tongue has also been noticed. 
Affection of the medulla of the bones is sometimes, though not 
constantly, manifested by pain over the bones, particularly 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 degree 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 leuksemia, 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 (?). 
It. Liebreich showed that the retina presents characteristic changes 
(retinitis leucsemica) 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 retinal hemorrhages. 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 
peripheral 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 is affected, the interference with vision may attract atten- 
tion before the other symptoms. 6 
Rarer phenomena are hemorrhages into the vitreous, or hemorrhages and lym- 
phomatous formations in the choroid and iris. Leber has described exophthal- 
mus 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 growths may develop in the lachrymal glands. The de- 
velopment of cataract is sometimes attributed to leukaemia. 
Auditory disturbances have been observed in leukaemia, and in one 
case Pulitzer found lymphomatous deposits in both labyrinths. 
A rare but characteristic sign is the appearance of leukaemic tumors 
in the skin and epididymis. 
A series of other symptoms may develop which are the result of 
anaemia, rather than of the leukaemia. 
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 membranes. 
The complexion 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 alscf been de- 
scribed. Cutaneous oedema is observed not infrequently, 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 be regarded as 
the result of defective nutrition of 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. 
Pettenkofer and Yoit found that, despite the diminished number of red blood- 
globules, the 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. The 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 the 
DISEASES OF THE BLOOD. DISEASES OF THE BLOOD. 
7 
stomach, eructations, and vomiting are not infrequent. A more serious 
symptom is obstinate diarrhoea ; this proves fatal in some cases. Vir- 
chow found 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 genito-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- 
sules, 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 
leukaemia occur either as true hyperplasiae in localities which contain 
lymph follicles, or they develop independently of them in a heteroplastic 
manner. They 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 and 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 sanguinolent, as the result of hemorrhages. 
Nodular or more diffuse lymphomata may be found beneath the epi- 
cardium, 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 venae cavae, and in all the other organs. 8 
DISEASES OF THE BLOOD. 
As a rule, the heart muscle is pale, occasionally infiltrated with small 
hemorrhages and fatty in places, it may also contain lymphomatoua 
new-formations. 
The pleural 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 large as a fist. The thyroid and 
thymus glands may also be very much enlarged and infiltrated with 
lymphomata. 
Ascitic fluid 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 16£ 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 trabeculae 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 been found. Virchow 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 
2,500 grams of splenic tissue, Salkowski and Stern found large amounts of pepto- 
noid bodies, 0.238 hypoxanthin, 0.134 of other xanthin substances, 0.426 tyrosin, 
succinic acid doubtful, no uric acid. In 1,400 grams of splenic tissue, Boeckedahl 
and Landwehr found: peptones, 15.5 grams; lactic acid, 0.16; succinic acid, 0.029; 
xanthin, 0,548 ; leucin in 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 we 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 Salkowski, chemical examination of the liver furnished the fol- 
lowing results : DISEASES OF THE BLOOD. 
9 
2,500 grams liver. 
32 peptonoid substances. 
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 lymphomatons 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 glands 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 the vessels and glomeruli. A 
rare complication is waxy degeneration of the kidneys. 
The suprarenal capsules are sometimes increased 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. Similar 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 of 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 and infectious diseases does not reach such a high 
grade, and is not permanent. 10 
DISEASES OF THE BLOOD. 
V. PkognOSIS.—The prognosis is unfavorable. Cases of improve- 
ment or recovery are very rare, and even these are not undoubted. 
VI. Tbeatment.—We may recommend nutritious, light food, and 
country air. Niemever obtained temporary effects from cold-water 
treatment. In addition, we may order iron, quinine, and cod-liver oil, 
and good effects are said to have been obtained from arsenic and phos- 
phorus. 
Many authors employ local treatment, i. e., directed against 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. Cold douches and compression, faradization, galvanization, 
and galvano-puncture of the spleen have also been employed. 
Splenotomy is contra-indicated in this disease, inasmuch as all the patients 
(16) died immediately after the operation. 
2. Pseudoleukcemia. 
{Hodgkin’s Disease. Adenie. Malignant lymphoma. Lymphosarcoma.) 
I. Etiology.—Pseudoleukaemia 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 syphilis, 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 classes 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 may 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), mikrocytes, and numer- 
ous elementary granules. DISEASES of the blood. 
11 
The disease generally runs a more rapid course than leukaemia, but 
occasionally lasts several years. Febrile phenomena are sometimes 
noticeable, particularly when new glands become affected. 
The pressure of the glands on adjacent organs may give rise to vari- 
ous complications, such as circumscribed oedema, paralysis of the recur- 
rent laryngeal nerve, tracheal and bronchial stenosis, icterus, ascites, etc. 
In some cases the disease is converted gradually into leukaemia. 
Some writers regard both diseases as identical, and believe that on 
account of the more rapid growth of the glands in pseudoleukaemia the 
lymph tracts are occluded, and the passage of white blood-globules 
into the blood thus prevented. Cohnheinr’s opinion, that pseudoleu- 
kaemia is an acute leukaemia in which death occurs before an excess of 
leucocytes enters the blood from the swollen glands, is disproved by the 
fact that the disease sometimes persists as such for several years. 
IV. Diagnosis and Prognosis.—With the aid of the microscope, 
it is easy to diagnose the disease, and to distinguish it from leukaemia. 
The prognosis is as unfavorable as in the latter affection. 
V. Treatment.—The causal indications (intermittent fever, syphi- 
lis, scrofula, rickets) should first be met. Cod-liver oil, potassium 
iodide, iron, and iodide of iron have been recommended in the treat- 
ment of the disease itself. The experience of Billroth and Czerny war- 
rants the administration of arsenic internally, and in the form of injec- 
tions into the glands. Trial may also be made of inunctions of green 
soap. Sapo virid., 3 iv.-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 
is treated in the same way as in leukaemia. 
3. Melancemia. 
I. Etiology.—In this disease, the blood contains granules of black 
or blackish pigment. 
Intermittent fever, of severe types, is the sole known cause of the 
melanaemia. It is most frequent in the pernicious intermittents of the 
tropics, but occurs occasionally in the fever of our own latitude. The 
development of melanaemia 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 cells, or in spindle-shaped cells which resemble the endothe- 
lium of the splenic veins, or they are contained in long, hyaline coagula. 
Finally, they may form long cylindrical structures, which sometimes ap- 
pear fractured at one end or on both sides (vide Fig. 3). The granules 
are deep black, reddish-brown, or yellowish. The older, black particles 
resist for a long time the action of mineral acids and caustic alkalies ; 
the younger ones grow pale very rapidly under their action. 
The majority of granules are inclosed in round cells, in which 
Mackenzie recently detected amoeboid movements. The coagula which 
are sometimes 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 albumi- 
noids derived from the destroyed red blood-globules. The pigment 12 
DISEASES OF THE BLOOD. 
masses, in the form of coagula, have been regarded as dislodged pigment 
emboli. 
The pigment granules are round or irregularly angular, and vary in 
size. They sometimes exceed the dimensions of the blood-globules, and 
their edges are then often lighter in color, and laminated. 
In some cases, the pigment disappears very rapidly after the cessa- 
tion of an attack of fever, and reappears with the next attack. In other 
cases, it circulates in the blood for weeks and months. Melanaemia is 
sometimes the sole symptom, and is only recognizable after microscopic 
examination of the blood. It is generally associated with impoverish- 
ment of the blood in red blood-globules (oligocythaemia) and not infre- 
quently with temporary increase of the white globules (leucocytosis). 
In some cases, other symptoms develop, the result in great pajt of the 
Fig. 3. 
Constituents of melanaemic blood, r, round cells, containing pigment; e, elongated cells with 
pigment (perhaps endothelium of the splenic veins) ; g, clots with pigment; c, cylindrical 
structures inclosing pigment. After Frerichs. 
passage of the pigment into the capillaries of various regions of the 
body. 
The skin assumes an ashen gray or grayish-yellow color. 
Disturbances have also been observed on the part of the cerebral, 
intestinal, and renal functions, but it is doubtful whether the greater 
part is the effect of the intermittent fever or the secondary melanaemia. 
There is no doubt that the symptoms in question may occur in perni- 
cious intermittent fever without co-existing melanaemia. 
The most frequent cerebral symptoms are headache and vertigo ; 
next coma or delirium ; the most rare are convulsions and paralyses. 
These symptoms are said to result from occlusion of the cerebral capil- 
laries by masses of pigment, and secondary extravasations of blood. 
Similar processes in the domain of the portal vein are said to give 
rise to diarrhoea, enterorrhagia, peritonitic symptoms, and ascites. DISEASES OF THE BLOOD. 
13 
Pigment emboli of the finer renal vessels cause anuria, albuminuria, 
and haematuria. Basch described a case in which the urine contained 
clumps of pigment, and similar ones were found in the blood. 
III. 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 
follicles 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 Virchow 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- 
globules. Since melansemia is absent in other infectious diseases, an injurious 
influence upon the red blood-globules must be atti'ibuted to the malarial poison. 
The 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 
DISEASES OF THE BLOOD. 
It should be treated prophylactically and causally with large doses oi 
quinine ( 3 ss.-i. daily), continued for a long time; otherwise purely 
symptomatic treatment. 
4. Chlorosis. 
(Chlorcemia. Chlorancemia.) 
I. Etiology.—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 period 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 hypoplasia 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 may also produce the 
disease in the absence of hereditary and congenital predisposition to 
chlorosis (acquired form). These include psychical conditions: excessive 
study, grief, homesickness, 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 
patients almost always suffer from menstrual disturbances, but we must 
be on our guard against mistaking cause and effect. Niemeyer states 
that all girls 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 modern civilization. 
II. Symptoms.—The symptoms generally develop gradually. They 
occasionally begin immediately after the first menstrual period. The 
patients generally 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, but has a pale, 
miserable appearance. 
The pale color of the skin is one of the most constant and earliest 
symptoms. It appears earliest and most markedly on the lobe of the 
ear. The cheeks also lose their red color and the mucous membranes 
(conjunctiva, lips, gums, and remainder of buccal mucous membrane) 
become pale-red 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. DISEASES OF THE BLOOD. 
15 
The sclera is often bluish-white, and the subconjunctival fat pale 
yellow. 
The amount of pigment sometimes diminishes in the skin, and even 
in the hairs, either in patches or diffusely. 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 chloroties, however, have a blooming complexion, as the 
result of dilatation of the subcutaneous vessels in the face. Others blush 
deeply with every bodily or emotional excitement, evidently from hyper- 
excitability of the vaso-motors. 
The panniculus adiposus is often unusually well developed. If it 
disappears very rapidly, a suspicion of the existence of some wasting dis- 
ease (generally phthisis) must be aroused. 
(Edema develops occasionally ; it is generally very slight, affects the 
ankles or lids, and disappears at night. In rare cases more extensive 
and permanent oedema of the legs is observed. The oedema is owing to 
the fact that the changes in the blood disturb the nutrition of the walls 
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 be 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 with extremely small ones. Changes 
in the shape are also very frequent. The globules are constricted, pear- 
shaped, or entirely irregular (poikilocytosis). In not a few cases the 
white blood-globules are diminished in number. In some cases there 
are numerous protoplasm granules, occasionally aggregated into large 
heaps. 
Accurate count has shown that the number of red blood-globules is sometimes 
unchanged, sometimes diminished. In one case Laacher found 2,440,000 red 
blood-globules in one cub. mm. (normally 4,430,000). 
Even the amount of haemoglobin may be unchanged, though, as a rule, it is 
diminished (sixty-seven per cent of the normal, on the average, in twenty-four 
cases examined by Laacher). 
Duncan noticed that if the red globules are placed in a solution of sodium 
chloride, they lose their coloring matter more readily than the blood-globules of 
healthy individuals. 
The amount of iron in the blood is diminished. The blood serum may be un- 
changed, or the proportion of albumin may be increased or diminished. 
The temperature of the body is almost always unchanged. There 
are occasionally slight elevations in temperature (39.8° in the rectum is 
not infrequent, according to Molliere, 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. 
As a rule, the patients exhibit a disinclination to mental or bodily 
work. They have a tired expression of the face, and often sleep during 
the day, while at night they toss about restlessly in bed. 
The mood is irritable, capricious, and tearful. The patients often 
complain of shortness of breath which is increased by movement. They 
are not infrequently 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 passages are not infrequent, and their development is evi- 
dently favored by the diminished 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 bodily effort. The vigorous action of 
the heart is often visible over several intercostal spaces. The right, 
rarely the left, ventricle is often dilated (anaemic dilatation). Systolic 
murmurs are often audible over one or several, or even all the valves. If 
the heart’s action is very vigorous, the second pulmonary sound is often 
intensified temporarily, thus arousing the suspicion of 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 yield. 
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 are heard in rare cases. 
In not a few cases, the carotids pulsate vigorously, and the cardiac 
systolic sound is often converted, in these vessels, into a murmur. A 
short, low systolic sound mav 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 sterno- 
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 may 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 right in- 
ternal jugular runs a more vertical course to the heart, so that a more vigorous 
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 
interruption 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 foetor ex ore is observed not infrequently in chlorotics. 
Anorexia is a frequent symptom, but sometimes we notice bulimia, in- 17 
DISEASES OF THE BLOOD. 
creased thirst, or a desire for peculiar articles (pica). Many complain 
of gastric distention, violent pain in the stomach, eructations, and 
vomiting. Constipation is quite a constant symptom. 
The urine is generally light-colored, watery, and of low specific 
gravity. The urea and uric 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 may 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 gastralgia, since chlorosis creates a predisposition to round 
ulcer of the stomach. 
Chlorotics often suffer from leucorrhcea, 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. 
Repeated epistaxis is often observed. 
Finally, chlorosis creates a certain predisposition to pulmonary 
phthisis. 
In three cases, Gowers observed optic 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 symptoms 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 flabby 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 of fatty degeneration are also often found in the heaat 
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 distensible. The intima has a bluish appearance 
and presents yellowish elevations. The microscope shows fatty degene- 
ration in the intima and tunica media. The intercostal arteries are very 18 
DISEASES OF THE BLOOD. 
often given off 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. 
Fatty 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 regard it as a primary affection of the blood-producing or- 
gans, which gives rise to the production of a diminished number of red 
blood-globules containing a diminished amount of haemoglobin. 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. Tinder 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 nrolonged 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 the the patient. Cold rubbings are 
useful in 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 doses 
of iron. 
Almost every practitioner has a favorite iron preparation. Our own prefer- 
ence is for Blaud’s1 pills. 
The various preparations may be arranged in the following order, with regard 
to readiness of assimilation: ferrum redactum, ferrum lacticum, ferrura pulver- 
atum (gr. iss. three hours after meals), tinct. ferri pomata, tinct. ferri acetici, 
tinct. ferri chlorid. (30 drops t. i. d.). 
In some individuals, the mildest preparations produce gastric symptoms. In 
such cases, iron has been used subcutaneously, especially ferrum oxydat. dialysat., 
ferrum pyrophosphoric c. ammonio citrico (1 : 5), ferrum pyrophosplioric. c. na- 
trio citrico (1: 6), one syringeful subcutaneously. The solutions should be freshly 
prepared, since fungi 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 gastro-intestinal tract, so that 
some writers think it acts by producing liyperasmia 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. 
(gr. iss. every two hours), syrup, ferri iodid. (3 ss. t. i. d.), etc. Cod- 
liver oil should also be administered ( § 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 
n wineglassful of lukewarm water one-half hour after dinner and supper). 
If gastro-intestinal peristalsis is inactive, we may order the bitters, for 
■example, tinct. chinae comp. ( 3 i. t. i. d.), elix. aurant. comp. ( 3 i. 
t. i. d.), strychnin, nitricum (gr. f, pulv. althaeae, q. s. ut ft. pil. No. 
xv. D. S. One pillt. 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. 
5. Progressive Pernicious Ancemia. 
{Essential Pernicious Ancemia. Idiopathic Ancemia. 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 of 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 anaemia 
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 typhoid 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 m Switzerland, particularly in Zurich and its vicinity. Even in Zurich 
its 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. 
II. Symptoms.—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 
palpitation, perhaps complain of dizziness, and grow paler day by dav. 
Finally they are unable to leave the bed. 20 
DISEASE OF TIIE 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 symptom. In a few cases, the skin assumed a gray ot 
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 at 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 of the bones may 
be tender on pressure. In rarer cases, there 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° CL 
or more), of a continuous, remittent, or irregular type. 
The pulse is generally 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 lie 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 they must be carefully guarded in 
order to prevent them doing injury to themselves 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 anaemia- DISEASES OF THE BLOOD. 
21 
There is also a tendency to epistaxis, which may he repeated, increases 
the angemia, and occasionally is directly dangerous to life. 
The circulatoy organs rarely escape functional disturbances. In 
many, attacks of palpitation occur spontaneously or after slight excite- 
ment. The movements of the heart are then unusually vigorous, but 
the subjective symptoms may also exist without increased heart’s action. 
Not infrequently there is slight dilatation of the heart, usually the right 
side alone, occasionally also the left. The first heart sound is often 
converted into a systolic murmur, which may be heard over one or all 
of the cardiac orifices. In rare cases, we hear diastolic murmurs of a 
purely accidental character. 
The carotids generally pulsate vigorously, and systolic murmurs are 
Fig. 4. 
Blood in progressive pernicious anaemia. 
Poikilocytosis and a few spherical microcytes. Enlarged 600 times. 
often heard over them. A short arterial sound may also he heard in 
peripheral arteries (brachial, axillary, radial). 
The bruit de diable over the jugular vein is a constant symptom. 
True or negative venous pulse is often visible in the external jugulars. 
The bruit de diable may also be heard in the crural vein, but, un- 
like that in the jugulars, it grows feebler during inspiration, stronger 
during expiration. 
If the finger is pricked with a needle, the blood flows freely. As a 
rule, it is light colored, sometimes of an amber yellow. Coagulation 
may take place very slowly. The white blood-globules are generally 
very scanty. The so-called protoplasm granules (elementary granules, 
hsematoblasts) are present in small numbers. The number of red blood- 22 
DISEASES OF THE BLOOD. 
globules is very much diminished. Kjellberg found in one case only 
571,000 ini 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 elliptical, 
provided with prolongations, pear-shaped, etc. (vide Fig. 4) (poikilocy- 
tosis). As a rule, their dimensions are increased (8-9 //.instead of 7.6 //). 
Not a few attain a diameter of 15 // (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 varies from 
3-4 //. 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 coffee-like color, in another 
it was unusually dark. Strieker describes brownish blood-globules. The haemo- 
globin has been found separated from the stroma and accumulated in drops. 
Pilz mentions amoeboid movements of the red blood-globules. A few nucleated 
red globules have also been observed. 
The changes described may also occur in other forms of anaemia. Franken- 
haeuser described, in the blood of pregnant women suffering from progressive 
pernicions anaemia, spherical movable bodies with a swinging lash, which are 
supposed to have entered the blood from the liver and to constitute a certain 
stage of development of leptothrix (?). In three of my cases these bodies were 
also noticeable, but I could arrive at no conclusion with regard to their nature. 
In one case Quincke found that the blood amounted to 5#, in another to 4.34# 
of the weight of the body (normally 8$). 
In one case Fraenkel found that 100 parts of the blood, four days before death, 
contained 11.57 solid matters, of which 1.81 were nitrogen (15.66# nitrogen 
in the dried blood). Healthy blood gave the following figures: in 100 parts 20.24 
solid matters, 3.27# nitrogen, 16.17# 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 foetor 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 hasmatemesis 
is observed occasionally. The latter may continue for a long time, and 
rapidly exhaust the patient. Diarrhoea, sometimes of a bloody character, 
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 quantities, 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 has been noticed. 
Albuminuria is rare; Laacher observed peptonuria. Hoffmann found Tactic 
acid in the urine and an increased amount of kreatinin. Hsematuria has been 
observed occasionally. 
The nervous system is very often affected. Twitchings, paretic and 
paralytic conditions, and paraesthesiae are not unusual, but generally only 
temporary. DISEASES OF THE BLOOD. 
23 
The nerves of special sense may be involved. The patients suddenly 
become deaf, lose smell and taste, or complain of abnormal sensations 
in some of the nerves of special sense. Sudden blindness develops occa- 
sionally, 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 are 
sometimes present in astonishing numbers (vide Fig. 5). They vary 
greatly in size, but are sometimes almost as large as the optic disc. 
Fig. 5. 
Retinal changes in progressive pernicious anaemia. 
Light centre in the hemorrhages. After Quincke. 
They are most abundant in the neighborhood of the papilla. They are 
generally streaked, and often radiate towards the papilla. The recent 
ones are ruby-red, the older ones brownish-red, the latter not infre- 
quently containing a light-yellow centre. Large numbers sometimes 
appear suddenly in the course of a single day, but they may be absorbed 
in a relatively short time (two to three weeks). 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 pernicious anaemia into other 
diseases have been reported. For example, it has been followed by the symp- 
toms of myelogenic leukaemia, or of sarcomatosis of the bones. In one of my 
cases it was followed by a beginning cancer of the pylorus. As the anaemia had 
existed for a year, and the cancer was just beginning, it would be irrational to 
regard the anaemia 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 cadaverous 
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 generally found to be intact. Berger 
found colloid degeneration of these organs. Mueller describes fatty degeneration 
of the diaphragm and intercostal muscles. E. Fraenkel noticed a large amount 
of yellow an«l brown pigment in the ocular muscles; the muscular fibres were 
cloudy and granular. 
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 hae- 
moptysis, haematuria, or liaematemesis, although no bleeding vessel can 
be 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 body had an acid reaction. According to 
Quincke, the specific gravity is 1028.2 (normally 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 DISEASES OF THE BLOOD. 
25 
in the left heart, particularly in the papillary muscles of the mitral valves. 
They are often so numerous that the heart muscle has a butter-yellow, 
speckled, 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 
parts are intact. Nuclear proliferation is absent, but there are often 
small interstitial hemorrhages. These appearances are rarely absent in 
progressive pernicious anaemia. 
The endocardium is thin and transparent, and occasionally presents 
hemorrhages, slight fatty degeneration and atheromatous changes. The 
valvular 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 occasionally oedema 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. 
Hemorrhages into the organ have also been reported. 
In one case, Leber found a large amount of leucin and tyrosin in the spleen, 
liver, lungs, and pancreas. Attention has been called recently to the large 
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. 
Hemorrhages are observed not infrequently. The gall-bladder is often 
filled with dark bile. Pepper observed ecchymoses in the mucous mem- 
brane of the gall-bladder. 
The hepatic cells are often in a condition of fatty degeneration. In one case, 
Mueller and Winge observed the development of adenoid tissue with an accu- 
mulation of round cells. 
A large amount of iron has been found in the liver. 
The gastro-intestinal mucous membrane often presents cedematous 
swelling and extravasations of blood. Enlargement of the intestinal 
lymph follicles and fatty degeneration of the glandular epithelium have 
also been observed. 
Juergens and Sasaki described fatty degeneration and atrophy of the nerve 
plexus of the intestines, but these changes are probably secondary. 
The mesenteric glands are often swollen, hypersemic in places, and 
speckled with blood. In one case, all the glands were swollen and red, 
and the lymphatics were dilated and contained bloody lymph. 
The pancreas may be very large and congested, with hemorrhages 
into the interstitial tissue. The glandular epithelium is in 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. Thickening 
of the Malpighian capsules, and fatty degeneration of the blood-vessels 
have also been noticed. Hemorrhages have been observed upon the mu- 
cous membrane of the urinary passages and sexual organs. 
Extravasations occur frequently in the meninges, particularly on the 
inner surface of the dura mater. 26 
DISEASES OF THE BLOOD. 
The brain almost always contains numerous capillary hemorrhages, 
generally in the white matter. Certain vessels are sometimes in a con- 
dition of fatty degeneration. In one case, Schumann found spindle- 
shaped and ampullary dilatations of the vessels. The brain and spinal 
cord are very pale. 
Changes in the sympathetic system (proliferation of the interstitial 
connective tissue, atrophy of the nerve fibres and ganglion cells) have 
been described in a number of cases, but Lubimoff has shown that we 
must be 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 hemorrhages consist solely of red blood-globules. In older 
cases, granular disintegration begins in the centre of the extravasation, and ex- 
tends peripherally; in such cases the ophthalmoscope shows a light yellow centre. 
In rare cases white patches are produced by the presence of white blood-globules 
in the centre of the extravasations. In one case, Krukenburg noticed varicose 
nerve fibres. 
The hemorrhages are generally situated free. In a few cases, the blood is situ- 
ated in the adventitious lymph space. 
The retinal vessels not infrequently contain spindle-shaped and ampullary di- 
latations. 
In many cases the medulla of the bones is unchanged. In other cases 
it contains hemorrhages, or the fat tissue disappears and is replaced by 
red lymphoid medulla. 
In addition to a large number of spherical red blood-globules, the medulla con- 
tains numerous nucleated red blood-globules (so-called transitional forms). It 
often contains a large number of cells which inclose blood-globules. 
The majority of writers believe that progressive pernicious ansemia is 
a disease of the haematopoietic organs which leads to insufficient forma- 
tion of blood. Perhaps the imperfectly formed red blood-globules some- 
times undergo unusually rapid destruction. Whether the spherical 
blood-globules are poorly developed or are approaching destruction, re- 
mains doubtful. 
All other anatomical and clinical symptoms depend upon the impov- 
erishment of the blood. The fatty degeneration of the heart and gland- 
ular epithelium, and the abundant development of the panni'culus 
adiposus are’probably owing to the fact that, on account of the impover- 
ishment of the oxygen-carriers in the blood, the albuminoids of the 
tissues not alone are decomposed freely into urea-forming and fat-forming 
substances, but that the latter remain in situ and are not oxidized into 
carbonic acid and water. 
The hemorrhages are sometimes the direct result of the impoverish- 
ment of the blood, rather than of fatty degeneration and rupture of the 
vascular walls. The nutrition of the vessels seems to be disturbed in 
such a way that the red-globules readily pass through by diapedesis. 
The changes in the medulla of the bones are also secondary and anse- 
mic in character, and E. Neumann has shown that they develop after 
other ansemic and cachectic conditions. 
IY. Diagnosis.—The diagnosis is by no means easy, particularly at 
the onset of the disease. Among other things, latent cancer may lead to 
error. The disease is readily distinguished from chlorosis, because the diseases of the blood. 
27 
latter occurs almost exclusively in women at the period of puberty, is 
apyrexial, and disappears rapidly under the use of iron. The occurrence 
of fever may lead to the diagnosis of typhoid fever, endocarditis, or 
meningitis, but the further course of the disease will clear up the diag- 
nosis. Finally, atrophy of the peptic glands may present the symptoms 
of progressive pernicious anasmia, but the former disease is rare, and its 
independent existence is even questionable. 
Ar. Prognosis.—The majority of patients are inevitably doomed. 
According to some writers, intermissions may last for months and years, 
but finally a fatal relapse supervenes. 
VI. Treatment.—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. As in chlorosis, we prefer Blaud’s pills; 
if these are not tolerated, the ethereal tinctures of iron may be employed. 
Some authors recommend phosphorus, and particularly arsenic. 
When the anaemia becomes excessive, it is said that transfusion of 
blood (perhaps sodium chloride is preferable) sometimes produces good, 
and even permanent effects. 
6. Purpura Simplex. 
I. Symptoms.—In this disease, hemorrhages occur into the skin. 
They are generally round, as large as a pin's 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. Etiology.—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. Prognosis, Treatment.—The prognosis is always favorable. 
The treatment consists merely of rest and nourishing diet, perhaps iron 
in anaemic individuals. 
7. Purpura Rheumatica (Peliosis Rheumatica). 
I. Symptoms and Diagnosis.—This disease consists of purpura of 
the skin, and painful swelling of the 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 joints, particularly the elbows. Not in- 
frequently there is slight swelling of the joints. 
Soon after, or coincidently with the pains in the joints, patches of 
purpura appear on the skin. They occur most abundantly and early on 28 
DISEASES OF THE BLOOD. 
the legs, later the trunk and upper limbs may be affected. The exten- 
sor surfaces are the favorite site, in some cases in the vicinity 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 pressure, 
and a few are elevated into papules. The legs are often oedematous, and 
oedema of the eyelids is also observed not infrequently. Urticaria may 
be present in certain parts, and either disappears or is replaced by hem- 
orrhages. 
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 may not be present. Kaltenbach noticed apyrexia in the morn- 
ing, elevation of temperature in the early part of the afternoon, and 
gradual defervescence at night. 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 
liaematuria, 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 age 
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 always 
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 Hemorrhagica. 
{Morbus Maculosus Werlhojii.) 
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. DISEASES OF THE BLOOD. 
29 
In many cases, no cause can be ascertained; in others, it is attributed 
to cold, exposure, damp dwellings, and insufficient nourishment, so that 
the disease is sometimes endemic in barracks, foundling asylums, and 
boarding-schools. 
The symptoms of the disease sometimes appear during convalescence 
from severe infectious diseases, particularly typhoid and intermittent 
fever, and also during pregnancy or child-bed. 
Dohrn reports a case in which a pregnant woman, suffering from purpura 
hemorrhagica, gave birth to a child who presented evidences of the same disease. 
This was evidently owing to the influence of the same causes upon the blood and 
blood-vessels of mother and foetus. 
A few cases of toxic purpura have been reported, for example, after 
the inhalation of sewer gas, after the ingestion of pork, and in a man 
who was buried in a well for ninety-six hours. 
II. Symptoms.—The disease begins suddenly, or it is preceded by 
prodromata. The latter consist of anorexia, general malaise, vomiting, 
vertigo, and slight fever. They last for a few hours or several days. 
• The first visible changes are the cutaneous hemorrhages. These ap- 
pear first on the legs, later on the trunk and upper limbs. In many 
cases, the face escapes. The extensor surfaces are affected more severely 
than the flexor surfaces. 
The majority of the extravasations are as large as the point of a 
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 ecchymoinata or vibices ; 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 extravasations 
changes to brownish-red, blue, green, and yellow. 
Among the rare complications is elevation of the epidermis into vesicles,, 
evidently from the accumulation of blood between the epidermis and rete Mal- 
pighii. Urticaria is occasionally observed. Suppuration or gangrene of the hem- 
orrhagic parts is a rare event. Still rarer is the escape of blood in fine drops 
upon the surface of the epidermis. Hemorrhages can sometimes be produced 
voluntarily by pressure upon the skin. 
Hemorrhages upon the mucous membranes appear at the same time, 
or soon afterwards. They are most frequent upon the nasal mucous 
membrane, and may cause more or less violent epistaxis. Hemorrhages 
into the lips, cheeks, and gums are not infrequent ; and those into the 
gums may give rise to very violent hemorrhage, although the parts are 
not swollen or loosened. In a few cases, vesicles form upon the buccal 
mucous membrane. Haematemesis or enterorrhagia indicates hemor- 
rhage from the gastro-intestinal mucous membrane. These symptoms 
are sometimes very violent, and may even terminate in perforation-peri- 
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 haematuria, metrorrhagia, and 
haemoptysis 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 becomes light yel- 
low as absorption occurs, and the focus may disappear entirely in a few 
weeks. There may be considerable retinal hemorrhage without visual 30 
DISEASES OF THE BLOOD. 
disturbance. Epileptiform attacks and paralysis are sometimes ob- 
served as the result of meningeal and cerebral hemorrhages. 
After extensive hemorrhages, the blood may grow lighter in color. 
Under such 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 anaemia 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. 
Relapses have been observed in a number of instances. In Rohlfs’ 
case, twelve relapses occurred in twelve years. 
The sequelae include paralysis as the result of cerebral hemorrhage, 
and in one case, diabetes mellitus (perhaps from hemorrhage into the 
medulla oblongata). Fagge 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 
petechise. Variot attempted to show that the 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- 
patic veins with red blood-globules which seem to have passed, by diapedesis, 
directly 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 ferric 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 walls 
of the vessels. 
IV. Diagnosis.—The diagnosis is easy. 
Purpura simplex is confined chiefly to the external integument; at 
all events, it presents no free hemorrhages. 
In peliosis rheumatica, the joint changes are prominent, and free 
hemorrhages do not occur. 
Scurvy shows the specific affection of the gums. DISEASES OF THE BLOOD. 
31 
Haemophilia is an hereditary or a congenital, permanent disease. 
Acute exanthemata of an hemorrhagic character are attended with 
high fever and specific cutaneous changes. 
Y. Prognosis.—As a rule, the disease runs a favorable course. 
Sudden onset, high fever, and profuse hemorrhages are grave symptoms. 
Death occurs with relative frequency in pregnant and puerperal women, 
because abortion and uncontrollable uterine hemorrhage may be pro- 
duced. 
VT. Treatment.—The patients should be kept constantly in bed. 
The diet should be nutritious, and stimulating articles, such as coffee, 
tea, and alcoholics, should be interdicted. Thirst should be relieved by 
sulphuric-acid lemonade. The bowels should be evacuated daily. If 
signs of weakness appear, we may order the following: 
Decoct, cort. chinae § vi. 
Acid, sulphur, dil 3 i. 
Syr. simp § ss. 
M. D. S. One tablespoonful every two hours. 
Otherwise, purely symptomatic treatment. 
9. Scorbutus. 
{Scurvy.) 
I. Etiology.—Scurvy is clinically related to purpura hemorrhagica 
•and purpura rheumatica. Hemorrhages occur upon the skin and mu- 
cous membranes in this disease, and are associated with a tendency to 
inflammations. 
Scurvy is an inanition process, which may result from various, some- 
times diametrically opposed causes. 
The most important cause is poor nourishment. 
In some cases, scurvy is the result of insufficient food, so that it is often ob- 
served in prisons, during famine, long sieges, long trips at sea, etc. 
It is not infrequently the result of the ingestion of spoiled articles of food, 
but this cause is often associated with the former one. Good drinking-water is 
an important feature in such cases. 
In a third group of cases, the quantity and quality of the articles of diet are 
sufficiently good, but their combination is defective. Most important is ab- 
stinence from fresh vegetables, particularly potatoes. Thus epidemics of scurvy 
have been observed in Ireland and England as the result of failure of the potato 
orop. On the other hand, there is no more certain and rapid means of relieving 
scurvy than by giving plenty of fresh vegetables. In like manner, abstinence 
from fresh meat may produe 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 ventilated, and overcrowded dwellings, and 
exposure to wet also act as causes of scurvy.. 
Epidemics due to these causes have been observed in prisons, bar- 
racks, orphan asylums, arctic explorations, etc. 
It is evident, from the foregoing considerations, that the geographical 
position and meteorological conditions influence the development of the 
disease. It is often observed in northern latitudes and in rainy, cold 
districts. Epidemics are more frequent in winter and spring than in 
summer and autumn. 32 
DISEASES OF THE BLOOD. 
Bodily and mental strain must also be included among the causes of 
scurvy. It has been observed repeatedly among sailors and besieged, 
when they were required to perform increased work (perhaps also, be- 
cause the food then proved insufficient). Sometimes, however, the 
hard-working individuals escaped, while the drones were attacked by 
the disease. It is also said that, under such circumstances, courage 
and a hopeful disposition antagonized the spread of scurvy, while the 
hopeless ones and cowards fell victims to the malady. Homesickness 
(nostalgia) has also been regarded as an important causal agent. 
Scurvy is more frequent 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 is sometimes congenital 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 is also more apt to occur inpatients who have 
suffered from malaria, dysentery, typhoid fever, or syphilis. 
Scurvy generally occurs in epidemics. The losses of life from this 
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 Ume, the disease is endemic in certain 
regions, for example, in Russia and Roumania. 
II. Symptoms.—Scurvy rarely develops suddenly, and such cases 
generally run an acute and often a pernicious course. As a rule, it is 
preceded by prodromata which sometimes last only a few days, but often 
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 eyes dull 
and sunken, and dark-brown patches of pigment are sometimes observed 
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. Dyspnoea 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- 
gins at the anterior surface of the incisors, and then extends internally 
and laterally. The changes are not observed in places where the teeth 
are absent, but they crawl along the stumps of teeth. 
The veins at the free edge of the gums are first distended, the gums 
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 tissue becomes necrotic and 
is converted into a brownish or blackish pulp. 
The inflammation of the gums is so much less intense the greater 
the distance from the free edge of the teeth, and it generally ceases en- tirely at the base. The mucous membraue 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 inflammation 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 foetor 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 gums 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. 
I he cutaneous hemorrhages generally appear as petechiae 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 infrequently becomes dry and fibrillated, 
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- 
iymg skin can be moved very little or not at all, feels doughy, is often 
painful on pressure, and its temperature is increased. Such hemorrhages 
are seen with special frequency around the tendo Achillis and ha'm- 
strings, and are often, the result of traumatic or mechanical causes. 
Ihey 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 of pes varo-equinus or other deformity, or of false ankvlosis 
oi tlie knee joint. The underlying muscles may also undergo atrophy 
DISEASES OF THE BLOOD. 
33 34 
DISEASES OF THE BLOOD. 
as the result of pressure. Inflammation and suppuration sometimes set 
in, the skin is perforated, and a chocolate-colored, sometimes foul-smell- 
ing mass is discharged. This terminates in ulcerations similar to those 
following cutaneous hemorrhages. Hemorrhages next to or beneath the 
nails may give rise to inflammation, sometimes to loss of the nails (ony- 
chia and paronychia scorbutica). 
Muscle hemorrhages occur most frequently into the calves, extensors 
of the thighs, buttocks, and abdominal muscles. They are so much more 
painful the more rapidly they develop. Suppuration and perforation 
through the skin may ensue, or sclerotic thickenings are left over with 
contracture and deformity of the limbs, or atrophy and muscular weak- 
ness develop. 
Hemorrhages from the mucous membranes (epistaxis, lisematemesis, 
enterorrhagia, haematuria, more rarely metrorrhagia and haemoptysis) are 
much less frequent, but they occasionally prove fatal. 
Painful swelling of the joints develops in some cases. The fluid in 
the joints may be purely serous or hemorrhagic. The process is some- 
times followed by suppuration, erosion, deformity of the ends of the 
bones, and true ankylosis. 
Hemorrhages and inflammations may also occur in the serous cavi- 
ties. The inflammations are generally hemorrhagic in character, and 
most frequently involve the pleura or pericardium, more rarely the peri- 
toneum. They often develop with extreme rapidity, and produce 
profound anaemia or place the patient in danger of suffocation from 
compression of the lungs or of paralysis of the heart. Some authors 
have observed rapid absorption of exuded fluid. Meningeal hemor- 
rhages ■ also occur and are characterized by pain, paraesthesia, spasms, 
contractures, paralyses, and apoplectiform attacks. 
Subperiosteal and epiphyseal hemorrhages are rare events in scurvy. The 
former chiefly involve the anterior surface of the tibia, but may also occur on other 
bones (scapula, lower jaw, hard palate). The accumulated blood forms a painful 
swelling, but generally undergoes absorption. The epiphyseal hemorrhages are 
relatively most frequent on the costal cartilages, where they cause separation of 
the ribs from the cartilages, so that the free ends of the ribs sink inwards. 
• 
Scorbutic changes-arc observed not infrequently in the eye. Con- 
junctival hemorrhages and inflammations may set in, likewise hemor- 
rhages into the anterior chamber or hemorrhagic chorioiditis. The 
peculiar form of keratitis (generally bilateral) with subsequent panoph- 
thalmitis, which is seen after disease of the trigeminus (vide Yol. III., 
page 68), has also been observed. Hemeralopia occurs with relative 
frequency, as a prodrome, during the development of the manifest 
symptoms or as a sequel. 
As the manifest symptoms of scurvy gradually develop, the general 
condition grows worse. The appearance of the patient becomes cachec- 
tic, and the panniculus adiposus and muscles ivaste away. In some 
cases, however, the general nutrition remains intact for a very long 
time. Fever may be absent or it is slight and irregular. Considerable 
elevation of temperature is generally the result of abscess formation. 
The heart presents anaemic dilatation and systolic murmurs, and the 
spleen is sometimes enlarged. There is occasionally diarrhoea which may 
assume a dysenteric character. In a number of cases a connection has 
been observed between scurvy and true dysentery. The urine varies in 
amount, is generally acid, and its specific gravity diminished. It often DISEASES of the blood. 
35 
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 excre- 
tion of uric acid. In a number of cases the amount of potash saits was increased. 
Grocco mentions peptonuria. 
Examinations of the blood do not furnish uniform results. The following 
changes have been observed at times : diminution or abolition of coagulability, 
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. 
III. Anatomical Changes.—Rigor 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 
infrequently contain clots, and manifest changes in the connective tis- 
sue which have termin'ated 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 calius 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 very 
small, so that the viscera are amende 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 cedema 
(sometimes hemorrhagic), or pneumonic or gangrenous changes, or hem- 
orrhagic infarctions following extravasations or emboli (the latter sec- 
ondary to cardiac thrombi). 36 
DISEASES OF THE BLOOD. 
The spleen is often enlarged and very soft, and not infrequently con- 
tains hemorrhagic infarctions. 
The gastro-intestinal mucous membrane frequently presents bloody 
suffusions, also follicular ulcerations and necrotic (diphtheritic) changes. 
Hemorrhages and fatty degeneration have been observed in the liver. 
The kidneys are generally intact. Bloody suffusions are frequent on 
the mucous membrane of the urinary passages and genital organs. 
Leven found fatty degeneration of the muscles, earliest in those which are 
most used, viz., the heart, muscles 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 cells 
were separated from one another, and the red blood-globules had passed through 
the interstices into the surrounding tissues. 
No corpuscular or chemical 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 at 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. 
t 
IV. Diagnosis.—The symptoms are so characteristic that the diag- 
nosis is easy. Special weight should be attached to the affection of the 
gums. 
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 
good water, fresh meat and vegetables, particularly potatoes and sauer- 
kraut. 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 the 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 ( § ij.-3 vi.) daily of certain cruciferae, such as 
cress, radish, sorrel, sauerkraut, various kinds of cabbage, dandelion, 
etc. Some recommend beer yeast in doses of § v.-x. daily. 
The drugs to be 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 (3 i. : or acetate of alumina (gr. xv.: % iij.) Ulcers on 
the gums and exuberant proliferations are touched with the solid stick. 
Drastics must be avoided in scurvy, since they are apt to produce 
dangerous intestinal hemorrhage. 
Hcemophilia. 
(Ilcematopliilia. HcemorrhopMlia.) 
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, haemophilia occurs 
in every generation; 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 
healthjr 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 bleeders, the children are almost always bleeders. 
Some of the male descendants escape the disease, and it is not probable that 
such individuals will beget haemophilic 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 
England, France, and North America. Among 210 families of bleeders, 94 lived 
in Germany, 52 in Great Britain, and 23 in North America. Among 780 cases, 
717 were males, 63 females. A predisposition to haemophilia has been attributed 
to the Anglo-Germanic 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 case in 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, haemophilia is sometimes masked behind profuse, long- 38 
DISEASES OF THE BLOOD. 
continued menstruation. Kehrer 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 epistaxis is frequent. 
In some cases, it is said 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 tying the umbili- 
cal cord. But, on the one hand, this does not occur very often, and, on 
the other hand, does not always depend on haemophilia. 
The first symptoms of the disease appear most frequently at the period 
of first dentition, in rare cases not until the period of 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 
rarely attain old age. The haemophilic 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 of 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 hasma- 
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. Cases 
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- 
ping are dangerous. Small wounds are sometimes more dangerous than 
larger ones, and Fordvce 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 Avet 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. DISEASES OF THE BLOOD. 
39 
Microscopical and chemical examination furnishes negative results. 
The number of red blood-globules is sometimes increased. Herard states 
that the organic constituents of coagula are diminished, the salts in- 
creased. 
The hemorrhages are sometimes so profuse that death ensues in a few 
hours. In other cases, they last for days and weeks. The enormous 
amounts of blood lost, and the rapidity with which the patients are re- 
stored, are often astonishing. Syncope following anaemia 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 anaemia is ex- 
cessive, oedema may develop, together with anaemic changes in the heart 
(dilatation, systolic murmurs). Febrile conditions are sometimes ob- 
served. 
It has been claimed that bleeders are characterized by slight 
physique, blond hair, blue eyes, superficial vessels, and a tendency to 
blushing, but there are many exceptions. Kunze observed premature 
grayness of the hairs, Legg and Sedgwick found multiple ntevi in 
bleeders. 
III. Anatomical Changes.—No constant changes have been found 
in haemophilia. Virchow noticed smallness of 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 spleen has also been 
described. 
Microscopical changes in the cutaneous vessels have been described in a few 
cases, but they were probably mere coincidences. Birch-Hirschfeld noticed 
enlargement of the endothelium cells in the capillaries and transitional vessels, 
swelling of their nuclei, and granular deposits in their protoplasm ; silver prepara- 
tions showed unusual irregularity of the endothelium. Kidd described increase of 
the endothelium, dropsical swelling of the muscular coat, and proliferation of its 
nuclei, in the finer vessels of the subcutaneous connective tissue and in the 
muscles. Legg was unable to find these changes. 
Nothing is known with certainty concerning the nature of the disease. 
Imraermann attaches chief importance to the narrowness and thin walls of the 
vessels, and to increase in the amount of blood, which occasionally seeks an out- 
let. In addition to the thinness of the walls of the vessels, Cohnheim assumes 
impoverishment of the blood in red blood-globules (unpro'ven) and a secondary 
tendency to hemorrhages. The following hypothesis seems to me to be the most 
plausible: diminution of the number of white blood-globules (Assmann), hence slow 
production and diminished resistance of coagula (Lossen), injurious effect of the 
changed blood on the vessels, with increased tendency to diapedesis and rhexis. 
Why the white globules are diminished in number is unexplained. 
IV. Diagnosis.—The recognition of the disease is not difficult if 
manifest symptoms are present. It is distinguished from scurvy by the 
fact that it is unattended with inflammation and proliferation of the 
gums, and is not a temporary condition. The latter circumstance also 
distinguishes it from morbus maculosus Werlhofii and purpura. The 
differentiation between hsemophilic 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. 
VI. Treatment.—Prophylaxis must first be directed against the 40 
DISEASES OF THE SPLEEN. 
spread of hereditary haemophilia, by prohibiting marriage in families 
in which the disease is hereditary. 
This alone, if carried into effect, would not extirpate the disease, 
since it sometimes develops primarly (congenitally) from unknown causes. 
Inasmuch as experience teaches that a number of children in a family suffer 
from the disease, it would be wise to recommend that the parents 
endeavor to prevent an increase in their family. 
Bleeders should be protected, as much as possible, against injuries. 
They should be exempt from conscription as soldiers. Their diet 
should not include stimulating substances, such as alcoholics, tea, or 
coffee. If a hemorrhage occurs, it must be treated according to surgical 
principles, by rest, elevation of the bleeding part, prolonged com- 
pression, the actual cautery, and sutures. Not much can be expected 
from 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. 
Bheumatoid and neuralgic complaints, and non-hemorrhagic swelling 
of the joints must be treated symptomatically. 
PART II. 
DISEASES OF THE SPLEEN. 
Acute Enlargement of the Spleen. 
(Acute Splenic Tumor.) 
I. Etiology.—Acute splenic tumor is a rapid enlargement of the 
organ which only lasts a short time. It is merely a symptom of certain 
primary affections. 
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. Anatomically, it consists of 
increased amount of blood, often of extravasations of blood, swelling, 
and proliferative processes in the cells of the splenic pulp. 
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 abundant absorption of the digested masses from the intestines im- 
pedes the flow of blood from the splenic vein. DISEASES OF THE SPLEEN. 
41 
Certain authors claim that the spleen may enlarge in cases of suppressed 
menses, as the result of arterial congestion. 
The most frequent and important form of splenic enlargement is 
that due to infection. It occurs in infectious diseases. It is rarely ab- 
sent in intermittent and typhoid fever, and is also observed in typhus 
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, coryza, variola, scarlatina, 
measles, erysipelas, pyaemia, septicaemia, 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 suffered 
from intermittent fever or syphilis during pregnancy. 
In many of these diseases, enlargement of the spleen is not a constant 
symptom, or at least it cannot always be demonstrated clinically. The 
severity of the infectious disease does not correspond to the degree of 
splenic enlargement. The latter not infrequently precedes the other 
symptoms 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, but of hyperplastic processes in the cells of 
the spleen. According to Friedreich, there is danger of a relapse in 
typhoid fever so long as the spleen is enlarged. 
It is well known that fine particles of pigment which are introduced into the 
circulation of an animal are deposited in great part in the spleen and even enter 
the cells of that organ. As we are justified in regarding bacteria as the cause of 
infection, it is probable that these likewise find a favorable place of deposit in the 
spleen. The cells of the spleen will then react with special facility to the irrita- 
tation produced by the bacteria, because these cells form an intermediate condi- 
tion, inasmuch as they are awaiting transformation into higher cells (red blood- 
globules), 
II. Anatomical Changes.—The spleen may attain six times its 
normal dimensions. 
In traumatic enlargement of the spleen, evidences of injury are 
generally found in the neighborhood of the organ. 
Embolic enlargement is characterized by the wedge-shaped infarction 
(vide page 46). 
In stasis spleen, there is striking distention with blood, together 
with changes in the district of the portal vein. 
In infection spleen, as a rule, the capsule is transparent and tense, 
and is only wrinkled when the process is undergoing involution. The 
splenic pulp is soft and diffluent, but this is partly the result of post- 
mortem change, since it is found even though the splenic tumor was felt 
to be quite hard during life. The spleen is often so soft that fine dis- 
tinctions in its structure cannot be recognized. Occasionally, it con- 
tains wedge-shaped foci, whose origin is not clearly recognized. 
In the spleen of infectious diseases, the microscope shows congestion, swelling 
of the splenic cells, increase of the nuclei, fatty degeneration; under certain cir- 
cumstances, increase of the blood-corpuscle-containing cells, infiltration of the 
walls of the vessels with round cells, and extravasations of blood. 
In sixty-eight cases of sudden death and suicide, Birch-Hirschfeld 42 
DISEASES OF TIIE SPLEEN. 
found that the average weight of the spleen was five ounces, or 0.26# of 
the weight of the body. 
III. Symptoms.—In the majority of cases, splenic enlargement is 
only recognized by directing special attention to the organ. Subjective 
symptoms may be absent, but complaint is sometimes made of tension, 
a feeling of pressure, or stitches in the splenic region. The pains occa- 
sionally radiate even into the left arm and leg. These symptoms may 
increase in left lateral or even in right lateral decubitus, because the 
heavy spleen drags upon its ligaments. 
Acute enlargement of the spleen is rarely so marked as to be recog- 
nizable on inspection. The splenic region would then be prominent, 
and perhaps, if the abdominal walls are thin and flaccid, a tongue- 
shaped prominence, which moves with respiration, is seen in the left 
hypochondrium. 
Palpation furnishes the most important results. The spleen can 
hardly ever be felt unless it is enlarged. If the tumor extends towards 
the linea alba, indentations can sometimes be felt in its anterior edge. 
Palpation sometimes gives rise to pain. 
During palpation, the patient should assume the right diagonal position, i. e., 
he lies upon the right shoulder in a position midway between right lateral and 
dorsal decubitus. The physician stands to the left of the patient, near his head, 
and the tips of the second, third, and fourth fingers are gently placed in the space 
between the lowest cortal cartilages and the free end of the eleventh rib. Dui-ing 
vigorous respiratory movements the organ will be felt, at each inspiration, pro- 
jecting beneath the left hypochondrium. If the pressure of the fingers is too 
great, the spleen is often pushed upwards and backwards, and soft tumors thus 
escape recognition. 
The spleen may be mistaken for digitations of the diaphragm, or the tendinous 
origin of the left rectus abdominis. In pleurisy, pneumothorax, emphysema, 
curvature of the spine, and pericarditis, the spleen is sometimes pushed down- 
wards and becomes palpable, although it may not be enlarged. 
Splenic enlargement may also be recognized by percussion, although 
this offers many sources of error. The most frequent source of error is 
distention of the stomach and colon with firm masses. On the other 
hand, in meteorism splenic dulness may be absent, despite enlargement 
of the organ. We must always be on our guard if splenic dulness is 
enlarged, but the organ cannot be felt. It is suspicious if the 
increased dulness varies from the ordinary shape of the spleen, if it 
changes from day to day or after evacuation of the bowels. 
In embolic enlargement of the spleen, it is conceivable that a peri- 
tonitic friction murmur may be heard and even felt if the infarction has 
given rise to inflammation of the capsule. Griesinger described inter- 
mittent and continuous roaring vascular murmurs in splenic enlarge- 
ment as the result of intermittent fever during the febrile period. Hos- 
ier states that these murmurs occur almost constantly during the period 
of chill, grow feebler in the hot stage, and disappear in the apyrexial 
period. Griesinger attributed the murmurs to the large abdominal veins, 
Hosier to contractions of the splenic artery. Hosier also described a 
splenic murmur in a case of relapsing fever. 
The duration of acute splenic enlargement depends upon the course 
of the primary disease. In rare cases, the soft spleen ruptures and gives 
rise to peritonitis and rapid death. 
In some cases the enlargement persists and becomes chronic. 
IV. Diagnosis and Prognosis.—The diagnosis is not always easy; 
smaller tumors often remain unrecognized. DISEASES OF THE SPLEEN. 
43 
The prognosis depends on the primary disease. Rupture of the spleen 
is so rare that this possibility hardly affects the prognosis. 
V. Treatment.—The treatment is almost always included in that 
of the primary disease. A subcutaneous injection of morphine may be 
necessary if the pains are very severe. If there is danger that the con- 
dition will become chronic, the remedies mentioned in the following 
section should be employed. 
2. Chronic Enlargement of the Spleen: 
(Chronic Splenic Tumor.) 
I. Etiology.—This term is applied to those cases in which enlarge- 
ment of the spleen exists for a long time. It sometimes develops 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 splenic 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- 
ka3mia, pseudoleukaemia, waxy degeneration, neoplasms, tubercle, 
gumma, and parasites. Chronic splenic enlargement has also been 
found in rickets and scrofula. 
The affection rarely occurs in children and old people.. But it is 
sometimes congenital, and then is often regarded as an indication of 
hereditary syphilis. 
II. Anatomical Changes.—The spleen sometimes attains ten to 
twenty times its normal dimensions, and it may weigh five to ten kilo- 
grams. 
The organ sometimes occupies the greater part of the abdominal 
cavity, compresses and displaces adjacent organs, and extends into the 
pelvis. The capsule is often thickened, and here and there may contain 
fibro-cartilaginous deposits. The anterior edge often presents very deep 
indentations, and these 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 
cheesy 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, as in leukaemia. In passive congestion of the 
spleen, the increase of the connective tissue predominates. In other 
cases, there is a combination of both lesions. In intermittent fever, the 
spleen is characterized by the abundance of black pigment. In neo- 
plasms and parasites, there is enlargement of the organ, although the 
splenic tissue proper is not infrequently diminished in amount. 
Ilf. Symptoms and Diagnosis.—The remarks made concerning 
the symptoms and diagnosis of acute splenic enlargement also hold good 44 
DISEASES OF THE SPLEEN. 
with regard to the chronic form. Subjective symptoms may be entirely 
absent. On palpation, the spleen generally feels firm. As the enlarge- 
ment is sometimes very great, symptoms of compression appear on the 
part of the lungs and heart (dyspnoea) or the abdominal organs. Ac- 
cording to some authors, chronic ulcers of the leg may be the result of 
chronic splenic tumor (pressure on the inferior vena cava). 
According to Piorry, pressure on the spleen sometimes produces chill 
and tremor. Naunyn observed cough 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 he has 
observed increased heat in the splenic region. Gerhardt recently de- 
scribed, 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 dyspnoea, anasmic 
.sounds are audible in the arteries, and murmurs in the veins, hemor- 
rhages occur into the skin and mucous membranes. They suffer from 
oedema, and finally die of cachexia. Some of these symptoms, it must 
be remembered, may be the result of the primary disease. 
The disease sometimes lasts for years. 
IV. Prognosis.—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 
splenic enlargement is the result of a neoplasm, we can merely maintain 
the strength of the patient as much as possible by nourishing food and 
tonics. In gummata of the spleen, astonishing results are often obtained 
by the administration of potassium iodide. Echinococci of the spleen 
must be treated surgically. Under more favorable circumstances, inter- 
nal and external remedies may be employed. 
The chief internal remedy is quinine, which may be given by the 
mouth or, better still, injected subcutaneously (with glycerin and water 
aa) in the splenic region. If quinine is not tolerated, we may order 
arsenic (I£ Liq. potass, arsenit., Aq. amygdal. amar., aa § ss. M. D. S., 
five to ten drops t. i. d. after meals). 
If there is pronounced aneemia, we should order iron or iodide of 
iron, combined with quinine. 
Individuals who live in a marshy and malarial region should change 
their residence. 
The various alkaloids of Peruvian bark, piperine, salicin, ergotin, potassium 
bromide, pilocarpine, etc., have also been recommended to diminish the size of 
the spleen. 
The efficacy of internal remedies may be aided by external measures. 
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. 
45 
Extirpation of the spleen (splenotomy) is indicated when death by 
suffocation threatens, as the result of compression. 
3. Inflammation of the Splenic Capsule. 
Perisplenitis. 
I. —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). 
II. 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. 
III. 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. Eirm 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 aud is not unusually large, or if 
splenic dulness remains, despite the occurrence of perforation-peritonitis. 
IV. Treatment.—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 rise more frequently to rupture of 
the spleen), and, according to some writers, of great bodily strain. 
Silberstein reported a case in which abscess of the spleen is said to have 
resulted from violent sneezing. In many cases the 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 wedge-shaped infarc- 
tions, but in which no embolus can be found, occur in infectious dis- 
eases (pyasmia, septicaemia, typhoid and relapsing fever, cholera), in 
protracted, exhausting diseases, and in Bright’s disease. 
Splenitis is sometimes propagated from adjacent parts. Round ulcer 46 
DISEASES OF THE SPLEEN. 
of the stomach, toxic gastritis, peritonitis, and perinephritis may extend 
to the spleen, and give rise to secondary inflammation of that organ. 
Pulmonary gangrene may also extend to the diaphragm and spleen. 
II. Anatomical Changes.—Among eightv-four cases of embolism 
following valvular disease of the heart, the splenic artery was affected 
thirty-nine times, the renal artery fifty-seven times. The relatively large 
lumen 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 of the splenic tissue remains intact. 
A wedge-shaped infarction of the spleen is recognizable by its pecu- 
liar shape. The broad base of the wedge is directed towards the sur- 
face of the spleen, the narrow apex towards the hilus (corresponding to 
the distribution of the obstructed artery). In the majority of cases, the 
infarction extends to the surface. The capsule may then be inflamed, 
and be covered with peritonitic deposits. 
Recent 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, crumbly, and brittle. 
Under favorable circumstances, the infarction may be almost entirely 
absorbed, leaving merely a depressed, often pigmented cicatrix. In 
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 infrequently becomes irregularly lobulated. Finally, the 
infarction may terminate in an abscess. 
The size of the abscess varies from that of a pea to that of a hen's 
egg. It sometimes exceeds the dimensions of the infarction and attacks 
intact splenic tissue. Cases have been reported in which the spleen 
formed a pus sac surrounded bv 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 ab- 
scesses. The pus forms a green, creamy, or light reddish-brown fluid, 
containing pus-corpuscles, granulo-fatty cells, fat granules, and liaematoi- 
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, 
lungs, or externally through the abdominal walls. In very rare cases, the 
pus becomes cheesy, sometimes calcified in places. 
In relapsing fever, splenic abscesses form which are restricted to the 
Malpighian corpuscles. This has also been observed in typhus fever. 
III. Symptoms and Diagnosis.—The diagnosis can only be made 
under certain favorable conditions. The most important one is the demon- 
stration of 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 symp- DISEASES OF THE SPLEEN. 
47 
toms develop : chills, profuse sweats, remittent fever, anorexia, emacia- 
tion, diarrhoea, death from exhaustion (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 splenic abscess. The sudden appearance of masses of 
pus, coincidently with diminution in the size of the spleen, also arouses 
the suspicion of splenic abscess. This event indicates perforation into 
adjacent organs, and the pus may be vomited, expectorated, discharged 
in the urine or stool, or through the integument. In the latter event, 
the skin may be undermined, sometimes even to the clavicle or axillary 
space, before perforation occurs. Perforation into the peritoneal cavity 
generally proves rapidly fatal after evidences of perforation-peritonitis, 
but previous peritonitic adhesions may give rise to encapsulation of the 
pus and prevent free perforation. In some cases, fatal pyaemia sets in 
because pus and infection-carriers enter the circulation through the 
splenic vein. 
IY, Prognosis and Treatment.—The prognosis of wedge-shaped 
infarctions is not always unfavorable; that of splenic abscess is grave, 
and the only hope of a favorable issue lies in judicious surgical mea- 
sures. 
Treatment is purely symptomatic. 
5. Waxy Degeneration of the Spleen. 
I. Etiology.—The causes of waxy degeneration of the liver will also 
give rise to a similar lesion in the spleen (vide Yol. II., page 213). 
The spleen is generally the first organ affected, and if death occurs very 
soon, it may be the only organ which has undergone waxy degeneration. 
According to Cohnheim, it may develop in four months. In very rare 
cases, the spleen escapes, while other organs are affected. 
Hoffmann found that among eighty cases of waxy degeneration the organs 
were attacked as follows: 
Spleen 74 times (92.5$). 
Kidneys 67 “ (84. #). 
Intestines 52 “ (65. %). 
Liver 50 “ (62.5#). 
II. Anatomical Changes.—Slight grades of the lesion can only be 
recognized by the aid of the microscope and chemical reagents (vide Yol. 
II., page 214). Advanced waxy degeneration is recognizable microscop- 
ically, and includes two varieties, viz., the sago spleen and diffuse waxy 
spleen. 
In the sago spleen, the Malpighian corpuscles are affected chiefly or 
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- 
vessel of the follicle. The nodules are often surrounded by a red halo of 
dilated vessels. On the application of iodine, the degenerated follicles 
assume 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- 
cupies a large portion of the abdominal cavity. The borders of the spleen 48 
DISEASES OF THE SPLEEN. 
are rounded and blunted, and its consistence is increased. It feels 
tense, firm, brittle, as if frozen. 
On making a section through the organ, large coherent pieces can be 
scraped olf 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 have 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 con- 
nective-tissue framework of the spleen. According to Sechtem and Eberth, the 
splenic cells proper are not affected by the degeneration, but undergo compres- 
sion atrophy, on account of swelling of the connective-tissue framework. Kyber, 
Cornil, and others claim that the spleen cells undergo waxy degeneration. Con- 
cerning the nature of the amyloid substance, we refer to Yol. II., 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. Prognosis and Treatment.—The prognosis is unfavorable, 
although a resolution of the process at the beginning of the disease does 
not appear 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 cavernoma, 
are anatomical rarities; others, such as sarcoma and cancer, are more frequent. 
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 nodules 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 occasionally in very 
young individuals (one case at the age of 12 years). The diagnosis is only 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 cellulosaa, and echinococci 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 either simple sacs, 
or the latter may contain daughter vesicles. The organ may increase very mark- 
edly in size, and compress adjacent organs (lungs, heart, stomach, intestines, or 
bladder), as shown by dyspnoea, vomiting, constipation, and dysuria. Exami- 
nation discloses a splenic tumor which moves with respiration, occasionally peri- 
tonitic friction sound and prominences. The latter correspond undoubtedly to 
echinococcus vesicles if they present fluctuation, but the tumors are not infre- DISEASES of the spleen. 
49 
quently hard and firm. An exploratory puncture may be made, but this does 
not always afford positive results, since the fluid may contain albumin, and is 
sometimes destitute of echinococcus hooks. The patients often complain of 
pain in the splenic region. Hectic symptoms set in if the vesicles undergo sup- 
puration. The disease may last more than sixteen years. Recovery can be 
effected by surgical measures alone. Otherwise death occurs from marasmus 
or suffocation. 
8. Rupture of the Spleen. 
I. Etiology.—When the organ is healthy, rupture of the spleen may occur as 
the result of injury in the splenic region. In acute enlargement of the spleen, 
rupture may take place spontaneously because the capsule is unable to resist the 
increasing pressure, or it is the result of trifling causes (lifting, vomiting, cough- 
ing, etc.). This happens most frequently after typhoid or intermittent fever, but 
may also occur in typhus, cholera typhoid, and even in miliary tuberculosis. 
II. Symptoms and Anatomical Changes.—The accident is generally attended 
with the symptoms of severe internal hemorrhage. The patients may experience 
a sensation as if something had burst internally. They complain of pain in the 
abdomen, confined at first to the spleen; the skin becomes cool and pale, the 
features sunken; then follow syncope, vomiting, imperceptibility of the pulse, 
increased splenic dulness, muscular twitchings. 
As a rule, death ensues; but a case of recovery has been recently reported. 
Cicatrization can be looked for only when the rent in the capsule is insignificant. 
Death may occur at once, or life is prolonged one to two, rarely several days. At 
the autopsy, the abdomen is found filled with fluid and coagulated blood ; peri- 
tonitic changes are generally absent. The capsule generally contains a single 
irregular rent. 
Cohnlieim described a case in which varicose dilatations of the splenic ves- 
sels had ruptured. 
III. Diagnosis, Prognosis, Treatment.—The diagnosis is based on the fact 
that, acute enlargement of the spleen being present, there are sudden signs of 
internal hemorrhage, pains in the region of the spleen, and increasing dulness. 
Prognosis unfavorable. Treatment: ice bag, ergotin subcutaneously, opium to 
relieve the pain, camphor and wine against threatening collapse. 
9. Changes in the Position of the Spleen. 
(Wandering Spleen.) 
Changes in the position of the spleen may be congenital or acquired, tempo- 
rary or permanent. Congenital dislocations include the situs viscerum inversus, 
in which the spleen is situated on the right side, the liver on the left. This con- 
dition may be confined to the liver and spleen, or involve the other viscera. 
In pleurisy, pneumothorax, spinal curvature, and deformity of the thorax, the 
spleen is not infrequently displaced downwards; in meteorism, abdominal tumors, 
and the like, it is often pushed upwards. 
The spleen sometimes sinks so far that it is felt below the epigastrium, most 
frequently in the left iliac fossa, but sometimes in the pelvis or right iliac fossa. 
It may be so movable as to change its situation in different positions of the body, 
and may even be turned around its own long axis. In other cases, the mobility of 
the spleen is impeded by adhesions to adjacent organs. The hilus generally looks 
upwards, while the anterior edge is situated along the anterior abdominal walls. 
The development of this condition is favored by along, flaccid gastro-splenic 
ligament, by a blow in the splenic region, lifting heavy loads, and diseases 
attended with cough. A fruitful source of displacement is the increased weight 
of tumors of the spleen, which drag upon the ligaments. The gastro-splenic lig- 
ament, with .the splenic arteries and veins and the pancreas, are drawn into a 
long cord, which is often twisted upon its long axis. The vessels of the spleen 
may undergo obliteration or the spleen may be freed from its ligaments, and then 
undergoes fatty degeneration and atrophy. 
The objective symptoms consist of the demonstration of a tumor in the shape 
of the spleen. In one of my cases, the tumor could not alone be felt through the 
thin abdominal walls, but the pulsating splenic artery could also be palpated 
in the hilus. Splenic dulness was absent from its usual position, and did not 
reappear until the tumor was replaced in the left hypochondrium. 50 
DISEASES OF THE SPLEEN. 
Some patients are entirely free from subjective symptoms ; others complain 
of a feeling of traction and pain ; adhesion to the bladder and rectum may pro- 
duce vesical and rectal tenesmus. Pressure on the nerves sometimes gives rise 
to formication and paralysis of the lower limbs. In Kiepert’s case, pain in the 
left shoulder was produced whenever the spleen was compressed. 
A case has been reported, in which pressure of the dislocated spleen upon the 
ileum produced death from intestinal occlusion. In another case, coils of the 
ileum had become incarcerated in an abnormal fissure within the elongated 
gastro-splenic ligament. Gangrene and dilatation of the stomach have also been 
observed, the former from excessive stretching and occlusion of the arteries of 
the fundus, the latter from pressure of the stretched pancreas upon the duode- 
num. 
Bandages may be employed to keep the spleen in place, and as a last resort 
splenotomy may be performed. SECTION IX. 
DISEASES OF NUTRITION. 
1. Obesity. Polysarcia. 
I. Etiology.—The term obesity is applied to an excessive accumu- 
lation of fat in the subcutaneous cellular tissue and in those internal 
localities (mediastinum, epicardium, omentum, mesentery, appendices 
epiploicse, renal capsule, etc.) which are characterized, under healthy 
conditions, by the presence of a large amount of fat. 
The disease not alone produces great annoyance, but also serious 
danger to life. 
The causes are either indirect (predisposing) or direct, but both sets 
of causes co-operate in the majority of cases. 
Heredity is the chief predisposing cause. In some cases, only a few 
members of a family are affected. In all probability, it is the result of 
an inherited defective power of oxidation of the cells. 
Age is a potent etiological factor. The disease is often ob- 
served during infancy and beyond the age of forty years, while 
childhood and early adult life generally escape. According to some 
writers, the tendency to obesity is 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 
of obesity; hence it is frequent in those who retire from business, 
or who are deprived of the use of the limbs on account of amputation 
or of other causes which act in a similar manner. 
Racial differences are also manifested. Thus, 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 in amount or 
improperly constituted. 
Apart from water and salts, our food consists of albuminoids, 
fats, and carbo-hydrates. The fat of the tissues is derived mainly from 
the albuminoids, which are oxidized into nitrogenous and non-nitrogen- 
ous substances, the latter representing the fat-producers. Whether 
the fat contained in the food is converted directly into the fat of the 
body has not been positively settled, but, at all events, this mode of 
formation is quantitatively inconsiderable, when compared with the 52 
DISEASES OF NUTKITION. 
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 carbo-hydrates. 
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 
powers of the organism, so that the fats remain unoxidized and are 
deposited 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 large quantities of albumin- 
oids, also partake of farinaceous articles, beer, wine, and other alcoholics. 
These considerations render it evident that the amount of food 
ingested should be regulated by the destructive disassimilafcion 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 still-born infant measured 62.5 cm. in length, and weighed seventeen 
pounds. • 
II. Anatomical Changes.—The pannicuius 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 have a pale, 
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. DISEASES OF NUTRITION. 
53 
The mediastinal cellular tissue generally takes part in the abnormal 
deposit of fat. This is also true of the subepicardial tissue, and results 
occasionally in compression atrophy and fatty degeration of the muscular 
fibres of the heart. The left ventricle may undergo hypertrophy. 
Atheromatous changes upon the intima of the great vessels are found 
not infrequently. The serum of the blood sometimes has a milky emul- 
sive character (lipgemia), the result of the presence of an unusual amount 
of fat in the form of granules. 
The greater omentum is particularly fatty. In Boerhave’s case, it 
weighed ten pounds. The appendices epiploicae are converted not infre- 
quently into large clumps of fat. The capsule of the spleen also con- 
tains a large amount of adipose tissue, so that deep incisions must be 
made before the organ is reached. The epithelium cells of the renal 
tubules sometimes contain accumulations of fat drops. The liver is still 
more frequently in a condition of fatty degeneration. The diaphragm 
is pushed upwards on account of the accumulation of the fat in the ab- 
dominal organs. 
III. Symptoms.—The symptoms develop very gradually, as a rule, 
but in rare cases they 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, 
abdominal walls, mons veneris, labia, and buttocks). 
The shape of the body approximates that of a globe. The cheeks 
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 expressionless, 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 
down upon the thighs. The umbilicus is either unusually sunken, or 
very prominent. Umbilical hernia is not uncommon. The genitals 
often appear buried in the surrounding masses of fat, and varicocele is 
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 
pounds, although it is claimed that one individual weighed eleven 
hundred pounds (?). 
The following table shows the enormous weights sometimes attained 
by children. 
A boy, set. U years 53 pounds. 
A girl, set. 4 years 82 “ 
A girl, set. 4 years 137 “ 
A boy, set. 5 years 189 “ 
A boy, set. 11 years 200 “ 
A girl, set. 11 years 450 “ 
The specific gravity of the body diminishes with increasing obesity, 
so that the individuals readily float in water. 
According to the complexion, we distinguish plethoric and anaemic 54 
DISEASES OF NUTRITION. 
obesity. Plethoric obese individuals have a red, congested face, and 
complain of a rush of blood to the head, frequently of dizziness and 
ringing in the ears; anaemic 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 phlegmatic. They avoid 
exercise as much as possible, on account of the discomforts connected 
with it. Many exhibit an unusual degree of somnolence. There 
are frequent complaints of rheumatoid muscular pains, probably as the 
result of the opportunity for catching cold offered 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 haemoglobin 
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 in cases of arterio-sclerosis. Leichtenstern 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 Yol. 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 organs 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 NUTRITION. 
55 
terference with the gastro-intestinal movements and of circulatory 
stasis. The latter accounts for the frequent development of hemor- 
rhoids. 
These individuals can perform very little muscular work, partly 
because the muscles are often rendered atrophic by the intermuscular 
proliferation of fat. There is not infrequently a tendency to syncope, 
and to nervous and hysterical disturbances. These become especially 
marked in febrile diseases, which are particularly dangerous to obese 
patients. Death often results from paralysis of the heart. In addition, 
the increased 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 of mercurials is also 
dangerous in obese individuals. 
Obesity furnishes a predisposition to other diseases, such as gout, 
calculi in the urinary and biliary passages, and diabetes mellitus. Some 
maintain that it is often associated with cancer and multiple furun- 
culosis. Rapidly fatal hemorrhage from the pancreas has been observed 
with relative frequency in obese individuals. 
Death may occur from 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 rather the result of the arterio-sclerotic 
changes which are associated with obesity. 
IY. Diagnosis avd Prognosis.—The diagnosis is evident at a 
glance. The prognosis is serious. The condition 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. 
Y. 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, anaemia, and convalescence from 
severe diseases may also disappear spontaneously. 
The methods of treatment adopted for the removal of fat from the 
body are manifold. 
Ebstein has shown that a relatively plentiful supply of fats diminishes 
obesity, and finally relieves it entirely. The fats 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, however, to carry 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. Breakfast, consisting of a large cup of black tea without milk or 
sugar, 3 iij. of wheat bread or toasted rye bread, well buttered (at 6 to 
6:30 o’clock in the summer; at 7:30 o’clock in the winter). 1. Dinner, 
2 to 2:30 o’clock: soup (often with the marrow of bone), § iv.-vi. of broiled 
or stewed meat (fatty) with a fat gravy, a moderate amount of vegetables, 
especially leguminosa, also the varieties of cabbage, but no potatoes or tur- 
nips; salad or stewed fruit without sugar; fresh fruit; two to three glasses 
of a light white wine; shortly after dinner a large cup of black tea with- 
out milk or sugar, c. Supper at 7:30 to 8 o’clock; in winter regularly, 
in the summer occasionally, a cup of black tea without milk or sugar, 56 
DISEASES OF NUTRITION. 
an egg, a fat roast, ham, sausage, smoked or fresh fish, 3 i. of wheat 
bread, well buttered, now and then some cheese or fresh fruit. 
In other words, we may recommend fatty articles, such as butter, fat meat, 
sauces, and ham, pate de foie gras, 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 long, and exercise a great deal. 
Anasmic 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 
have 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 cautious in- 
gestion of solid food produced vomiting and diarrhoea. 
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 § 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 3 v.-vij. of 
light white wine. At a later period, after the obesity and circulatory 
disturbances have disappeared, the dinner may be 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 
meat, 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. Supper: 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 withdrawing 
the fats and hydrocarbons very gradually at the beginning of the cure, DISEASES OF NUTRITION. 
57 
and gradually restoring them a little, after our immediate object is 
attained. 
Yoit furnishes the following tables of the daily amounts ingested by 
healthy individuals, and in the various cures for obesity: 
Vigorous laborer, 
ALBUMEN. 
. 118 
FAT. 
56 
HYDROCARBONS. 
500 
Well-to-do physician, 
107 
89 
362 
Ebstein, . 
. 102 
85 
47 
Oertel, .... 
155 
25 
70 
Banting, .... 
. 172 
8 
81 
The number of plans of treatment has not yet been exhausted. Tar- 
nier orders a strict milk diet (six to eight pints daily). We may also 
mention grape cures, massage, and inhalations of oxygen, inhalations of 
compressed air, iodine wells, salivation, hunger, or sweat cures. 
2. Gout. Arthritis Uratica. 
I. Etiology.—Gout is a change in the nutritive processes in the body 
which inclines it to inflammations in the various organs and tissues, and 
often gives rise to the deposit of urates. The joints are affected most 
frequently, but by no means constantly; the first joint of the great toe 
is the one attacked earliest and most constantly. 
In the majority of cases, there is an hereditary predisposition; the 
disease appears in one generation after another, or one or more genera- 
tions may escape. 
According to Hutchinson, the younger children of gouty parents are more apt 
to suffer than the first born; hereditary transmission is more probable when both 
parents suffer from the disease, and the gout of the father is more apt to be 
transmitted than that of the mother. 
In the majority of cases, auxiliary factors are necessary to cause an 
outbreak of the disease. 
The most important are dietetic errors—heavy meals, excessive inges- 
tion of albuminoids, wine, beer, and other alcoholics. These conditions 
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 
to luxurious habits. Whether mental strain favors the development of 
the disease has not been positively settled. 
The previous considerations explain the frequent coincidence of 
obesity and gout, the former to a certain extent forming a prodrome of 
the latter. 
But although the disease results, in the majority of cases, from high 
living, in rare instances it follows deprivation and insufficient supply of 
food. 
Toxic gout is a special form of the disease. French writers have 
shown that gout, particularly renal gout, is not infrequent in workers in 
lead, and there is no doubt that the introduction of lead into the system 
changes the nutritive processes in such a manner as to produce a uric- 
acid diathesis. 
A peculiar form of toxic gout is that attributed by some writers to gastro- 
intestinal catarrh, and to the formation and absorption of abnormal products of 58 
DI8EASES OF NUTRITION. 
disassimilation (uric acid and lactic acid). Others maintain that the gastroenter- 
itis in such cases is a manifestation of primary gout. Our own observations have 
led us to coincide in the latter opinion. 
England is the classical territory, so to speak, of gout. Next follow 
France and Holland, while it is less frequent in Germany, Spain, and 
Italy. According to Charcot, gout is infrequent in Russia, Sweden, 
and Norway, although the population is strongly addicted to the use of 
alcohol. These variations are due to dietetic, rather than to climatic 
conditions. 
Age exercises great influence on the manifest development of gout. 
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. 
Rheumatic causes seem to exert a certain influence; at least, attacks of 
gout are most frequent in the autumn and spring. It has been noticed 
in 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. 
IT. Symptoms.—As a rule, the symptoms do not occur unexpectedly. 
The patients generally give a history of hereditary gout, or they have 
long suffered from the symptoms of increasing obesity. Complaints are 
generally made of increasing girth of body, dyspnoea, palpitation, vom- 
iting, pyrosis, flatulence, constipation, dizziness, 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 existing hemor- 
rhoids ; the urine grows scanty and deposits a brick-red sediment of 
urates, more rarely 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 dizziness, 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 tired feeling in the limbs, dragging and painful sensations in the mus- 
cles, especially of the calf, sometimes transitory pains in certain joints. 
In certain cases paraesthesiae, paretic symptoms, tremors, and cramps in 
the calves make their appearance. 
The paroxysm of gout is so much more violent the longer the dura- 
tion of the prodromata. 
The manifest symptoms of gout appear most frequently in the form 
of acute gouty inflammation of the joints, although some gouty patients 
remain free for life from any affection of the joints. 
It is characteristic of articular gout that, in the majority 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 DISEASES OF NUTRITION. 
59 
joints are not attacked until after repeated gouty paroxysms. The ones 
that are most frequently involved are the fingers, and especially the 
thumb, but also the knee, hip, shoulder, elbow, and the articulations 
of the clavicle, vertebrae, maxilla, and costal cartilages. 
In the first attack, the great toe is generally alone affected, and even 
in subsequent seizures the same joint may be repeatedly attacked. The 
inflammation rarely occurs at the same time in several joints, more fre- 
quently one joint becomes involved after the other. 
G-outy inflammation generally begins suddenly in the middle of the 
night, usually from twelve to three o’clock. The patient who went to 
bed almost entirely free from suffering, is suddenly roused from sleep by 
excruciating pain in the great toe. The pain is described as boring, 
compressing, burning, sometimes as a painful sensation of cold. The 
patients groan aloud, throw themselves about in bed, and cannot tolerate 
the slightest contact. The skin is hot and dry, the bodily temperature 
increased, and the pulse is hard and accelerated. The pains generally 
moderate considerably 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 is uniformly swollen, the integument covering it is very 
red, almost erysipelatous, is hot and cedematous ; the surrounding integ- 
ument not infrequently contains varicose vessels. The oedema some- 
times extends over the entire dorsum of the foot, and even to the ankle. 
During the day, the patient experiences little pain if the limb is kept 
quiet, but in the following night the suffering 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 joint remains a little stiff for a while, but soon 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 symptoms which indicate the accumula- 
tion of urates in the blood. Their 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. 
In some cases, the urates in the blood escape through the skin, a white 
deposit being left upon the integument after evaporation of the perspi- 
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 addition 
of acids. 
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 demonstrated in the blood, exudations, or transudations by 
Garrod’s thread test. For example, the blood is allowed to coagulate, and four to 
eight ccm. serum placed in a watch-glass, to which six to twelve drops ordinary 
acetic acid (30$) are added. A cotton thread, which is not too smooth, is then dip- 
ped into the fluid, the whole covered with a glass slide and allowed to stand one or 
two days at a temperature of 16 to 20° C. Crystals of uric acid are then deposited 
upon the thread. 0.025 per cent is the minimum amount of uric acid which will 
deposit crystals (two to three). They are readily recognized under the micro- 
scope (vide Fig. 6). The contents of blisters may be directly experimented 
upon in the manner just described. Atkinson states that he has found an abun- 
dance of uric acid in the coating of the tongue. 60 
DISEASES OF NUTRITION. 
During the attack, the urine is generally scanty, saturated, acid, and 
often deposits a brick-red sediment. The specific gravity is increased. 
Garrod found that the amount of uric acid in the urine diminishes very 
markedly shortly before the attack, and sometimes merely a trace is left. 
During the first part of the attack, it remains small, but gradually in- 
creases, and after the termination of the seizure may even exceed the 
normal amount. 
Stokvis states that the amount of urea excreted during a paroxysm is dimin- 
ished to one-third the normal. This author also observed diminution of phos- 
phoric acid, especially of that portion which is combined with the alkaline 
earths. 
Acute gout may end with a single attack. This is particularly true 
of those individuals who ever after refrain from dietetic errors. De- 
spite such self-restraint, another attack may occur as the result of a 
blow, fracture or dislocation, or a 
cold. But the majority of patients 
soon discard their abstemious habits. 
Nevertheless, from two to five or 
more years may elapse before another 
attack supervenes. In other cases, 
an attack occurs quite regularly at 
the end of a year, or in the spring 
and autumn. As a general thing, 
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, 
often leave permanent residua in the 
shape of gouty nodes or tophi; in 
fine, the symptoms of chronic gout 
develop. 
Chronic gout is often, though not always, a sequel of acute attacks. 
In rare cases, it appeal's from the start in a chronic manner. Many 
joints are generally attacked, particularly those of the feet and hands. 
As a rule, the joint changes present remissions and exacerbations. The 
pains in the joints are not so severe as in acute attacks, but the swell- 
ing is often greater. The redness of the skin is much less, and often 
entirely absent. After the pains have disappeared, the swelling 
subsides very slowly, and does not often disappear entirely. Hard 
nodes appear in the vicinity of the 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 
as hard as a stone. The overlying skin is often pale in the middle, 
while the periphery is very red and contains dilated vessels. These 
nodes (tophi) consist chiefly of urates which are deposited upon the out- 
side of the joint. They sometimes attain the size of a cherry, or are 
even much larger. The overtying skin may inflame and ulcer- 
ate, and a chalky or mortar-like 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 often 
Fig. 6. 
Garrod’s thread test. Uric acid crystals 
deposited on a cottOD thread. Enlarged 
90 times. DISEASES OF NUTRITION. 
61 
Fig. 7. 
Gouty deposits in the fingers and the bursa of the elbow. After Garrrod. 62 
DISEASES OF NUTRITION. 
present luxuriant, easily bleeding granulations. Their base sometimes 
contains chalk-like tophi, which may assume stalactite shapes. 
These tophi may produce such deformity that Sydenham has com- 
pared the appearance 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 convey a creaking and scratching sensation and 
sound. Sub]fixations are produced, so that the terminal phalanges of 
the fingers are deflected towards the ulnar side, and the other phalanges 
are bent towards the palm. The entire limb may be rendered useless, 
and the patient crippled for life. 
Chronic gout also attacks the bursas, fasciae, tendons, cartilages, 
bones, and skin. 
The bursae, particularly those of the elbow and patella, become 
swollen and painful, the skin overlying them is reddened and swollen. 
Fig. 8. 
Fig. 9. 
Gouty deposits in the cartilage of the ear. After 
Garrod. 
Crystals of acid urate of soda, from gouty de- 
posits in the cartilage of the ear. Enlarged 
450 times. 
After some time, the swelling and pain subside, but firm deposits are 
discovered which gradually grow larger, and finally form voluminous 
masses, composed chiefly of urate of soda (vide Fig. 7). 
Among the tendons, the extensor tendons of the fingers are affected 
most 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 
spots which may attain the size of a pea, the centre white, the periphery 
surrounded 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 case reported by Garrod). 
The overlying skin sometimes ulcerates, and they then fall out of the 
auricular cartilage. They are not infrequently the site of painful sen- DISEASES OF NUTRITION. 
63 
sations shortly before the onset of an acute gouty affection of the 
joints. 
In rarer cases, gouty’ deposits occur in the palpebral and nasal carti- 
lages. Virchow has also described gouty deposits beneath the perichon- 
drium of the arytaenoid cartilages, and states that these may determine 
the diagnosis in doubtful cases. 
Gout 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 overloaded with urates, while there 
is a diminution of the urates in the urine. The phosphoric acid in the 
urine is also diminished in quantity. 
Stokvis calls attention to notable differences in nutrition in gouty and healthy 
individuals. After the ingestion of inorganic acids (phosphoric or hydrochloric 
acids), the amount of phosphoric acid in the urine was increased both in gouty 
and healthy individuals, but in the former there was an increase of the phosphoric 
acid which was combined with the alkaline earths, in the latter of that combined 
with the alkalies. After the ingestion of oi-ganic acids, the excretion of phospho- 
ric acid was increased in the healthy alone. 
Patients who suffer from chronic gout sometimes attain an old age. 
But in other cases marasmus develops at an early period, asthenic or 
atonic gout develops, and the patients die from increasing exhaustion. 
Death also occurs not infrequently from internal 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- 
vious 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 GarnxPs 
thread test of the blood furnishes positive results. The matter is much 
simplified 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, but the old doctrine of metastasis is not 
looked upon with special favor at the present time. 
Renal gout is the most important form of visceral gout. It produces 
the symptoms of small contracted kidneys and similar anatomical 
changes ; it is recognizable by the large amount of pale urine of low 
specific gravity, slight sediment, moderate amount of albumin, and hy- 
pertrophy of the left ventricle. It may constitute the sole symptom and 
terminate fatally. 
Not every albuminuria during the course of 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 encephalorrhagia, the 
latter resulting from gouty atheromatous changes in the vessels. Psy- 
choses have been attributed to gout in a number of cases. The symp- 
toms of meningitis and myelitis have been ascribed at times to gout of 
the spinal cord; neuralgiform, paretic, and paralytic symptoms and par- 
aesthesiae, 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 vitreous body. Gouty patients are also said to exhibit a 
tendency to the formation of cataract. Choroiditis and retinitis are rare. 64 
DISEASES OF NUTRITION. 
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 heart, 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. 
Verite 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 in gangrene. Iluchard 
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. 
G-outy parotitis, angina, and cesophagismus have been observed. 
Dyspeptic and cardialgic attacks, vomiting, hgematemesis, and inconti- 
nence of the pylorus have also been described. Functional and ulcera- 
tive changes in the intestines occur occasionally. 
Grout, 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 gonorrhoea). 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 
phlebectasise. In not a few cases, injury to the skin is followed, in gouty 
individuals, by severe inflammations, accompanied by high fever, and 
even terminating in gangrene. 
Visceral gout often develops in a slow and insidious manner, but it is 
more dangerous than the articular variety. 
Grout 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. Anatomical 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. They 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- 65 
pheral parts often remaining intact for a long time, though in many 
cases their blood-vessels are congested. The more the earthy deposits 
increase the more the surface of the cartilage is perforated and the sub- 
stance destroyed and defibrillated. The urates extend occasionally 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. 
G-outy concretions are especially apt to form on the outer surface of 
the capsule of the joint, where they appear as tophi. Garrod observed 
one in the hand weighing two ounces. 
Gouty deposits are also found in the bursae, tendons, fasciae, and be- 
neath the periosteum. 
Virchow recently described uratic deposits in the spongy portion of 
the phalanges. Garrod mentions a tendency of the bones to brittleness, as 
a result of the formation of cavities filled with masses of fat. Gouty 
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, 
and fatty degeneration. Chronic inflammation of the endocardium is 
not infrequent, and these foci of inflammation may contain uratic 
deposits. Pericarditic changes may also be connected with gout. 
Garrod found uric acid in exudations. 
The aorta is often the seat of arterio-sclerotic changes, in which 
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 exhibit the signs of inflammation ; 
in the lungs, these terminate occasionally in abscess and gangrene. 
The statements concerning gouty deposits in the lungs require confirm- 
ation. 
Swelling, inflammation, and even ulcerative destruction of the 
mucous 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 be swollen. 
The renal changes appear at times as simple, contracted kidneys 
(atrophy of the organ, nodular surface, adhesions of the latter to the 
capsule, atrophy 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 
uratic deposits. The former are especially numerous in the pyramids, 
rarer in the cortex. They sometimes form grayish-white streaks along 
the straight tubes, or appear as dots at the apices of the pyramids. 
Gouty deposits and inflammatory changes are found occasionally in 
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 in the neurilemma. 
According to Ebstein, the gouty deposits begin interstitially in all organs. At 
first, a circumscribed necrotic focus forms in the tissues. After the necrosis is 
completely developed, the affected part becomes the site of a deposit of needle- 
DISEASES OF NUTRITION. 66 
DISEASES OF NUTRITION. 
shaped crystals of the acid urate of soda. These often fill the necrotic focus so 
completely that the latter becomes visible only after the crystals are dissolved ; 
in other cases, the transparent crystalline masses are found surrounded by a 
bright zone. Finally, as the result of reactive inflammation, the necrotic focus 
becomes surrounded by a zone of round cells. 
The gouty deposits are composed, in great part, of the acid urate of soda. The 
following tables give the results of chemical examination by two observers : 
Marchand. 
Lehmann. 
Urate of soda, 
(Tophi from thigh.) 
(Tophi from metacarpus.) 
34.20 
52.12 
Urate of lime, 
2.12 
1.25 
Carbonate of ammonia, 
7.86 
— 
Phosphate of lime, 
. . . 
4.32 
Sodium chloride, 
14.12 
9.84 
Animal matters, 
. . . 32.53 
28.49 
Water, .... 
Losses, 
6.80 ) 
3.98 
2.27 f 
100.00 
100.00 
Budd states that he has also detected hippuric acid in the deposits. 
Marchand and Lehmann also analyzed the osseous tissues, and found a dearth 
of earthy matters, and excess of fat. 
Phosphate of lime, 
Marchand. 
Ulna. Femur. 
. 43.18 42.12 
1st Case. 
35.16 
Lehmann. 
2d Case. 
35.83 
3d Case. 
37.22 
Carbonate of lime, 
8.50 
8.24 
8.41 
9.82 
8.99 
Phosphate of magnesia, 
. 0.99 
1.01 
1.31 
1.05 
1.13 
Cartilage, ) 
45.96 
46.32 
38.14 
38.28 
40.03 
Fat, j 
12.11 
13.37 
9.15 
Soluble salts, 
. 1.37 
2.27 
2.93 
2.03 
1.82 
All are agreed that the excess of urates in the blood is the main cause of the 
production of gouty symptoms, but opinions differ as to the source of origin of the 
uric acid. This is owing to the fact that we know so little concerning the site of 
production of uric acid under normal conditions. 
As a matter of course, the excess of uric acid in the blood will become still 
greater if the formation of uric acid is increased by an excessive supply of food, 
or if, under the influence of lead poisoning or deprivation and want, the processes 
of oxidation are rendered less active, and a portion of the albuminoids are con- 
verted, not into urea, but only into uric acid. 
Garrod believes that the paroxysmal character of gout is owing to the fact 
that the kidneys at times prove unable to excrete the excess of uric acid, so that 
its transitory accumulation provokes a paroxysm. This theory is opposed by 
the fact that attacks of gout may occur, although the kidneys are intact. It 
is, therefore, much more plausible to assume an intermittent increase in the 
formation of uric acid, rather than disturbed excretion. 
The paths of conduction for the uric acid from the tissues to the lymph and 
blood currents often suffice, but local stasis is apt to ensue if the circulation is dis- 
turbed by inflammation, injury, etc. For example, Charcot observed, in a case 
of hemiplegia, that gout developed only in the joints upon the paralyzed side. 
The unusually frequent localization of gout in the joints appears to be owing to 
the fact that the muscular tissue and medulla of the bones take an active part 
in the production of uric acid which they transmit in part through the lymph 
channels of the cartilage, and also to the slowness of the circulation in the bones 
and the consequent opportunity for stasis. 
The frequent implication of the great toe is owing perhaps to its extreme peri- 
pheral situation, and to the fact that it carries the weight of the body, and is 
especially subjected to mechanical irritation. 
IV. Diagnosis.—Acute gout of the joints is generally recognized 
very readily from the typical situation and specific course of the disease, 
assocated with hereditary and constitutional factors. 
As a rule, the diagnosis of chronic gout of the joints is also easily 
made. It has generally been preceded by typical acute attacks, and toplii DISEASES OF NUTRITION. 
67 
are found in the joints, often in the bursae, tendons, cartilages of the ear 
and nose, and sometimes of the larynx. It might possibly be mistaken 
for arthritis deformans, but this could be excluded by examination of the 
blood and the chemical constitution of the contents of a vesicle (pro- 
duced by application of emplast. cantharidis). 
The recognition of visceral gout may be difficult so long as gouty de- 
posits are not observed. Careful attention must then be paid to the 
previous history and constitution of the patient, and Garrod’s thread 
test should be made. 
V. Prognosis.— The prognosis is always serious. It is doubtful 
whether the gouty constitution can be subdued permanently, although 
some patients who are careful in their habits experience only a single 
attack. 
The paroxvms of acute gout of the joints almost always terminate in 
speedy recovery. Chronic gout often gives rise to deformity of the 
joints and renders the limbs useless. Visceral gout is always attended 
with danger, and is sometimes followed quickly by a fatal termination. 
VI. Treatment.—The prophylactic measures are the same as those 
described under 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 
salieylated wadding. Schroeder recently recommended 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 
has been shortened by the administration of salicylic acid (gr. vij. 
every hour) until tinnitus aurium was produced, but the effect is never 
so pronounced as in acute articular rheumatism. 
After the pains have subsideded, the stiffness of the joint may often 
be relieved rapidly by cautious massage and movement of the limb. 
As a general thing, the treatment should not be too energetic, since grave and 
even fatal symptoms of internal gout have been known to develop under such 
circumstances. For this reason we should avoid the application of ice, leeches, 
and blisters to the joint, and the administration of emetics, drastics, large doses 
of colchicum, etc., to prevent a threatening attack. The warm-water cure of 
Cadet de Vaux (200-250 ccm. of hot water taken every quarter of an hour, for 
twelve hours) should not he employed, since this plan is sometimes followed by 
sudden death. 
Acute exacerbations in the course of chronic gout must be treated 
likethe paroxyms of acute gout. Much cannot be expected from internal 
remedies. Those recommended are : tincture or wine of colchicum 
(gtt. x.-xij. t. i. d.), aconite, lithium carbonate (gr. iss. t. i. d.), 
potassium iodide (3 ij. : 3 v., one tablespoonful t. i. d.), and salicylic 
acid. The functions of the skin should be kept active by lukewarm 
baths and frictions, and the occurrence of stillness of the joints should 
be prevented by massage. 
Importance is attached to the use of lithia wells and artificial lithia 
waters. 
Obese patients should take a cure at Marienbad or Carlsbad; 
if there is a tendency to the formation of uric-acid gravel, at Vichy, 
Neuenahr, or Ems. Feeble, exhausted individuals may resort to the 
acratothermal springs (Gastein, Wildbad, Ragaz, Teplitz), while pro- 
nounced gouty deposits, gouty ulcers, or cutaneous eruption are treated 
with sulphur baths (Neundorf, Eilsen, Meinberg, Aix, etc.). 
Symptoms of visceral gout generally require stimulating measures, 68 
DISEASES OF NUTRITION. 
and also treatment like that pursued when similar symptoms are the 
result of non-gouty causes. It is also recommended that the gout be 
diverted from the internal organs to the joints by the application to the 
latter of blisters, mustard poultices, or other derivatives. 
3. Diabetes Mellitus. 
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 (glyclosuria or mellituria). The disease ap- 
pears to be increasing in frequency, perhaps because the urine is now exam- 
ined more carefully 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 
create a predisposition to the development of diabetes. 
In certain cases it is the direct effect of a nervous affection, particu- 
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, near 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 the part referred to. 
Functional nervous diseases, for example, chorea, epilepsy, and psy- 
chopathies, may also be associated with diabetes. There 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. Cantani 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 fever, measles, scarlatina, 
or dysentery. Syphilis, either with or without lesions of the 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. DISEASES OF NUTRITION. 
69 
It develops most commonly between the ages of 20 to 50 years, a lit- 
tle earlier in females than in males. 
A case has been reported in a girl set. 7 months. Rollo reported one in a man 
of 77 years. 
It is generally assumed that the disease is more common in the well- 
to-do classes. 
II. Symptoms.—The specific symptoms of diabetes are preceded not 
infrequently by prodromata, consisting of gastric disturbances (changes 
in appetite, eructations, vomiting, flatulence, irregularity of the bowels) 
with mental depression, hypochondriacal ideas, dizziness, rush of blood 
to the head, etc. 
In other cases, there are no prodomata, but 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 pruritus, obstinate eczema, chronic furunculosis and, in wo- 
men, pruritus vaginae should lead us to examine the urine for sugar. 
Diminution of sexual potency is sometimes associated with diabetes. 
Nocturnal 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 by certain accidents, 
such 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 sugar), 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, breathed sterto- 
rously, and died in coma. In both cases the bladder was found very 
markedly distended, and the urine contained sugar. The patients were 
females, ast. 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 ccm.). 
Biermer described a case in which 16 litres, Harnack one in which 
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 mellitus is preceded by diabetes insipidus. The reverse 
condition also obtains in some cases. The patients pass water frequently 
and are often disturbed at night. According to Lecorche, a larger 
amount of urine is passed at night in the early stages, during the day in 
the later stages. 
In some cases the amount of urine voided never exceeds the normal amount. 
The urine is unusually pale and sometimes is hardly distinguishable 70 
DISEASES OF NUTRITION. 
from water; it is so much lighter in color the larger the amount. The 
urine 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, and disappeared when the 
patient was placed on low diet. 
The urine generally possesses a peculiar sickening odor, occasionally 
it resembles the smell of fruit or chloroform. In the latter event, 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 products 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 (1.008 to 
1.002). 
It has been claimed by some authorities that sugar 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 placed on an 
exclusively nitrogenous diet, the sugar in the urine disappears entirely in 
many cases, in others it persists in smaller amounts. The former cases 
are the 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. 
Kuelz found that there are mixed forms, i. 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 DISEASES OF NUTRITION. 
71 
doubtful, the patient should be allowed to partake freely of saccharine 
and farinaceous food, and the urine examined two to four hours later. 
As a rule, the excretion of sugar dependent on the food ceases at the end 
of six hours. 
Before the examination for sugar is made, the physical qualities of the urine 
(quantity, color, reaction, specific gravity, odor) should be known. If the urine 
contains albumin, it should be boiled in a test-tube and a few drops of dilute acetic 
acid added 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. 
The most convenient practical test 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 are heated over a spirit lamp. The heated parts grow yellow, then 
reddish, finally brownish-red and mahogony colored. The light yellow color is 
produced often in normal urine; the mahogony color alone is decisive to a cer- 
tain extent. If a drop of nitric acid is added to the boiling urine, it bubbles over 
and emits the odor of burnt sugar or molasses. 
If positive results are obtained, Trommer’s test should be applied, after the 
manner modified by Salkowski. A test-tube is filled one-fifth full with urine, and 
about a third part of officinal liquor potassae is added. A ten-per-cent solution 
of sulphate of copper is then added, drop by drop. With each drop is formed a 
light blue, cloudy deposit of hydrated oxide of copper, which at first dissolves 
completely on shaking, and gives a beautiful deep blue color. The drops of acid 
are added until the hydrated oxide of copper no longer dissolves completely. The 
upper layers are then heated to boiling, and if sugar is present they will turn 
yellowish-red from the production of suboxide of copper. This color will spread 
through the fluid even if the tube is removed from the flame. A deposit of the 
suboxide, after prolonged boiling or on cooling of the boiled urine, is not proof of 
the presence of sugar. 
If 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 tests may also be tried. The following is that suggested by Boettger: the 
urine in a test-tube is mixed with an equal volume of a solution of sodium carbo- 
nate (1:8) and a little basic nitrate of bismuth added. After prolonged boiling, 
metallic bismuth will be deposited, if sugar is present, as a gray, then a black 
precipitate. 
In doubtful cases, the fermentation test may be employed. In the presence of 
yeast, grape sugar undergoes alcoholic fermentation, and is split into carbonic 
acid and alcohol, with glycerin and succinic acid as by-products: 
C6H1308 = 2C2H604 4- 2C02 
(grape sugar) (aethyl alcohol) (carbonic acid) 
Into a fermentation tube (vide Fig. 10) urine is poured until the long vertical arm 
of the tube is filled with urine. Shaking the tube and the formation of froth must 
be avoided, since, after sufficient urine has been added, it should come directly in 
contact with the top of the long arm. A piece of compressed yeast as large as a pea is 
then added, and finally the long arm is separated from the bulb by the introduc- 
tion of mercury. If the apparatus is put in a place which is not too warm (not 
over thirty degrees), bubbles of carbonic acid begin to form within a few hours, 
and rise to the top of the straight tube. The test is only decisive when we are 
sure that the yeast is free from sugar, 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 are placed thirty to fifty ccm. urine, to which yeast is added, and lime or 
baryta water is placed in B'. The carbonic acid developed in B' passes through 
the tube t' to B', where it produces carbonate of lime or barium, as shown by 
increasing cloudiness. 
The quantitative analysis of sugar in the urine may be made with Fehling’s 
solution or the fermentation test, but we must refer the reader for details to the 
treatises on urinary analysis. 72 
DISEASES OF NUTRITION. 
It is now generally believed that grape sugar is not the only form of 
sugar in diabetic urine. 
In a few cases it contains inosit, which does not affect the plane of 
polarization, and does not ferment or reduce an alkaline solution of 
oxide of copper. Vohl reported a case in which the grape sugar was 
gradually replaced by inosit, so that the diabetes was converted into 
pure inosituria. 
In one case, Reichardt found dextrin in the diabetic urine. 
The urine may also contain fruit sugar (levulose). This deflects the plane of 
polarization to the left, and reduces the salts of copper. 
But Worm-Mueller has shown that the urine contains substances which are 
not varieties of sugar, but nevertheless possess the property of deflecting the 
Fig. 10. 
Fig. 11. 
Fermentation tube, one- 
fourth natural size. 
Glass bottle apparatus for fermentation test. 
plane of polarization to the left; for example oxybutyric acid. Hence, the 
presence of levulose is not proven unless the supposed substance is capable of 
undergoing fermentation. 
Great importance has been attached to the so-called iron-chloride 
reaction, and to the demonstration of acetone in the diabetic urine. If 
ferric chloride is diluted until it assumes the color of Rhine wine, and then 
added drop by drop to a test-tube half filled with urine, a dark cherrv- 
red or Burgundy color (so-called ferric chloride reaction) appears not 
infrequently in diabetic urine, in addition to the flocculent cloudiness 
produced by the deposit of phosphates. It should be distinguished from 
the reaction observed on adding ferric chloride to the urine of diabetics 
who have taken salicylic acid. In the latter event, the color is a violet 
blue, and is not transparent. DISEASES OF NUTKITION. 
73 
Diabetic urine which gives the ferric chloride reaction generally has 
a peculiar sour, aromatic odor, somewhat like that of chloroform or 
apples, and acetone (and alcohol) has been discovered in the urine in 
such cases. It was very natural that a connection was sought between 
the ferric chloride reaction and the acetone in the urine. This was sup- 
posed to be proven by Gerhardt and GeutheFs case, according to which 
the ferric chloride reaction is produced by sethyldiacetic acid, and which, 
under the action of alkalies and after the absorption of water, is decom- 
posed into acetone, alcohol, and carbonic acid : 
CcH10O3 + H,0 - C3H60 + CaH60 + CO, 
sethyldiacetic water acetone sethyl carbonic 
acid alcohol acid 
According to this view, the ferric chloride reaction is owing to the 
presence of sethyldiacetic acid in the urine, and the apple odor to one of 
its products of decomposition, viz., acetone. Since diabetics who pre- 
sented the reaction in question sometimes diffused the odor of acetone in 
the expired air, and Petters discovered acetone in the expired air of dia- 
betics, there was a tendency to attribute to acetonsemia (overloading of 
the blood with acetone) those conditions of coma and grave impairment 
of the central nervous system (diabetic coma) in 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 
sometimes 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 
cases, is not connected with sethyldiacetic 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 
the decomposition of sethyldiacetic acid. It appears probable, therefore, 
that in many cases the ferric chloride reaction is the result of an 
abnormal fermentation of the sugar, for which Markofnikoff and 
Fleischer assume a special acetone ferment. 
With regard to acetonsemia, it must also be remembered that human 
beings can tolerate large doses of acetone, and the view is gaining ground 
that diabetic coma is the result of various conditions. 
The ferric chloride reaction and acetone in the urine are not alone not con- 
stant in diabetes mellitus, but have also been observed in infectious diseases, febrile 
conditions in general, and cachexia. 
The ferric chloride reaction sometimes appears in diabetes mellitus or becomes 
very marked when the patients are placed on a strictly meat diet. Ebstein 
observed it increase on the occurrence of typhoid fever. It sometimes continues 
for days, and gradually subsides. If the urine is allowed to stand for some time, 
the reaction gradually grows weaker. 
In addition to sugar, acetone, and alcohol, diabetic urine sometimes 
contains albumin. Slight albuminuria (often transitory) is not unusual. 
It may be the result of cachexia, calculi in the urinary passages, cystitis, 
perhaps of an implication of that part of the floor of the fourth ventricle 
whose irritation, according to Bernard, produces albuminuria. True 
nephritis is rare. Frerichs observed it sixteen times among three hun- 
dred and sixteen cases of diabetes. In one of my patients who returned 
from Carlsbad with the urine free from sugar, severe parenchymatous 74 
DISEASES OF NUTRITION. 
nephritis developed at the end of a month, and proved fatal in three 
weeks. 
The daily amount of urea in the urine is increased. Examinations in healthy 
and diabetic individuals, living under the same external conditions, and with the 
same diet, have shown that the latter produce more urea, i. e., decompose more 
albumin. The daily amount excreted sometimes exceeds five ounces. The 
amount of urea and sugar are not directly connected with one another, and 
although both increase and diminish simultaneously, nevertheless there are 
numerous exceptions to this rule. 
The amount of uric acid is diminished; occasionally, a sediment of urates is 
deposited. Budd states that in diabetics who suffer from renal gravel and cal- 
culi, the symptoms referable thereto grow less with the increasing severity of 
the diabetes. 
The kreatinin may be slightly increased or diminished in amount. If fever 
occurs, the urea, uric acid, and kreatinin increase as in non-diabetics. 
Wickl states that the amount of hippuric acid is increased. 
Hallevorden and Leube noticed increased excretion of ammonia. 
While the amount of chlorides is unchanged, that of the phosphates and sul- 
phates is increased. The relation between the phosphates and urates varies. 
Teissier observed cases in which all the symptoms of diabetes mellitus (increased 
thirst, hunger, increased urine, furunculosis) were present, with the exception of 
sugar in the urine, while the phosphates were considerably increased; in other 
cases, the presence of sugar alternated with increased excretion of phosphates 
(phosphatic diabetes). In one case, Fuerbringer noticed the alternation of sugar 
and oxalic acid in the urine. 
The excretion of lime and alkalies in the urine is increased in diabetes. 
Urinary sediment is generally absent, but urates and oxalate of lime have been 
observed in a few cases. Renal casts are sometimes present in nephritic com- 
plications. Leptothrix has been observed in freshly passed urine. If the urine 
is exposed to the air and undergoes fermentation, it contains cloudy opacities 
which are composed of yeast cells. 
Insatiable hunger and unquenchable thirst are among the most fre- 
quent symptoms of diabetes. In three of Petters’ cases, five to eight 
litres fluid were drunk daily, and Dupuytren reports that one of his pa- 
tients ate in a single day an amount of meat which almost equalled one- 
third the weight of his own body. The thirst is especially increased 
immediately after the ingestion of food, and also after eating sugar and 
starchy food. The greater the amount of food and drink ingested the 
greater the amount of sugar excreted in the urine. 
The increased hunger and thirst are not alone the result of increased nutritive 
changes, but also of disturbances of innervation. In some cases of diabetes, how- 
ever, hunger and thirst are not increased. 
Despite the excessive ingestion of food, the body steadily emaciates 
the longer the diabetes lasts. The panniculus adiposus disappears, the 
muscles become flabby and weak. The patients are sometimes confined 
to the bed for weeks and months on account of exhaustion. They are 
sometimes reduced almost to skin and bones, while the face not infre- 
quently remains unusually red, almost hectic. 
The skin is generally dry and brittle, and often covered with thin, 
grayish-white scales of epidermis. Local pallor and diminished sensi- 
bility (local vascular spasm?) are occasionally noticeable. There is very 
little tendency to diaphoresis, but hectic sweats may occur if the disease 
is complicated with advanced pulmonary phthisis. The sweat may or 
may not contain sugar. 
There is often a tendency to obstinate inflammations of the skin DISEASES OF NUTRITION. 
75 
(furunculosis, eczema). Many complain of obstinate pruritus, which 
interferes with sleep and is sometimes one of the first symptoms of a 
latent diabetes mellitus. Wounds of the skin 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 sets in in parts of 
the limbs. All these trophic changes are attributed to overloading of 
the blood with sugar and other excrementitious products. 
Koch mentions, as a constant symptom, enlargement of the peripheral lympha- 
tic glands, as the result of irritation by the sugar-containing lymph. This is not 
confirmed by my own experience. 
It is said that diabetics sometimes pass a larger amount of urine than 
is accounted for by the fluid ingested, and this has been explained by the 
aspiration of fluid from the atmosphere through the skin and respiratory 
mucous membrane. Such aspiration does not take place. It is true 
that, in a few cases, the amount of urine temporarily exceeds that of the 
fluid ingested, but this is explained by the withdrawal of water from 
the tissues. 
Pettenkofer and Voit found that diabetics inhaled a diminished amount of 
oxygen. 
The bodily temperature is not infrequently unusually low, and the 
pulse is generally rapid. Attacks of dyspnoea sometimes occur, either 
as the result of disease of the heart muscle, or as one of the symptoms 
of diabetic coma. (Edema may be expected after cachexia has developed. 
Psychical changes develop very often. The patients grow fretful, 
morose, hypochondriacal, and sometimes apathetic. Delirium and mania- 
cal 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 Maschka noticed frequent absence of 
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. Certain 
ocular 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, Ga- 
lezowski observed keratitis attended with severe pain, although the 
sensibility of the cornea was lost. The vitreous body sometimes pre- 
sents 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. 
The ocular changes, even including cataract, may disappear under proper 
treatment. The changes in question are attributed to nutritive disturbances 76 
DISEASES OF NUTRITION. 
due to the excessive amount of sugar in the blood, and often in the secretions and 
excretions. This may produce disturbances 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 very often in diabetics. Phthisical pro- 
cesses are more frequent, abscess formation is a rarer event. Pulmon- 
ary gangrene develops occasionally, but the sputum generally has very 
little or no gangrenous odor. Many of the patients die of phthisis. The 
sputum may contain sugar. 
The pulmonary changes are probably the result of irritation of the tissues by 
the blood which is overloaded with 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 the urine generally emits the 
same odor, and furnishes the ferric chloride reaction. 
The circulatory organs are often unaffected for a long time. Leyden 
has observed cardiac asthma, and Lecorche 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 (lipnemia). Its proportion of water may be increased 
or diminished. Bock and Hoffmann found that it contained 0.3 to 0.35$ 
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 saliva 
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 (stearrhoea). 
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. DISEASES OF NUTRITION. 
77 
Nocturnal eneuresis is frequent in children. Erosions and papillary- 
excrescences are observed in not a few cases near the urethra. Male 
patients often suffer from inflammatory phimosis. Masses of leptothrix 
occasionally accumulate in the preputial sac. 
Disturbances of the sexual apparatus are very common symptoms. 
At the outset of the disease, I have repeatedly observed unnatural in- 
crease of sexual desire in men. But gradually desire is lost, the testi- 
cles become small and flaccid, and complete impotence results. 
In Buzzard’s patient, the semen contained a few motionless spermatozoa. 
Lesions of the external genitalia are frequent in females. In some 
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. Phlegmonous 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 vaginae. According to my experience, this is 
almost always associated with the development of fungi, 
Israel observed spontaneous necrosis of the ovary, and, in another case, of the 
pancreas. Hofmeier states that atrophy of the ovaries is a not infrequent cause 
of sterility in diabetics. According to Duncan, pregnancy in diabetics is often 
interrupted by abortion and death of the foetus. 
Emaciation generally occurs; but at the beginning of the disease 
many patients are well-nourished 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 as 
a sequel of pulmonary phthisis. The marasmus is accelerated occasionally 
by cutaneous gangrene following accidental wounds. Death may he 
the ri suit of cerebral hemorrhage which, according to some writers, is 
not infrequent in diabetics. In rarer cases, nephritis and anaemic symp- 
toms terminate the scene. This should not be mistaken for diabetic coma, 
which may assume various forms. In some cases, there is quite sudden 
unconsciousness, feebleness of the pulse, increasing collapse, and death. 
In others, there is increasing weakness, followed by headache, restless- 
ness, delirium, maniacal attacks, a feeling of anxiety, difficulty of 
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 somnolency increasing coma, and death ensue. In these cases, 
likewise, there is generally an odor of acetone in the expired air, and the 
urine gives the ferric chloride reaction. Such conditions may develop 
in patients whose diabetes had been unrecognized. They have been ob- 
served in several cases in which a strict meat diet was suddeqly inaugu- 78 
DISEASES OF NUTRITION. 
rated. They are susceptible of recovery, although fatal relapses often 
take place. 
Until recently, these conditions were attributed to acetoneemia, but this is 
rendered very doubtful from the fact that human beings tolerate considerable 
doses of acetone. Perhaps the symptoms are produced by other unknown excre- 
mentitious products in the blood. It has recently been held that diabetic coma 
is secondary to lipaemia, which results in fatty embolism of the pulmonary and 
cerebral vessels. According to Frerichs, some cases are the result of weakness of 
the heart muscle. 
III. Anatomical Changes.—The lesions found in autopsies on 
cases of diabetes are in great part accidental and secondary. If tumors, 
hemorrhages, softening, or sclerosis are found on the floor of the fourth 
ventricle, they may be regarded as direct causes of the disease. 
The corpse exhibits a tendency to rapid decomposition. Furuncles, 
ulcers, or gangrenous patches are often seen upon the integument. 
The muscles are pale and flaccid, or they have a deep brown color. 
Sugar is generally found in any transudationg or exudations which 
may be present in the serous cavities. 
Phthisical, purulent, or gangrenous processes may be noticeable in 
the lungs. Leyden noticed a striking degree of endarteritic changes in 
those parts which were affected by phthisis. 
Frerichs has observed deposits of glycogen in the heart; they are 
sometimes visible as white patches to the naked eye. 
The stomach is n,ot infrequently dilated, its walls thickened, and the 
mucous membrane congested. Cantani described atrophy of the peptic 
glands. The gastric contents often emit the odor of acetone. The mes- 
enteric glands may be swollen and congested. 
In one case, Buhl noticed gastro-intestinal changes similar to those of Asiatic 
cholera: distention with fluid, blackish-gray masses, swelling, mucoid degenera- 
tion and active desquamation of the epithelium. He is inclined to associate these 
changes with the symptoms of diabetic coma. 
Lesions of the pancreas are not infrequent, and include the following:, 
atrophy, fatty degeneration, necrosis, proliferation of interstitial con- 
nective tissue, and formation of calculi, with secondary cystoid degenera- 
tion of the excretory ducts. 
The spleen is unchanged. The liver often exhibits enlargement, 
hypertemia, proliferation of the interstitial tissue, interstitial hemor- 
rhages, more rarely abscesses, calculi, waxy degeneration, atrophy, and 
portal thrombosis. 
The liver cells sometimes contain glycogen many hours after death; this sub- 
stance is found particularly in the cells at the periphery of the acini. In my own 
cases, the entire cell presented the glycogen reaction (intense brown color on the 
addition of iodine and potassium iodide solution). Rindfleisch claims to have 
seen it confined to the nucleus of the cells. The amount of fat in the liver is 
sometimes very slight. 
The kidneys are often hypertrophic, and may present cysts, waxy de- 
generation, tubercles, and abscesses. The mucous membrane of the uri- 
nary passages may be in a condition of catarrhal inflammation. 
Armanni and Ebstein found hyaline degeneration (diabetic swelling of the 
epithelium) in a large part of Henle’s tubes in the cortex (the epithelium con- DISEASES OF NUTRITION. 
79 
verted into transparent vesicles with well stained nuclei); Ebstein also noticed 
patches of epithelial necrosis in the cortex. Frerichs observed glycogenic degen- 
eration of the renal epithelium, and considers it identical with hyaline degenera- 
tion. These lesions are perhaps associated with diabetic coma. 
The lesions observed in the central nervous system are meningeal 
thickenings, adhesions, and hemorrhages. Thickenings of the ependyma 
of the ventricles are also mentioned. Dilatation of the blood-vessels, 
atrophy or pigmentation of the ganglion cells, proliferation of the inter- 
stitial connective tissue have also been described, but these lesions are 
accidental, or unimportant. 
The sympathetic may be intact or its ganglia, particularly in the 
solar plexus, may exhibit proliferation of the interstitial connective tis- 
sue, pigment degeneration and atrophy of the ganglion cells, and dilata- 
tion of the vessels. 
In a series of cases, there is no doubt that diabetes mellitus is the result of dis 
turbances of cerebral innervation, the starting-point being found in the floor of 
the fourth ventricle. It may also be regarded as certain that the liver is concerned 
in the formation of sugar, and that the sympathetic forms the connecting link 
between the medulla oblongata and the liver. Hence, diseases of the central ner- 
vous system which are associated with vaso-motor disturbances in the hepatic cir- 
culation may result in diabetes mellitus. But why the blood becomes overloaded 
with sugar is not 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 them 
from the food through the portal vein; hence the excess of sugar passes into the 
hepatic vein and thus into the general circulation. Or there may possibly be 
complete conversion of the sugar derived from the food into glycogen, but the 
hepatic cells supply the blood with an unusual amount of glycogen and thus of 
sugar. Or perhaps both processes are combined. 
Similar conditions are to be expected if the nervous system is affected, not in 
the medulla oblongata, but in the sympathetic. 
Nor is it impossible that some cases of diabetes mellitus develop in a reflex 
manner, for example, in peripheral neuralgias. 
In addition, there is also a gastro-hepatic form of diabetes mellitus. Clinical 
experience teaches that the excessive ingestion of sugar and starchy food may 
give rise to diabetes, either because the liver cannot convert its entire supply of 
sugar into glycogen, or because the hepatic cells, which are ovei'charged with 
glycogen, furnish an excess of sugar to the hepatic veins. The symptoms of dia- 
betes are preceded not infrequently by those of gastro-intestinal catarrh, so that 
the disease has been attributed to abnormal processes of decomposition and ab- 
sorption in the gastro-intestinal tract and the portal circulation. Diabetes melli- 
tus sometimes follows diseases of the portal vein or liver itself. 
In some cases the source of the sugar has been sought in the muscles. There 
is no 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. Diagnosis,—A suspicion of diabetes mellitus is often aroused 
by prominent symptoms. As the sulphate of copper in Trommer’s test 
is also reduced by uric acid, kreatinin, or pyrocatechin, various tests, 
especially the fermentation test, should be made. 
In intermittent diabetes, only certain portions of urine contain sugar, 
so that, if the symptoms of diabetes are present, but sugar is absent from 
the urine, it is well to allow the patient to take a hearty meal of sweet 
farinaceous articles, and to examine the urine two to four hours later. 
In mild cases, the sugar disappears on purely animal diet; in severe 
cases, it merely diminishes. 
Abeles and Hoffmann report a case in which an hysterical woman introduced 80 
DISEASES OF NUTRITION. 
Bugar into the urine and then injected it into the bladder, in order to deceive her 
physicians. ' 
V. Prognosis.—The prognosis is always grave, and many authors 
believe that permanent recovery never takes" place. 
As a general thing, the prognosis is worse in children than in adults, 
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 
heredity plays a part. 
VI. Treatment.—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 the administra- 
tion of drugs. We should endeavor to give the patient as much animal 
food, especially meat, as possible. A certain amount of variety in the 
diet is secured by allowing the patient to take all kinds of fats, although 
this increases, 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 we 
may recommend carbonated or alkaline waters (Selters, Apollinaris, 
Vichy, Giesshuebel, etc.), or lemonade made with lactic acid (Aq. destil., 
1 vij.; Acid, lactic., gr. vij.; Natrii bicarbonic., 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 is a table of the articles of diet allowed and inter- 
dicted: 
Articles of food allowed : all kinds of fresh meat, ham, sausage, corned beef, 
smoked beef, tongue, fowl, and game of all kinds. Fresh and smoked fish, 
mussels, oysters, lobster, roe, gelatin without sugar, cheese, butter, lard, cod- 
liver oil, olive oil, cooked green vegetables without sugar (cauliflower, spinach, 
green tips of asparagus, kohlrabi, beans, white cabbage). Lettuce, endive, horse- 
radish, 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, farinaceous 
articles, rice, sago, arrow root, potatoes, maccaroni, oatmeal or barley, milk, 
whey, chocolate, beer, sweet wines, champagne, alcohol, liquors, sweet or pre- 
served fruits, turnips, 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 mountain tours, 
if excess is avoided. A trip to the mountains in the summer, and to an 
uniformly warm climate in the winter is very serviceable, and in some 
cases is followed by considerable diminution or even disappearance of 
the sugar in the urine. DISEASES OF NUTRITION. 
81 
. ie m°st important medicinal agents are opium, arsenic, salicylic 
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 
grams a day have been administered. Morphine has a similar favorable 
t effect, but no certain results are obtained from other narcotics (narceine,, 
narcotine, potassium bromide, strychnine, belladonna, chloral, cannabis 
mdica). 
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. f!] 
• o '"5 i- sveiy tvvo hours), the latter in the form of powder (gr. vii. every 
?} t'vo until tinnitus aurium is produced). We must experiment 
with these remedies, since different patients react differently. 
mAu°wf other remedies have been employed, but it will suffice to mention 
itS g: « A.lk^ie® (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 hit 
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, quinine, d. Creasote, thymol, benzoic acid, iodo- 
foirri. e. Glycerin. /. Pilocarpine, g. Gall and biliary salts, h. Beer yeast, 
Dmretics, drastics astringents, ergotin. Jc. Galvanization of the 
ceivical 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 part, to the 
strict diet. The sugar generally returns after the strictness of the diet is 
relaxed. 
lecommended a strict milk diet, and Diihring claims to have 
cured (.) a cases by the following plan : Three to four meals 
dady, consisting of 3 iij. to iv. p. d. of rice, hominy, barley groats, or buck- 
wheat grits, 3 vuj. of smoked or broiled meat, stewed dried apples, 
plums, 01 chemes, coffee and milk with wheat bread, and red wine and 
water after meals. 
Ihe various complications of the disease require symptomatic treat- 
iiiGTit. In diabetic coma, stimulants should be given, Surgical opera- 
tions must be avoided as much as possible. 
Appendix. 
Mellituria (glycosuria) is the term applied to the temporary excretion of sugar 
“:ielutnne; It.18 nTieyely,a symptom of various conditions and rarely requires 
special treatment. It has been observed under the following circumstances : 
a. Excessive ingestion of sugar and farinaceous food. 
. I unctional and organic diseases of the nervous system, viz., cerebral hemor- 
rhage, epilepsy acute delirium, melancholia, general paralysis of the insane, 
sciatica and other neuralgias, violent mental excitement, cerebral concussion, 
ana meningitis. 
c. Disturbances in the pulmonary interchange of gases (?). 
a. 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- 
e. Convalescence from infectious diseases (cholera, variola, pneumonia, mala- 
ria, phlegmonous inflammations, etc.). 
j. After poisoning with carbonic oxide and illuminating gas, glycosuria is 82 
DISEASES OF NUTRITION. 
sometimes observed for several hours. Whether the reducing substance found in 
the urine after opium and chloral poisoning is really sugar requires further inves- 
tigation. The reducing substance found in the urine after nitrobenzol poisoning 
is not sugar. Arsenic poisoning and prussic-acid poisoning produce true glyco- 
suria with increased thirst and increased amount of urine. 
g. Sugar is found in the urine of puerperal women, especially if they do not 
nurse, and in that of infants. Hoffmeister and Kaltenbach showed that milk 
sugar is found in such cases (lactosuria). 
h. According to Liveing, glycosuria is not very rare in chronic eczema. 
4. Diabetes Insipidus. 
I. Etiology.—Diabetes insipidus is an independent disease whose 
chief symptoms are increased excretion of urine (polyuria) and increased 
thirst (polydipsia), 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. 
Middle life (fifteen to forty-five years) is attacked most frequently. 
Kuelz recently collected thirty-five cases in children; two of these cases 
began in the first year of life. 
The disease is sometimes hereditar}r, 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 nervous system, hydrocephalus, chronic 
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 the floor of the fourth ventricle has been 
affected. 
Bernard showed that injury to the floor of the fourth ventricle, above the site 
whose irritation causes diabetes, will give rise to increased excretion of urine. 
According to later experimenters, irritation of adjacent parts produces the same 
effect. Polyuria is produced in rabbits by irritation of the vermis of the cerebel- 
lum, in dogs by section of the splanchnic nerves; also after section of the spinal 
cord below the twelfth vertebra. 
Diabetes insipidus is sometimes attributed to mental and bodily 
strain, fright, insolation, cold, exposure to wet, and taking cold drinks 
when the body is heated, but such statements are 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. Symptoms.—The symptoms sometimes develop within a few hours 
after the action of the etiological factor. In other cases, they develop 
so 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 be 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 
quantity discharged at one time. The urine is light-yellow, sometimes DISEASES OF NUTRITION. 
83 
almost as clear as water, has an acid reaction, but readily becomes neu- 
tral or alkaline after standing, 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 urea is generally increased: Senator has found as 
much as two and one-half ounces per diem. In a doubtful case, re- 
ported by Hoffmann, the uric acid was replaced by hippuric acid. Ac- 
cording to Senator, the excretion of kreatinin is unchanged. The phos- 
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 the urine 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 short time, the 
amount of urine 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 urine is increased 
more rapidly in the former, but persists in the latter for a longer time, 
inasmuch as the excretion of urine occurs more uniformly. 
The increased feeling of thirst produces a sensation of dryness 
and stickiness in the mouth and throat, and occasionally a feeling of 
constriction in the pharynx. Children sometimes drink their own urine 
or any other fluid which falls into their hands. 
That polydipsia is the result of polyuria is evident from the fact that the latter 
•continues after the patients are deprived of fluids. In very rare cases, however, 
there appears to develop a primary polydipsia with secondary diabetes. Noth- 
nagel recently reported the following case: A mason, aet. 85 years, fell on the 
back of the head; unconsciousness; half-hour later, intolerable thirst; two and a 
half to three hours later, permanently increased excretion of urine. In primary 
polydipsia, the amount of urine must diminish very rapidly and become sub- 
normal if the patients are deprived of fluids. 
The insensible perspiration is usually diminished, but occasionally 
unchanged. The skin is very dry and brittle. Some patients complain 
of paraesthesise and pruritus; furunculosis is rare. Ilyperhidrosis and 
salivation have been observed in exceptional cases. 
The bodily temperature may be abnormally low, and the patients 
grow cold very quickly, owing to the fact that a large amount of heat is 
given off in order to warm the large amounts of fluid ingested. 
If the disease develops in early childhood, the bodily development is 
often very much retarded. In other cases, general nutrition is very 
little impaired. The appetite is more frequently diminished than in- 
creased. There is sometimes a desire for peculiar articles of diet. Gfas- 
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 abducens. 
The following ocular changes have been observed: retinal hemor- 84 
DISEASES OF NUTRITION. 
rhages, neuroretinitis with fatty degeneration as in Bright’s disease, 
atrophy of the optic nerve, hemianopsia, and amblyopia; cataract does 
not develop. 
The disease may last many years (fifty years in Willis’ case). Re- 
missions 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 Changes.—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 unusual amount of blood; Neuffer noticed dila- 
tation of the urinary tubules and fatty degeneration of the epithelium. 
The nature of the disease is unknown, but the symptoms are probably the 
result of vaso-motor disturbances in the renal circulation, in the production of 
which the sympathetic renal fibres play the chief part. 
IV. Diagnosis.—The diagnosis is made from the increased excre- 
tion of urine of low specific gravity, and the increased feeling of 
thirst. The following conditions must be taken into consideration in 
differential diagnosis : 
a. In diabetes mellitus, the specific gravity of the urine 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 withdrawal of fluids upon the amount of urine. 
d. Transitory and symptomatic polyuria is only of short duration. 
Transitory polyuria is observed under the following conditions : after the on- 
set of cerebral apoplexy, after mental strain in hysteria, and during convales- 
cence from severe infectious diseases, especially typhoid fever. I observed it 
twice after the administration of digitalis, once after salicylic acid. In some in- 
dividuals (especially females) it occurs after coitus. It is also observed fre- 
quently in diseases of the urinary passages. 
Y. Prognosis.—Permanent recovery from diabetes insipidus occurs 
only in exceptional cases, but life is often maintained for a long time. 
The prognosis is so much more serious the more rapid the emaciation 
and the more grave the primary disease. 
YI. Treatment.—Causal indications must first be met. In a pa- 
tient set. 6 years, in whom the disease was associated with syphilis, 
Demme obtained successful results by means of the inunction treatment. 
If there is marked anasmia, I have obtained great benefit from iron pre- 
parations, notably tinct. ferri acetic, and tinct. ferri chlorat. aither. 
( 3 i- three or four times a day). 
If there are no causal indications, we would recommend the adminis- 
tration of opium and lead in combination (Plumb, acet., gr. f ; Opii. puri, 
gr. ss. ; Sacch. alb., gr. vij., one powder every three hours). As in dia- 
betes mellitus, very large doses of opium often are tolerated. The 
thirst may be quenched with acid drinks ; the patients should wear thin 
flannel to avoid catching cold. DISEASES OF NUTRITION. 
85 
The other remedies employed include the following : a. Valerian, 
potassium bromide, ergotin, arsenic, belladonna, digitalis, castoreum, 
asafoetida. b. Jaborandi and pilocarpin. c. Creasote, carbolic acid, 
sodium salicylate, d. Tannin, turpentine, copaiba, potassium iodide, 
calomel, nitric acid. e. Constant galvanic current to the spinal cord 
and renal region, also to the medulla oblongata, cervical cord, pneumo- 
gastric, and sympathetic. 
5. Rickets. Rachitis. 
I. Etiology.—The nutritive changes which lie at the bottom of ra- 
chitis are manifested chiefly by abnormalities in the growih of the 
bones. Proliferation of the cartilaginous and periosteal portions, with 
imperfect and irregular calcification, produces deformities of the bones 
which are such a prominent part of the clinical history that we might 
almost be tempted 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 five years. 
In a number of cases, the bone changes develop in utero (foetal rachitis). But 
it is not certain that these changes are histologically identical with the rachitic 
process. 
The term congenital rachitis is applied to those cases in which the disease 
appears very soon after birth. 
Some authors assume the existence of rachitis tarda, in which the disease 
develops during the period of puberty, but this assumption is still unproven. 
The disease is more common among the children of the poorer 
classes. 
It is an extremely frequent disease of childhood. According to Rit- 
ter v. Rittershain, 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 
born of parents who suffer from phthisis or the late stages of syphilis 
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 children, 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 also 
been asserted that anaemia of the mother favors the development of 
the disease. 
In many cases, the 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 in vegetables. It is more apt to de- 
velop if the patients, in addition, live in overcrowded, dark, damp 
rooms. The exciting cause is sometimes furnished by intercurrent 
diseases. 
The disease is extremely frequent in England, Holland, France, and 
Germany, while it is extremely rare in the tropics. It is said not to de- 
velop beyond the height of 3,000 -feet above the sea level. 
II. Symptoms.—In some cases, rachitis begins without special pro- 86 
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 foul-smelling diarrhoea. 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. 
Rachitis of the skull is characterized by the peculiar shape of the 
head (vide Fig. 12). While the skull appears to have increased consid- 
erably in size, the face appears very much smaller. The 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 bone are found occasionally 
DISEASES OF NUTRITION. 87 
in the parietal, sphenoid, and even the frontal bone. Slight grades of 
this condition are said to be observed at times in non-rachitic children. 
The hair of the scalp, especially over the occiput, is apt to fall out, on account 
of the profuse sweating and the constant recumbent position. The hairs become 
brittle and break, finally they fall out, and the occiput then appears more or less 
bald. 
DISEASES OF NUTRITION. 
Fig. 12. 
Kachitic child, set. 2 years, with rachitic skull and thickenings of the costal cartilages and epi- 
physes. 
The systolic cerebral murmur is a blowing, vascular sound, coincident with 
cardiac systole, and which is generally heard with greatest distinctness over 
the large fontanelle, but occasionally over ihe parietal bone and lesser fontanelle. 
This was erroneously held to be characteristic of the rachitic skull. Juracz has 
shown that it is observed in children from the age of three months to the end of 
the sixth year. It occurs only when a similar sound is heard in the internal 
carotid, whence it is conveyed to the surface of the brain. According to Juracz, 88 
DISEASES OF NUTRITION. 
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 shape 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 the jaw turns, its upper surface 
being directed more posteriorly and internally, 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 jaw, 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 laterally 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 month, 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 carious 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 twenty-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. 
During 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. 
Among 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 the 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 the 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 long 
diameter of the thorax is shortened. Retractions 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 DISEASES OF NUTRITION. 
89 
place, the soft ribs yield to the inspiratory traction of the lungs inwards, especially 
since the disease is often complicated by obstinate and extensive bronchitis. In 
addition, the ends of the ribs, on account of their changed growth, grow anteri- 
orly past the enlarged costal cartilages and thus favor a bending inwards (Hueter). 
Nor should we underestimate -the effect of lifting the children up by means of 
the hands pressed beneath the lateral surfaces of the thorax. 
Fig. 13. 
Transverse section of the rachitic thorax. St, sternum; W, vertebral column. The numbers in- 
dicate centimetres. One-fourth natural size. 
The ribs sometimes present fractures or subperiosteal enlargements. Finally, 
a prominence, possessing a very acute angle, may develop between the manubrium 
and the body of the sternum, and the latter may form a more or less deep furrow. 
Fig. 14. 
Transverse section of a rachitic thorax, with a furrow-shaped depression of the sternum. TV, spine; 
St, sternum. At the level of the fifth costal cartilage. The numbers indicate centimetres. One- 
fourth natural size. 
The clavicles often present rachitic changes. Both epiphyses are en- 
larged into shapeless masses, the gentle carves are replaced by angular 
flexions, and partial, even complete fractures may ensue, generally as the 
result of vigorous pressure with the arms. The scapulas may also pre- 
sent thickening of the free border, sometimes partial fracture of the 
lower half. 90 
DISEASES OF NUTRITION. 
Thoracic deformities are greatly increased after rachitic spinal curva- 
tures supervene. 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 vertebrae. 
Kyphosis, lordosis, and scoliosis are often combined. 
The pelvis not infrequently presents the characteristics of the fiat, 
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 become a source of difficult labor. In addition, 
the acetabular region is occasionally pushed inwards, so that the trans- 
verse section of the pelvis becomes heart-shaped. These deformities are 
produced not alone by the weight of the body, but also by the traction 
of the muscles inserted into the pelvis. 
The most noticeable change in the bones of the limbs is the enlarge- 
ment of the epiphyses, particularly 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 which does not yield until the rachitis is cured, and often 
terminates in broncho-pneumonia. The heart may be displaced on 
account of the deformity of the thorax and spine. Leucocytosis, nucle- 
ated or red globules, and 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 symptoms of 
tabes mesenterica appear, there is usually insatiable 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 liine 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 DISEASES OF NUTRITION. 
91 
a sensation of increased heat under the bed-clothes, so that they are apt 
to lie uncovered at night. 
The disease generally lasts several months. Acute rachitis (sudden 
onset and rapid course of a few weeks) has been described, but the 
symptomatology is so different from the typical clinical history of rickets 
that great care must be exercised in the interpretation of such cases. 
Complications are frequent. The disease is very often associated 
with scrofula, but we do not believe that rickets, per se, gives rise to 
enlargement of the peripheral lymphatic glands. The scrofula may be 
followed by phthisical changes in the lungs and miliary tuberculosis. 
Spasm of the glottis often occurs in rachitic children; chronic hydro- 
cephalus and eclamptic attacks are also observed. Waxy degeneration 
sometimes develops. According to Rehn, rickets may be associated with 
osteomalacia. Cortical cataract has also been observed in rachitic chil- 
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 dwarfish. Supernumerary bones de- 
velop not infrequently in the cranial sutures, and the fontanelles and 
sutures appear very deep. The bones are sometimes very much con- 
densed (rachitic sclerosis or eburnation), in later years they may become 
extremely brittle. The patients are placed in special danger by spasm 
of the glottis, bronchitis, broncho-pneumonia, exhaustion from obstinate 
diarrhoea, or tubercular processes. 
III. Anatomical Changes.—The bones are affected almost exclu- 
sively, 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- 
blasia of the cellular elements), accumulation of fat in the liver. 
The rachitic bones present the following lesions: enlargement of the 
epiphyses, thickening and hyperplasia of the subperiosteal layers, un- 
usual congestion of these parts, flexibility and softness of the bones. 
The bones, especially those of the skull, may not infrequently be cut 
vith a knife. If a longitudinal section is examined, it is seen that the 
epiphyseal changes start from the cartilage situated between the epi- 
physis 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 converted into osseous 
tissue. 
The healthy epiphyseal cartilage is divided into the epiphyseal and 
diaphyseal zones. The former has a bluish-white color, and is one to 
two millimetres in height. It is subdivided into two parts. In the 
younger one, adjacent to the epiphysis, the process consists chiefly of 
proliferation of cartilage cells and gradual arrangement in longitudinal 
rows (hyperplastic portion), while in the older one, nearest to the 
diaphysis, there is chiefly an increase in the size of the cartilage cells 
(hypertrophic 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 line. 
In rickets, both portions of the epiphyseal cartilage are greatly in- 
creased in height. The proliferation zone may be several centimetres in 92 
DISEASES OF NUTRITION. 
thickness, and project laterally from the side of the bone. The sharp 
boundary between the two layers of the epiphyseal cartilage is lost, and 
both are abnormally vascular. In the zone of temporary calcareous in- 
filtration, the vessels are increased in size and number, and extend into 
the proliferation 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 infiltrated with lime which, in places, 
extends into the proliferation layer. In this manner the diaphyseal por- 
tion assumes a porous, spongy character (spongoid tissue). 
The growth of bone in thickness depends upon the periosteum. 
On the surface of the periosteum adjacent to the bone proliferations 
form, and are gradually converted into osseous tissue. At the same 
time an absorption of osseous tissue occurs 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 surface 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 unusually 
flexible. The medulla is generally very red, and occasionally has a 
lymphoid appearance. 
The microscopical changes are still the subject of dispute. The proliferation 
layer presents excessive proliferation of the cartilage cells. The cell groups con- 
tain an unusually large number of closely aggregated cells, between which the 
basement substance has disappeared in great part. The latter loses its homoge- 
neous character and assumes a more fibrillated structure. 
In the zone of temporary calcareous infiltration, the development of medullary 
spaces, and of vascular spaces within them, is unusually extensive; contrary to the 
rule, this often extends into the proliferation zone. Calcification and ossification 
occur irregularly, and also extend into the proliferation zone. Some of the carti- 
lage cells are converted directly into bone corpuscles. Klebs found that others 
were converted into medulla cells, and then into connective-tissue corpuscles, so 
that the vascular spaces in the medullary spaces were surrounded in many places 
by dense masses of connective tissue. Similar processes are observed in the peri- 
osteum. 
The specific gravity of the bones is diminished. In a child set. 8 years, Trous- 
seau found that the entire skeleton weighed one kilogram (normal weight, seven 
to eight kilograms). 
Friedleben found an increased amount of water, fat, and carbonic acid in the 
bones, diminution of lime salts ; in general, increase of organic, diminution of 
inorganic constituents. 
Concerning rachitic changes in bones, two factors must be distinguished, viz.: 
the proliferative processes and excessive vascularization, and the irregular and 
imperfect calcification. 
It is evident that a deficiency 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 contains sufficient amounts for the development of bone. It has 
been claimed that rachitic changes may be produced experimentally in animals 
by depriving them of lime salts, but this has been denied. 
From the fact that obstinate diarrhoea is a prodrome of rachitis in many cases, 
it was assumed that lactic acid was formed by the fermentation of ingested milk, 
that this, being absorbed by the blood and tissue juices, dissolved the lime salts 
and prevented their precipitation in the bones. Great importance was attached DISEASES OF NUTRITION. 
93 
to the fact that lactic acid was said to be demonstrable in the urine. But this 
has recently been sought for in vain in the urine, and it has never been found in 
the bones. Nor does the urine contain an unusually large amount of lime salts. 
Senator has recently called attention to the view that the carbonic acid in the tis- 
sues perhaps acts as a solvent 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 the large 
amount of the potassium combinations in milk (particularly of animals), and to a 
still greater degree in vegetable food. When the potassium salts are absorbed 
they combine with all the chlorine at their disposal,-so that very small amounts of 
chlorine remain to aid the absorption of lime salts. Hence, the latter pass in 
the faeces, 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 
opinion, rachitis may be explained as follows : disturbances of nutrition in con- 
sequence of perverse nutritive processes or other general causes; a predominantly 
local inflammatory affection of the epiphyseal cartilage; imperfect and irregular 
calcification, on account of deficiency of lime in the tissues and the existing in- 
flammatory conditions in the cartilage. This theory tallies with the experiments 
of Wegner, who produced inflammations 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 rachitic changes in the 
bones. 
IV. Diagnosis.—The diagnosis is easy. Delayed and irregular den- 
tition and profuse sweating of the head and obstinate diarrhoea point 
towards latent rickets. 
Osteomalacia occurs almost exclusively in adults. In cases of congenital 
syphilis, the epiphyseal cartilages may become separated, but the patients are 
only a few weeks old, and there are other evidences of syphilis on the skin and 
mucous membranes. The rachitic skull should not be mistaken for chronic hydro- 
cephalus. In the latter, spasms often occur, and mental development is im- 
perfect. 
V. Prognosis.—The prognosis is not unfavorable as regards life, if 
the disease is not too far advanced, or associated with scrofula, tabes 
mesenterica, or other serious complications. Deformities of the bones 
may subside spontaneously. Persistent deformities of the thorax and 
spine may give rise to shortness of breath and a tendency to inflamma- 
tions of the air passages. 
VI. Treatment.—Proper nourishment 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 be regulated; infants should be nursed at the breast, 
if possible, or should receive cow’s milk with the addition of lime-water; 
older children should receive less vegetable, more animal food. 
The children should be kept a good deal in the open air, and should 
sleep upon a hard mattress. They should not be urged to walk, and in 
carrying them care should be taken not to produce artificial de- 
formities. 
A teaspoonful of cod-liver oil is given morning and evening. For 
four weeks, a sodium-chloride bath should be given every morning 
(28° K ; sodium chloride, § xxx.-l.; twenty minutes’ duration; then 
one-half to one hour’s rest in bed). 
The following prescription may be ordered: 94 
DISEASES OF NUTRITION. 
$ Ferri lactic., 
Calcar, phosphoric aa 3 iij. 
Magnes. carbon., 
ISTatr. chlorat., 
Sacch. alb aa3iss. 
M. D. S. The point of a knife full t. i. d. after meals. 
Diarrhoea offers no contra-indication to this plan of treatment. 
Preparations of iron and lime, bitters, tonics, phosphorus, and arsenic have 
also been recommended in rickets. 
6. Softening of the Bones. Osteomalacia. 
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. Among 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. Rehn 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 the spine. 
The pains 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 occurs. The promontory of the sacrum passes deeply into the 
pelvic cavity; the acetabula are bent inwards. The rami of the pubis pro- 
ject like a beak, and the transverse section of the pelvis assumes a cordate 
shape. The narrowing of the pelvis may not alone interfere with labor, 
but also with the evacuation of the bladder and rectum. Individuals 
suffering from softening of the pelvis complain very quickly, -while 
sitting, of pain in the tubera ischii. The normal curves of the spine 
are morbidly increased. The cervical curve is sometimes so great that 
the chin and sternum come in contact. Considerable deformity appears 
in the lumbar spine. The spine is shortened, and the patient sometimes 
shrinks to dwarfish dimensions. The ribs and sternum often present 
serious deformities, and these may be associated with partial or complete 
fractures. Hence compression and displacement of the lungs and heart, 
palpitation, dyspnoea, and asthmatic attacks. The limbs may also be 
subject to curvature and fracture, and the gait becomes waddling and 
finally impossible. Multiple fractures after slight injury are sometimes 
the first evidence of osteomalacia. In fractures, the formation of callus 
may be absent or incomplete, or it may undergo absorption at a later 
period. Softening rarely occurs in the bones of the skull. The teeth 
are not attacked, although they may become carious and drop out. DISEASES OF NUTRITION. 
95 
The muscles are soft and flabby. Fibrillary twitcbings, spasms, and 
painful contractures have been described. They occur spontaneously 
or after slight cutaneous irritation. 
The sweat, saliva, and milk are said to be overloaded with lime 
salts, and the latter are also said to be excreted through the bronchial 
and gastro-intestinal mucous membrane (?). 
No specific changes are noticed in the urine. There is sometimes 
temporary increase of uric acid. The specific gravity is generally 
diminished. As a rule, the excretion of urea and phosphoric 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 hemialbumose (vide Vol. II., page 245) are 
found occasionally. 
The urine, often contains a sediment of carbonate, phosphate, and 
oxalate of lime, and the kidneys may contain concretions of a similar 
character. 
Leube found 0.345 gm. lime in the fasces in two days. 
The disease generally lasts many years. The most acute case lasted 
nine months; the most protracted, thirteen years. Remissions 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 
bones. They are sometimes as flexible as if the lime salts had been re- 
moved with acids, or they form membranous structures like the intes- 
tines. and arq 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, aud 
becomes yellow, finally atrophic and gray. 
The Haversian canals are increased markedly in size and filled with 
reddish succulent 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 
occurring from the medullary cavity towards the periosteum. Finally, 
only a thin layer is left beneath the periosteum, and even this may 
disappear almost entirely. The periosteum is thickened, its pro- 
liferation layer congested and contains extravasations. According as 
the remaining masses of bone are flexible or still contain firm portions, 
the diseased bone presents a varying tendency to fracture. 
The microscope shows great changes in the osseous tissue in the immediate 
vicinity of the medullary cavity and Haversian canals. This part stains readily 
with carmine, has lost the lime salts and assumed a fibrillated structure, and con- 
tains a few spindle-shaped, unbranched remains of bone-corpuscles. At a later 
period gradual mucoid liquefaction and absorption seem to take place. At 
the boundary between the healthy and diseased tissues are found the so-called 
Howship’s lacunae, in which myeloplaques have been found. 
The medulla of the bones and the contents of the Haversian canals present 
congestion of the vessels (passive hyperaemia, according to Rindfleisch) and 
numerous extravasations. In the red marrow we find only the remains of 
fat cells, in great part lymphoid cells; at a later period numerous pigment cells 96 
DISEASES OF NUTRITION. 
make their appearance. In the gray atrophic medulla the basement substance 
predominates, and the cells which are poor in fat and scanty have an almost 
epithelioidal character. 
According to O. Weber, the bones sometimes contain lactic acid. Their 
specific gravity is diminished, they are rich in fat, and unusually poor in inor- 
ganic constituents, especially the lime salts. In one case, Huppert found phos- 
phate of iron. Not alone simple atrophy and fatty changes, but also degen- 
eration have been found in the muscles. 
Many claim that the disease is the result of the formation of lactic acid 
in the medullary spaces, this giving rise to decalcification of the osseous 
substance. Rindfleisch attributes a solvent influence to carbonic acid, which is 
perhaps produced excessively in the medullary spaces as a result of stasis 
of blood. But Langendorff and Mommsen showed that osteomalacic changes 
do not consist simply of decalcification. For example, they found, in the base- 
ment substance of the bones an imperfect formation of lamellar systems, 
longitudinal striation and fibrillated formations, and in such places there 
were often large masses of Sharpey’s fibres. Cohnheim does not look upon the 
limeless places as having been previously healthy, but regards • them as an 
apposition of diseased tissue. The frequent occurrence of the disease during 
pregnancy has been attributed to the fact that the maternal organism supplies 
the foetus with a large amount of lime, and thus retains an insufficient amount 
for its own consumption. 
The obscurities of the problem have not been cleared up by experimentation. 
IY. Diagnosis, Prognosis, Treatment.—The disease is distin- 
guished from rachitis by the fact that the bones, instead of remaining 
soft, grow soft. 
The prognosis is unfavorable, 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. Kohls 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. 
Gaskoin maintains that arthritis deformans develops after psoriasis, lichen, 
variola, and particularly after area Celsi. 
II. Symptoms.—The disease always develops gradually and slowly. 
It may attack only one or a number of joints. In the former event, 
the hip is frequently involved, particularly in old men (malum coxae 
senile). Polyarticular arthritis includes two varieties, according as it 
attacks the trunk and large joints of the limbs, or the phalangeal and DISEASES OF NUTRITION. 
97 
metacarpo-phalangeal joints of the feet and hands. The disease may be 
strikingly symmetrical. 
Obstinate hemicrania has been noticed in women as a prodrome of 
the disease. 
The symptoms generally begin with pains in the joints. These may 
extend over the entire limb, and are either confined to a definite nerve 
tract or are of a vague character. Remissions and exacerbations are fre- 
quent, the latter occurring particularly in windy, damp, and cold 
weather. Some patients complain of paraesthesise, 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. 
Fig. 15. 
In the hands, it is generally Hound 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 extensive, the patients are rendered completely 
helpless, although life may be maintained for twenty or thirty years. 
The internal organs are generally intact. Hueter has noticed disease of 
the endocardium, and early arterio-sclerosis is sometimes noticeable. 
Death is generally the result of intercurrent diseases. 
III. Anatomical Changes.—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 into the joint cavity. Some 
of the villi may undergo ossification, and they may become separated 
Position of the fingers in arthritis deformans. 98 
DISEASES OF NUTRITION. 
and float free in the joint. Parts of the capsule 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 
ivory, and destitute in great part of cartilage. 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 joint 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. 
Weichselbaum 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 consists 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 
bony 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 the 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-liver 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. 
Good results have been obtained from massage and galvanism (to the 
sympathetic, spinal cord, nerve plexuses, or the joints). SECTION X. 
INFECTIOUS DISEASES. 
A. INFECTIOUS DISEASES WITH TYPICAL LOCALI- 
ZATION. 
PAET I. 
ACUTE INFECTIOUS EXANTHEMATA. 
1. Measles. MorbilU. 
I. Etiology.—Measles is an exquisitely contagious disease which is 
conveyed only by contagion, although, as a matter of course, it must 
have developed originally in an autochthonous manner. 
Experiments have shown that the contagious matter is conveyed in 
the blood, tears, nasal secretion, sputum, 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 disease during the period of desquamation. 
The contagious substance possesses 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 
presence 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 infectious matter leaves the organism through the exhalations from 
the skin and lungs. 
The virus of measles may also be conveyed through the medium of 
other individuals and inanimate objects. Hence, physicians may spread 
the disease from affected 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. 
Hence, during an epidemic of measles, all individuals should be quaran- 
tined who are apparently suffering merely from simple coryza, cough, 
and conjunctivitis. 
In accordance with the recent views concerning the origin of infectious dis- 
eases, we assume that measles are produced by low organisms (bacteria, schizomy- 
cetes), but the bacterium has not been discovered with certainty. Babes and 
Cor nil, Braidwood, Murray, and Vacher, and Lebel, have recently claimed to 
have found the bacteria of measles in the expired air, blood, tears, nasal secre- 
tion, and some of the internal organs. 100 
ACUTE INFECTIOUS EXANTHEMATA. 
A susceptibility to infection with measles is possessed by the major- 
ity of individuals. The greater number are exposed during childhood, 
so that the disease is regarded as one of childhood. But in isolated 
places which have long been free from measles, and have been accident- 
ally infected by diseased sailors, it has been found that young and old 
alike are attacked. A diminished susceptibility is attributed to the 
first six months of life, although cases are known in which children were 
attacked with measles a few days after birth, or even at birth. Indeed 
it is even held that the foetus in utero may pass through the disease, and 
therefore remain free from subsequent infection. 
Other diseases at the most delay the outbreak of measles. Immu- 
nity is not conferred by pregnancy or the puerperal condition. Measles 
are sometimes associated with another infectious disease. The known 
combinations are : measles with typhoid fever, variola, scarlatina, ery- 
sipelas, roetheln, varicella, pemphigus, and mumps. The combination 
of measles and pertussis is not at all rare. 
As is true of the majority of other infectious diseases, a single attack 
of measles confers an immunity against subsequent attacks. Cases of 
double or triple infection are rare. In some epidemics, however, rein- 
fection is relatively frequent. In some cases, many months or years 
■elapse between the two attacks ; in others, only a few weeks. Cases in 
which, a few days after the disappearance of the eruption, another 
undoubted eruption develops are probably instances of a relapse 
(extremely rare). Some individuals seem to possess a temporary immu- 
nity. Despite opportunity for infection, they escape in one epidemic, 
but may be attacked in the next. 
The disease occurs sporadically, more frequently in epidemics. In 
large cities, sporadic cases are observed almost constantly. Such cases 
occasionally form the starting-point for epidemics. Epidemics appear 
not infrequently at certain definite intervals (two, four, and six years). 
It appears as if a certain amount of “ measles material ” must be collected 
before the disease can spread extensively. The most favorable opportu- 
nity for infection is afforded by schools and places of public amuse- 
ment. The danger of infection is less in the open air than in closed 
rooms. 
Epidemics are more frequent in the winter and spring than in other 
seasons. Those occurring in the former seasons are often complicated 
by respiratory diseases, while obstinate diarrhoea is not infrequent in 
summer epidemics. 
An epidemic generally lasts four to six months. As a rule, it rapidly 
reaches its height, and at this period the cases are generally more seri- 
ous than at the beginning or end of the epidemic. 
At certain times measles spreads pandemieally, i. e., over large areas 
of country. According to Guttcet, the whole of Russia was ravaged, in 
1866, by an epidemic of measles. 
II. Symptoms and Anatomical Changes.—If the virus of measles 
is conveyed to a healthy organism, a certain period elapses, during which 
the poison increases and accumulates in the system before the first signs 
of poisoning become noticeable. During this stage of incubation, which 
lasts ten days in typical cases, the individual often feels entirely well. 
Although the length of the period of incubation is tolerably constant, never- 
theless variations do occur. These will depend, among other things, upon the 
amount and virulence of the poison introduced, and upon the power of resistance 
of the individua5 ACUTE INFECTIOUS EXANTHEMATA. 
101 
This stage is followed by the prodromal period, which lasts, on the 
average, three days. It is characterized by severe affection of the 
mucous membranes of the nose, conjunctiva, mouth, pharynx, larynx, 
trachea, and bronchi. Some writers consider these inflammations as 
co-ordinate with the subsequent eruption on the skin, and Kehn pro- 
poses to call this the stage of mucous membrane exanthem (enanthem). 
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, 
seven days. 
During the stage of incubation, especially in the first half, the gen- 
eral health is often undisturbed. In the second half, there are some- 
times slight temporary elevations of temperature. The children be- 
come irritable and fretful, lose their appetite, suffer from eructations 
and foul breath, and a coated tongue; sleep is disturbed, or there is un- 
usual somnolence. As the prodromal period approaches, the inflamma- 
tions of the mucous membrane become noticeable. 
The prodromal stage often begins with a single chill or repeated 
chilly feelings. This is followed by fever, which may reach 40° 0. on 
the first night. On the two following days the temperature may return 
to the normal, or there is a slight elevation at night, rarely in the morn- 
ing. Hence many patients feel sick only on the first day of the pro- 
dromal stage. 
The inflammations of the mucous membranes, which are often ob- 
served towards the close of the period of incubation, now increase in 
severity. The injection of the conjunctiva increases and extends to the 
conjunctiva bulbi; subconjunctival oedema (chemosis) sometimes de- 
velops. The lachrymal caruncle is reddened and swollen so that the 
tears cannot pass freely into the lachrymal canal, and in part flow over 
the edge of the conjunctiva. The patients dread the light, complain of 
itching, burning, and the feeling of a foreign body in the eyes, rub the 
lids often, and may suffer from spasm of the lids. Nasal catarrh is 
manifested by impermeability of the nose and a feeling of burning and 
dryness, which is soon followed by increased secretion. Frequent sneez- 
ing occurs, and this may be increased into a sneezing spasm. If the in- 
flammation extends into the frontal sinuses, the patients complain of 
pain and pressure in the frontal region. Pharyngeal catarrh produces 
a sensation 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 the laryngeal region, and a thickening sen- 
sation under the sternum indicate catarrh of the air passages. The 
cough may become spasmodic, or it grows hoarse and barking, and as- 
sumes 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 take an active part in the 
inflammatory swelling, and become visible as small nodules. The injec- 
tion of the vessels may be unusually marked, and sometimes slight sub- 
mucous 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 autopsies seem to indicate that other mucous membranes may 
also become inflamed. Patches of congestion have been found upon the 102 
ACUTE INFECTIOUS EXANTHEMATA. 
mucous membrane of the bronchi, stomach, intestines, and genitalia, 
and even upon the pleura. In one case, Weil observed pleurisy. 
As the eruptive stage approaches, the bodily temperature suddenly 
rises to 39° 0. or more. As a rule, the temperature continues to rise in 
the next two days, and at the end of the third or fourth day (usually at 
night) returns in a crisis to the normal or even subnormal. Then "the 
condition generally remains apyrexial, or there are occasional slight rises 
of temperature. The height of the fever generally coincides with the 
greatest development of the eruption. 
The eruption on the skin often appears quite suddenly, and this, 
together with the renewed increase of temperature, sharply separates the 
prodromal stage from the eruptive stage. In some cases, however, the 
transition is more gradual. The eruption appears first on the chin, 
cheeks, and forehead, and soon follows upon the scalp, the integument 
over the mastoid processes, and the neck. In twelve to thirty-six hours 
the trunk and limbs are also covered. The patches are most abundant 
on the face, chest, and back, most scanty on the lower limbs. The 
Fig. 16. 
Temperature curve in uncomplicated measles, 
flexor and extensor aspects of the limb are affected alike, the palms of 
the hands and soles of the feet are also attacked. Certain parts of 
the body sometimes escape, or the eruption spreads in a different man- 
ner from that described. The occurrence of the eruption is attended 
occasionally with slight itching. 
The exanthem of measles forms red patches, of a round, elongated, or 
semilunar shape, varying in size from two to six millimetres. On pres- 
sure, they grow pale; at a later stage, a yellowish or pale brown patch is 
left after pressure (combination of exudation and even diapedesis of red 
blood-globules with the primary hyperaemia). The borders of the 
patches are sharply defined, and not infrequently irregular and jagged. 
The patches are slightly elevated. The centre of well-developed patches 
often forms a prominent papule (provided in many places with a central 
hair) which is the result of swelling of a sebaceous follicle, and is some- 
times better felt with the finger than seen. Both forms are almost 
always associated with one another. If there has been profuse diapho- 
resis, the epidermis of the patches may be raised in places into small 
vesicles. Or the inflammation in the patches may be so active that the 
blood-vessels rupture and give rise to small cutaneous hemorrhages. ACUTE INFECTIOUS EXANTHEMATA. 
103 
This phenomenon possesses no special significance. The patches may 
coalesce in places (generally in the face, where it may give rise to oedema 
of the face and lids), but they never coalesce on all sides. 
The eruption extends over the entire body in twenty-four to thirty- 
six hours, and remains at its height for twelve to twenty-four hours. 
The patches in the face have occasionally paled before the limbs are 
attacked. At the height of the eruption we sometimes notice enlarge- 
ment of the peripheral lymphatic glands and slight enlargement of the 
spleen. The heart 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 characteristics of febrile urine; it contains occa- 
sionally traces of albumin, often furnishes the acetone reaction, and is 
said at times to contain sugar (?). 
Various statements are made concerning the anatomical changes in 
the skin. Hebra and Mayr assumed, from analogy, inflammation and 
swelling of the sebaceous follicles. Simon found the cutaneous glands 
intact on microscopical examination. The epidermis and cutis were also 
intact, the latter being swollen into a papule, probably as the result of 
fluid exudation. Fine molecules, which did not dissolve in acetic acid, 
were found between the cutis fibres. Neumann recently described dila- 
tation of the vessels of the cutis, emigration of white blood-globules 
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 
arreotor. 
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- 
sity of the color of the eruption occasionally varies slightly, the red- 
ness increasing with the increased bodily temperature. The patches often 
leave yellowish or light-brown pigment spots, which persist into the sec- 
ond week. 
The stage of desquamation runs an apyrexial course. It occurs in 
very fine scales, earliest and most distinctly in the face. It is only 
slightly indicated on covered, perspiring portions of the body, or if 
baths have been employed. It is often associated with pruritus. The 
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 
most frequent is a change in the duration of the individual stages. The 
individual periods may be longer or shorter, and the eruptive stage is so 
slight at times that care is requisite in order to recognize the disease. 
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 observed. Desquamation occurs, nevertheless, in 
some of these cases. In other cases the eruption on the skin was present, 
but the inflammations of the mucous membrane remained absent. 
The disease is sometimes said to run an apyrexial course, but the 
diagnosis is not always certain in such cases. In others, there is unu- 
sually protracted and high fever—a phenomenon which leads us to the 
consideration of the complications of measles. 
The stage of incubation sometimes begins with high fever, followed 
by somnolence, delirium, and epileptiform convulsions. These symptoms 104 
ACUTE INFECTIOUS EXANTHEMATA. 
are not frequent, and their development is favored by accidental inter- 
current affections. 
The nervous symptoms referred to may also be observed in the sub- 
sequent course of measles as the result of abnormally high temperatures. 
Anatomical diseases of the nervous system are rare, although meningitis 
has been observed in a number of cases. 
A very grave complication is malignant hemorrhagic measles, which 
is observed with relative frequency in feeble, cachectic individuals. Hem- 
orrhages appear, not alone upon the external integument, but also 
into the subcutaneous cellular tissue, and from the nose, air passages, 
gastro-intestinal tract, and genito-urinary apparatus. The temperature 
is generally high. The patients often lie in a typhoid condition: tongue 
dry, lips and tongue covered with sordes, abdomen distended, diarrhoea 
frequent. There is rapid exhaustion and death after symptoms of in- 
creasing collapse. This is no doubt the result of a general septic condi- 
tion. 
Every organ may be the site of complications during the course of 
measles, and some epidemics are characterized by the frequent occur- 
rence of certain complications. 
Erythema of the skin is sometimes observed during the prodromal 
and eruptive stages. Urticaria, more rarely pemphigus, may also be as- 
sociated with the eruption of measles; herpes facialis is occasionally 
observed. 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 phlyc- 
tenular inflammation of the conjunctiva, epithelial erosions of the cor- 
nea, keratomalacia or ulcerating keratitis, conjunctival blennorrhcea 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 
naso-pharyngeal space to the Eustachian tube and even the middle ear; 
the 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- 
quently contains a slit-shaped opening, through which the secretion 
trickles, but this generally recovers spontaneously. If swelling of the 
mucous membrane and impairment or abolition of hearing on both sides 
is left over, deaf-mutism maybe produced in young children. Gottstein 
described desquamative 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. 
Ulcerations have been found on the posterior wall of the larynx, and 
also 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- 
common; fibrinous pneumonia is observed less frequently. We often find 
atelectasis and acute pulmonary distention, particularly on the anterior 
median borders of the lungs. Pulmonary abscess and gangrene and ACUTE INFECTIOUS EXANTHEMATA. 
105 
pleurisy are rare complications. Inflammatory changes in the lungs 
produce unusually protracted and high fever, and give rise to the danger 
of suffocation, or, at a later period, of incomplete absorption, tubercular 
infection, and caseation of the inflammatory products. 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 digestive organs are especially apt to be affected in summer epi- 
demics. The tongue may lose its white coating and, as in scarlatina, 
become diffusely red and papular from swelling of the papillae. Fre- 
quent vomiting is not uncommon. There is occasionally violent diar- 
rhoea, of a cholera-like or dysenteriform character. I know of one case 
in which a medical student died in twenty-four hours with choleriform 
symptoms, shortly after the eruption of measles had paled. 
Serious renal changes are rare, although albuminuria, together with 
the presence of casts, and haematuria 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 
hemorrhages into the skin and mucous membranes, particularly the 
gums. The skin exhibits a tendency to chronic inflammations, and 
obstinate eczema, impetigo, and furunculosis, etc., develop. Measles 
are often the starting-point of scrofula and tuberculosis, enlargement or 
suppuration of the lymphatic glands, diseases of the joints and bones, 
chronic pulmonary phthisis, or miliary 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 
times as sequelae; the amaurosis generally recovered in a few days or 
weeks. 
Measles sometimes exert a favorable influence on other diseases, and 
have been known to cause the disappearance of chronic skin eruptions, 
epilepsy, chorea, even diseases of the bones and joints. Diseases of the 
respiratory organs are always rendered worse after measles, and the 
combination of pertussis and measles is almost always followed by severe 
pneumonic and bronchitic symptoms. 
Uncomplicated measles are rarely fatal, but complications may be 
attended with great dangers. 
III. Diagnosis.—The diagnosis is easy if we direct attention, not 
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 
is not uniformly red as in the latter disease, by the absence of the 
scarlatina tongue and diphtheritic changes in the pharynx, and by 
the rare occurrence of nephritis. If measles and scarlatina are preva- 
lent at the same time, violent vomiting during the prodromal period 
would favor the diagnosis of scarlatina. 106 
ACUTE INFECTIOUS EXANTHEMATA. 
Roetheln is distinguished 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 papules 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. 
Typhus 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 syphilitic 
roseola, other evidences of syphilis are present. 
IV. Prognosis.—In uncomplicated measles the mortality is hardly 
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 sequelas 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 (5ft) 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, and 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 15° 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.m., duration fifteen minutes. After the bath the body is ACUTE INFECTIOUS EXANTHEMATA. 
107 
quickly dried with warm cloths, and the shirt and bedding are also kept 
warm. We are convinced that measles run a milder and shorter course 
in many cases under this plan of treatment with baths. 
If the temperature of the body rises above 39.5° C. in the morning, 
or 40° C. at night, on account of the severe infection or complication 
with inflammations of internal organs, baths must 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.-lxv. 
to | ij. of lukewarm water per rectum) is preferable, on account of its 
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, 
and at the end of another week may go into the open air if no residua 
of the disease are left over. 
2. Scarlet Fever. Scarlatina. 
I. Etiology.—Like measles, scarlatina is one of the infectious dis- 
eases, 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 objects that 
have come in contact with scarlatina 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 virus is supposed to be present in the blood, lachrymal fluid, 
nasal secretion, sputum, epidermis scales, urine, and perhaps the faeces 
of the patient. Oases have been reported of successful inoculations with 
blood and the contents of miliary vesicles on the skin. But such experi- 
ments are not always successful, 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 
desquamation. As a general thing, the patient should be kept secluded 
until the end of the sixth week. 
The nature of the scarlatina virus is not known. Bacteria have been sought for, 
but with the exception of the recent statements of Pinkus, none point with cer- 
tainty to the scarlatinous character of these organisms. 
The susceptibilty to scarlatina is not so general as that to measles. If 
measles and scarlatina are rife in any locality at the same time, it is 
often found that children who had suffered from scarlatina are at- 
tacked by measles, while many escape scarlatina entirely. As in the case 
of measles, some individuals seem to possess a temporary immunity 
against scarlatina. On the other hand, certain accidental circumstances 
may create an increased susceptibility. This is true of injuries and recent 
delivery, especially in primiparse. Under such circumstances, we must 
be cautious in making a diagnosis, since erythemata (generally pyaemic 
or septicaemia) may occur and be mistaken for scarlatina. 108 
ACUTE INFECTIOUS EXANTHEMATA. 
It is also said that deaf-mutes possess an increased, phthisical and scrofulous 
individuals a diminished, susceptibility to the disease. 
The majority of individuals suffer from scarlatina during childhood, 
but more adults are attacked than in the case of measles. Scarlatina 
is rare in the first six months of life, most frequent from the age of 
two to seven years. It has been observed, however, a few days after 
birth, and even at birth. Cases of the latter variety require the strictest 
criticism, since scarlatina may be mistaken for erythema neonatorum. 
In childhood the sexes are affected alike; among adults females are 
said to be attacked more frequently. 
A single attack generally confers permanent immunity, although there 
are occasional exceptions to this rule. Some individuals have been 
known to suffer as many as four attacks at intervals of a few years. 
Relapses within a few days or weeks after an attack are also rare. 
The term pseudo-relapses is applied to those cases in which the eruption 
returns before desquamation has occurred. 
Scarlatina is combined occasionally with other infectious diseases, for 
example, measles, variola, varicella, typhoid fever, and mumps. 
Sporadic cases occur constantly in large cities. At times these de- 
velop into epidemics, which may spread over a large territory (pan- 
demic). Epidemics of scarlatina run a longer course than those of measles, 
present repeated exacerbations and remissions, and in isolated cases are 
often protracted more than a year. In some localities the epidemics are 
said to appear at certain definite intervals (four to six years). The 
majority of epidemics begin in the autumn. They are sometimes ex- 
tremely dangerous. 
II. Symptoms.—The disease is divided into the stage of incubation, 
prodromata, eruption, and desquamation. 
The stage of incubation often varies greatly in duration. On the 
average, it lasts four to seven days. In some it lasts hardly half a day, 
and in others it is reported to have lasted two or three weeks or even 
months (?). 
The prodromal stage is sometimes barely indicated; in other cases, it 
lasts twenty-four to forty-eight hours. 
During the stage of incubation, the majority of patients feel almost 
entirely well. In some, there is a general feeling of malaise, and there 
may be a slight rise of temperature, often only at night, towards the 
end of this period. 
The prodromal stage often begins suddenly. It begins more fre- 
quently with repeated chilly sensations than with a single violent chill. 
The temperature rises very rapidly to 39 or 40°, and even higher. There 
is a burning feeling in the throat, and often disturbance of deglutition. 
The movements of the jaws are painful and swollen; painful glands are 
found behind the angles of the lower jaw. The pharynx is red, and its 
follicles swollen. At first the redness is sometimes found in patches, 
which begin at the uvula and then extend to the soft palate and its 
arches, but do not attack the posterior wall of the pharynx. Gastric 
symptoms are often prominent, especially repeated- vomiting. In chil- 
dren, the high fever sometimes gives rise to delirium and convulsions, 
which are not necessarily of grave omen. 
When the stage of eruption begins, the exantliem appears first on 
the neck, in the region of the mastoid processes, and on the nape, and 
then extends over the entire body. It is least distinct in the face, be- ACUTE INFECTIOUS EXANTHEMATA. 
109 
cause it is concealed partly by the flush of fever (thus offering a contrast 
to the eruption of measles), and the chin, angles of the mouth and nose 
are apt to be extremely pale (local spasm of the vessels). The back and 
chest are generally attacked with special severity. The extensor sur- 
faces of the limbs are more affected than the flexor surfaces, with the 
exception of the dorsal surfaces of the hands and feet. In little chil- 
dren, it is very evident that the scalp is also covered with the eruption. 
The outbreak of the eruption is sometimes accompanied by slight prick- 
ing and itching in the skin. 
The exanthem begins in the shape of fine, deep-red or scarlet patches, 
so that the skin appears 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 the skin 
assumes a diffuse red color, in which very fine, dark-red points are 
visible. The integument is swollen and in places slightly cedematous, 
so that, for example, the palpebral fissure may be diminished in size, as 
the result of oedema of the lids. The eruption is sometimes preceded, 
for a few hours, by temporary erythemata. As a rule, the eruption 
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 laevigata). 
The eruption may present variations in shape. The term scarlatina 
papulosa is applied to those cases in which the follicles of the skin are 
markedly swollen, and the patches have a papular appearance. Slighter 
grades of swelling are observed almost constantly on the forehead and 
dorsal surfaces of the hands and feet. In scarlatina miliaris, very fine 
vesicles, with clear, alkaline contents, appear upon the skin. This form 
is favored by profuse sweating, but may appear independently, and is 
the result of active exudation between the rete Malpighii and epidermis. 
The little vesicles sometimes attain considerable size (scarlatina vesicu- 
losa s. pemphigoidea). In scarlatina hsemorrhagica, 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- 
urinary or respiratory organs. In some cases, the eruption of scarlatina 
appears in circumscribed hypersemic patches (scarlatina variegata). 
The affected skin at first pales completely on pressure. Later, a yel- 
lowish or even a dirty, hemorrhagic color is left, showing that simple 
congestion has been followed by exudation and diapedesis of red blood- 
globules. Despite the hyperaemia of the skin, the irritability of the walls 
of the vessels appears to be increased. On stroking the skin with a hard 
substance, the irritated parts remain pale for some time. 
The eruption is most marked on the 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 by 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 mucous membrane of the cheeks and 
lips, and there produces a burning sensation. Swelling of these parts is' 
absent or very slight; 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 
its surface has a more or less thick, grayish, or grayish-yellow coating, 110 
ACUTE INFECTIOUS EXANTHEMATA. 
from which the swollen fungiform papillas project as bright-red papules. 
In a few days the coating is shed, so that the entire surface of the tongue 
becomes bright red. The marked swelling of the papillae makes the 
surface warty or nodular (strawberry tongue). The size of the organ is 
generally increased, as is evident from the impressions of the teeth upon 
its edges. 
The bodily temperature rises still higher with the outbreak of the 
eruption, and, as a rule, exceeds 40° C. The rapidity of the pulse often 
exceeds one hundred and forty beats a minute. Towards the end of the 
week the temperature diminishes gradually, not suddenly as in measles. 
Complications may maintain the elevation of the bodily temperature for 
weeks. 
The symptoms mentioned occupy the foreground. Dulness in the 
head, headache, and delirium are not uncommon. The appetite is lost; 
thirst is generally increased. Eructations and repeated vomiting are 
common symptoms. The urine is scanty (febrile urine), often shows 
Fig. 17. 
Fig. 18. 
Temperature curve in scarlatina of moderate 
severity. 
Temperature curve in scarlatina of short dura- 
tion. 
the ferric chloride reaction; Brieger found a large amount of phenol. 
Febrile systolic murmurs may be heard over the heart. The spleen and 
even the liver are sometimes slightly swollen. As a rule, the eruption 
first pales on those parts of the skin which were first attacked, and the 
stage of eruption is rapidly followed by that of desquamation. Upon 
the integument of the neck and face, later on the trunk and limbs, 
appear fissures, and scales of epidermis are raised. Upon the face 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 subsequent desquamation. 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. 
The typical course of scarlatina may bS changed by numerous anoma- 
lies, complications, and sequelae. 
The individual stages of the disease may vary greatly in duration. 
The clinical history may consist merely of fever, lasting a few hours, ACUTE INFECTIOUS EXANTHEMATA. 
111 
fleeting redness of the skin, and insignificant disturbances of deglutition. 
Fig. 18 shows the temperature curve of such a case : sudden repeated 
vomiting at 12 p.m.; next day, scarlatina eruption over the entire body ; 
the day after, a few remains of the eruption on the limbs ; subsequently, 
marked desquamation. Such mild cases may be followed by severe 
sequelae, particularly nephritis. Nephritis in children sometimes appears 
to be of spontaneous origin, but on careful questioning it is - found to 
have been preceded by brief redness of the skin, followed by desquama- 
tion. In other cases, the stages of the disease are unusually prolonged. 
For example, cases 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 limbs, or certain parts 
of the body remain unaffected. Desquamation often occurs several times 
on the same place. Or desquamation may also affect, in part, the nails 
and hair. It is sometimes 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 
without eruption, i. e., a pharyngitis produced by infection with scar- 
latinous virus, unattended with an eruption, but capable of conveying 
scarlatina to others. Desquamation is said to occur despite the absence 
of eruption. In other cases, the eruption develops, but angina is not 
produced. 
Leichtenstern believes that certain forms of nephritis also belong to the cate- 
gory of fragmentary scarlatina. He thinks that during epidemics nephritis may 
be produced by the action of the scarlatinous virus, without eruption or angina, 
and that it may give rise, by infection, to fully developed scarlatina. Parotitis, 
gastro-enteritis, and simple febrile conditions have also been described as frag- 
mentary scarlatina. 
The most frequent and important complications are diphtheria, 
nephritis, and inflammation of the joints. 
Diphtheria of the pharynx is almost constant in certain epidemics, 
and is often more favorable than the primary disease. In some cases, it 
develops after the outbreak of the eruption; in others, it is present dur- 
ing the prodromal period. It may not produce very severe symptoms 
at first, so that its onset can only be recognized, in many cases, on in- 
spection. Some cases of scarlatina sine exanthemate appear as diph- 
theria scarlatinosa sine exanthemate. It is often the starting-point for 
other dangerous complications. It extends not infrequently to the mu- 
cous membrane of the nose. At first, the children present the symp- 
toms of ordinary coryza, complain of stoppage of the nose and a bufning 
sensation. Then a scanty, serous secretion appears, then a stinking, 
light brownish-red sanguinolent ichor flows almost constantly from the 
nose, thus proving that 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 necrosis of the bones. The diphtheria may also 
extend to the Eustachian tube and middle ear, giving rise to tinnitus 
aurium, impairment of hearing, violent pains in the ear, and usually in- 112 
ACUTE INFECTIOUS EXANTHEMATA. 
creased fever. These may eventuate in the production of pus, perfora- 
tion of the membrana tympani, thrombosis of the sinuses, meningitis, 
cerebral abscess, uncontrollable hemorrhage, etc. In exceptional cases, 
the diphtheria extends to the larynx, trachea, and even the bronchi. A 
more frequent complication is inflammation of the submaxillary lym- 
phatic glands and surrounding cellular tissue of the neck. The parotid 
and submaxillary glands are sometimes involved. The inferior maxillary 
region as far back as the mastoid processes is swollen, hard, hot, and 
painful. At first, the overlying integument is often very pale. If sup- 
puration occurs and the pus is about to perforate the skin, the latter be- 
comes soft, doughy, and reddened. The pus often contains gangrenous 
shreds of tissue, which is necrosed on account of the compression exer- 
cised by the inflamed tissue and the partial interruption of circulation. 
The pus sometimes makes its way into the mediastinum, pleural or peri- 
cardial cavity, or it may produce fatal hemorrhage by erosion of large 
vessels in the neck. 
Opinions differ as to whether scarlatina merely creates a predisposition to 
diphtheria, or whether the latter is the.direct result of the actiqn of the scarlatinous 
virus on the pharynx. In the latter event, it must be assumed that the diphtheria 
of scarlatina is essentially different from primary diphtheria. The former view 
seems better founded, since Loefler found the same micro-organisms in scarla- 
tinous diphtheria as in the primary form. Attention has been called to the fact, 
however, that the two forms differ clinically, inasmuch as scarlatinous diphtheria 
rarely extends to the respiratory organs and is still more rarely followed by diph- 
theritic paralysis. Others claim that there are also anatomical differences, that 
in scarlatinous diphtheria the membranes are thinner, that necrosed epithelium 
is situated beneath them, and that fibrinous exudation can be traced deep into 
the submucosa. 
In some epidemics, renal changes are almost constant; in others, they 
are very rare. Their connection with the height of the fever, intensity 
of the eruption, and scarlatinous diphtheria cannot always be proven. 
Nor are they often the result of leaving the bed too early. 
The mildest form of renal disturbance is slight transitory albumi- 
nuria, which may depend on the fever, the infection, or both. This 
appears generally in the first days of the disease, and disappears with the 
fever and eruption. 
The condition grows more serious when abundant renal epithelium 
cells are present in the urinary sediment, an evidence of a desquamative 
process in the kidneys. In addition, there may be hyaline or epithelial 
casts in the urine. The latter are sometimes very long, flat, convoluted, 
and the ends defibrillated (so-called cylindroids). These processes may 
exist independently or they are associated with albuminuria. In the 
former event, they may rapidly disappear and form prodromata of an 
acute nephritis. In some cases, numerous casts have been found, but 
no epithelium from the tubules. Bacteria have been found repeatedly 
in the urine, and schizomycetes have also been observed upon the casts. 
The symptoms of an acute nephritis often develop quite suddenly. 
They generally appear from the beginning of the third week to the end 
of the sixth week, rarely earlier, still more rarely at a later period. The 
urine becomes scanty and bloody, and contains a large amount of albu- 
min and sediment. Symptoms of uraemia are frequent, and in some 
cases are the first to direct attention to the urinary changes. Urhidrosis 
has been observed occasionally in cases of anuria, the urea being deposited 
upon the skin, after evaporation of the sweat, in the shape of a fine, ACUTE INFECTIOUS EXANTHEMATA. 
113 
white crystalline deposit (vide Yol. II., page 261). In some cases, 
cedema is the first suspicious sign, and may even appear before the urine 
contains albumin. It has been found that, despite the existence of 
nephritis, the urine is temporarily free, in some cases, from albumin, 
perhaps because certain parts of the kidneys functionate normall}7, while 
the secretory power of the diseased portions is entirely abolished. The 
bodily temperature sometimes rises with the onset of nephritis, and the 
pulse 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 some authors that the kidneys excrete the scarlatina virus 
from the organism, and thus undergo inflammatory changes. Others call atten- 
tion to the relation between diseases of the skin and kidneys, which is seen in 
other conditions. Still others look upon the nephritis, not as a complication, but 
as the direct result, like eruption and angina, of the scarlatinous virus. 
Inflammations of the joints are much rarer than the renal complica- 
tions. They sometimes occur at the height of the disease, more fre- 
quently after the eruption has disappeared. The small joints of the 
fingers 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 
combined with swelling, redness of the skin, and increased warmth. The 
phenomena are similar to those of acute articular rheumatism, and, as in 
the latter disease, the symptoms may jump from one joint to another. 
The effusion into the joints is generally serous, rarely purulent. The 
sheaths of the tendons may also undergo inflammation. 
Purulent arthritis in scarlatina is sometimes the result of pysemic conditions. 
In pus obtained from the joints, Bahrdt and Heubner recently found cocci ar- 
ranged in chains ; these were also found in the diphtheritic deposits on the tonsils, 
retropharyngeal pus, and in the blood. 
We will content ourselves with a brief description of the most impor- 
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, but 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 then manifest typhoid 
symptoms (apathy, dry tongue, sordes on the lips, meteorism, diarrhoea). 
In some cases early death, before the appearance of the eruption, seems 
to be 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 
graver complications are diphtheria, keratitis, keratomalacia, hypopyon, 
keratitis and iritis, choroiditis, and neuroretinitis. Sudden amaurosis 
with preserved pupillary reaction, and the changes of retinitis Brightica 
have been observed occasionally in scarlatinous uraemia. The amaurosis 
disappeared in a few days or weeks if the uraemic symptoms improved. 
Auditory disturbances are frequent. Impaired hearing and tinnitus au- 
rium may be the result of occlusion of the Eustachian tube. Graver 114 
ACUTE INFECTIOUS EXANTHEMATA. 
conditions are produced by extension of diphtheritic and purulent in- 
flammation into the middle ear. 
The pharynx sometimes contains superficial erosions, resulting from 
destruction of swollen mucous follicles. More serious symptoms are 
produced by parenchymatous inflammation of the tonsils with abscess 
formation. The violent pain, high fever, and difficulty in breathing, 
produced by swelling of the pharyngeal tissues, torture the patient. 
Danger of suffocation may arise from rupture of the abscess during 
sleep, and the passage of its contents into the larynx. Gangrene of the 
pharynx sometimes develops, may spread widely, and prove fatal from ex- 
haustion or the erosion of large vessels. Noma is rarer than in measles. 
Laryngeal and tracheo-bronchial catarrh is much less frequent than 
in measles. Attention has been previously called to the extension of 
diphtheria from the pharynx to the larynx and deeper air passages. 
(Edema of the glottis develops occasionally, either as the result of neph- 
ritis and uraemia, or of inflammatory changes near the entrance to the 
larynx. Catarrh and fibrinous pneumonia are rare, pulmonary gangrene 
and abscess are still rarer. 
Inflammations of the serous membranes are not very uncommon; the 
pleura is attacked most frequently, the peritoneum least frequently. 
Such inflammations are usually purulent. 
Endocarditis is not a rare complication, and the majority of cases of 
valvular lesion of the heart in children are associated with the endocar- 
ditis of scarlatina. It sometimes appears as septic endocarditis, which 
gives rise to embolic changes in various organs. Hypertrophy of the 
heart sometimes occurs very rapidly during scarlatinous nephritis. I 
have also noticed the rapid appearance and disappearance of cardiac 
dilatation. 
Severe complications are sometimes the result of changes in the 
blood. These result in extravasations beneath the skin and free hemor- 
rhages from various organs, and often prove rapidly fatal. 
Obstinate and threatening diarrhoea sometimes occurs, and may 
assume a dysenteriform character. Hsemoglobinuria and mellituria have 
been reported in a few cases. Serous, purulent and bloody discharges, 
abscess, gangrene, diphtheria, and inflammation of the testicle have been 
described. 
Desquamation is sometimes so active that excoriated and bleeding 
surfaces of skin make their appearance; in rare cases, there is gangrene 
of the skin or certain parts of the extremities. 
The complications of scarlatina cannot be distinguished sharply 
from the sequelse, since the latter often develop directly from the 
former. In some cases, general feebleness persists. The convalescent is 
weak, even the mental powers are sluggish, and fatal diseases of the 
respiratory organs or intestinal tract are apt to supervene. Tubercular 
affections of the lungs, lymphatic glands, bones and joints, rarely of the 
meninges, sometimes develop after scarlet fever. Some patients suffer 
from chronic skin eruptions (including furunculosis). Disturbances of 
audition are frequent after scarlatina. If the disease is bilateral and 
occurs in the first years of life, it may terminate in deaf-mutism. Ex- 
tensive destruction of the petrous portion of the temporal bone results 
occasionally in facial paralysis. Foerster reported a case in which scarla- 
tina had given rise to bilateral deafness and facial paralysis, and, 
associated with the latter, bilateral ulceration of the cornea and blind- 
ness. Accommodative asthenopia is sometimes observed after scarlatina. ACUTE INFECTIOUS EXANTHEMATA. 
115 
Like other infectious diseases, it may also give rise to paralyses. Chorea 
has also been observed. Suppuration of the joints may result in anky- 
losis. Valvular lesions of the heart are relatively frequent sequelae. 
The renal changes generally disappear in cases which do not terminate 
fatally; chronic nephritis is a rare outcome, but I have seen two cases of 
this kind. Zinn described a case of mellituria which lasted a long time. 
Wollenberg observed albinism of the skin and hair after very marked 
desquamation. 
In rare cases, scarlatina exercises a favorable influence on existing 
diseases. Thus, Gibney observed spontaneous recovery of an obstinate 
coxitis after scarlatina, and Thompson reports that chorea disappeared 
in two cases. 
III. Anatomical Changes.—In the corpse nothing remains visible 
of the eruption, but the skin is often peculiarly tense and oedematous. 
Microscopical examination of the skin shows swelling of the cutis tissue, 
ampullary dilatation of the vessels, swelling of the cells in the rete Malpighii, 
especially of the nuclei; in the deeper layers of the rete are spindle-shaped, elon- 
gated cells, and between them an accumulation of round cells and red blood- 
globules, and an accumulation of round cells around the excretory ducts of the 
follicles. Fenwick described hemorrhages into the sweat glands, and active 
desquamation of their epithelium. 
The muscular tissue is not infrequently very pale and brittle; the 
microscope shows cloudy swelling and fatty degeneration of the muscu- 
lar fibres. 
There is not infrequently swelling of the entire lymphatic gland 
system: the peripheral and mesenteric glands, the solitary follicles, and 
Peyer’s patches 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 
ulceration. Klein found hyperplasia of the lymph follicles of the root 
of the tongue, the pharynx, tonsils, larynx, and trachea; the mono- 
nuclear lymph cells were scanty, the multinuclear cells very numerous, 
so that giant cells were abundant. The veins of the cervical glands, 
were occluded by plugs 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 bodies similar to those in the 
peripheral glands. 
The heart is often very flaccid, pale, and yellowish in color, and 
presents dilatation and hypertrophy. The muscular fibres are often in 
a condition of fatty degeneration and cloudy swelling. The blood is 
dark and its coagulability diminished; the white globules are not infre- 
quently increased. 
Diphtheritic changes are sometimes found in the intestines, more 
rarely in the oesophagus and stomach, to which they have probably 
spread from the pharynx. In hemorrhagic scarlatina, the intestines 
sometimes contain bloody masses. The liver often presents cloudy 
swelling and fatty degeneration, with proliferation of round cells in the 
interstitial connective tissue. Harley states that the solid constituents 
of the bile are diminished; the biliary acids are sometimes entirely 
absent. 
The kidneys are generally enlarged. In recent cases, extravasations 116 
ACUTE INFECTIOUS EXANTHEMATA. 
are visible upon their surface and upon cut sections; in older ones, the 
organ has a yellowish color, produced by fatty processes. 
Friedlaender describes three forms of scarlatina kidney, which are rarely as- 
sociated and never pass into one another, a. Initial catarrhal nephritis; this 
appears with the eruption, or a few days later, soon disappears, and is charac- 
terized by cloudiness, swelling, and desquamation of the epithelium of the renal 
tubules; a few round cells in the interstitial tissue, b. Glomerulo-nephritis; this 
form is almost characteristic of scarlatina. The glomeruli are enlarged, the 
nuclei of their walls increased in number, the walls of the coils of vessels thick- 
ened, the epithelium of the capsule thickened, sometimes proliferated, c. Large, 
flabby hemorrhagic kidney (septic interstitial nephritis). This depends less upon 
scarlatina than upon complicating diphtheria and inflammation of the cellular 
tissue of the neck, and generally proves fatal in a short time. The kidney is 
large, flabby, infiltrated with large and small hemorrhages, with numerous 
round cells in the interstitial tissue; micrococci emboli are frequent. Deposits of 
lime salts in the tubules have been described. 
IV. Diagnosis.—The recognition of scarlatina is easy, if symptoms 
other than the eruption are also taken into consideration. Primary 
diphtheria of the pharynx is sometimes associated with erythematous 
cutaneous changes; but 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 run a mild course may prove fatal by complications and sequelae. 
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 the rule. As a 
general thing, the prognosis is so much more serious the younger the pa- 
tient. The greater the number of complications the less favorable the 
outlook. Uraemic 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 measles. 
Prophylaxis is extremely important. The patients must be strictly 
isolated, and all articles used by 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 as 
measles; we can especially recommend the use of lukewarm baths. Other- 
wise, the treatment is purely symptomatic. 
3. Roetheln. Rubeola. 
I. Etiology.—Some maintain that rubeola is a special form of 
measles; others, that it is 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 contagious and is generally acquired by contact with ACUTE INFECTIOUS EXANTHEMATA. 
117 
other patients, or by remaining in the same room; but it can also be con- 
veyed indirectly by other persons or objects. Slight contact is some- 
times sufficient. 
One attack almost always confers immunity against another. Re- 
lapses are rare. The disease does not afford immunity against measles 
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 
duration varies. Schools and overcrowded houses furnish the most 
favorable localities for the spread of the disease, which is probably con- 
tagious in 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 
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, cough and sneeze a good deal, complain of slight 
epiphora and photophobia. A few hours later the eruption appears. 
But as we have remarked above, prodromata may be entirely absent, 
and the symptoms mentioned then appear with the eruption. This 
consists of pale-red, roseolar patches, from the size of a pin's head 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 petechiae 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 the time that 
the lower parts of the body are affected, 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 slight oedema of the face. The 
peripheral glands are often swollen, particularly the cervical and auricu- 
lar glands. 
The eruption is sometimes followed by slight desquamation. 
The outbreak of the eruption is constantly accompanied by slight 
catarrhal inflammation of the mucous membrane of the pharynx, respira- 
tory organs, and conjunctiva. The pharyngitis often appears in patches, 
particularly upon the middle of the uvula. It never attains the severity 
of the pharyngitis of scarlatina, and disappears as the eruption pales 
(one to three days). 
The temperature may remain unchanged; a slight rise is often no- 
ticed at the outbreak of the eruption. 
The general condition is often entirely undisturbed. Albuminuria 
has been observed in a few cases, and oedema of the subcutaneous cellu- 
lar tissue and tonsillar hypertrophy as sequelae. 
III. Diagnosis, Prognosis, Treatment.—During epidemics, the 
diagnosis 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. 
Treatment is purely dietetic and symptomatic. 118 
ACUTE INFECTIOUS EXANTHEMATA. 
4. Typhus Fever. Exanthematic Typhus. 
(,Spotted Fever, Petechial Fever.) 
I. Etiology.—The mode of infection in typhus fever is the same as 
in measles and scarlatina, i. 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 frequently, 
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 perhaps 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. 
Typhus fever is endemic in certain regions. Ireland is, in a measure, 
the classical home of the disease, and it often follows Irish emigrants to 
England, Scotland, and America. The European continent also con- 
tains abiding places of typhus, for example, certain parts of Russia, Gal- 
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 by the disease two or three weeks later in some remote lo- 
cality, and this explains the fact that many cases appear to develop au- 
tochthonously. 
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 autochthonous 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- ACUTE INFECTIOUS EXANTHEMATA. 
119 
strated, 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 had been preceded by the appearance of a 
few cases of typhus which had been imported by workmen from Upper 
Silesia. 
The disease is mainly one of personal intercourse, so that climatic 
and telluric influences 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 
spring. 
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 between the ages of 15 and 25 
years. The disease is rare before the age of five years, and only a single 
case 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, but 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 virus. 
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 typhus fever are 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 cases, the 
patient suffered first from typhoid fever, and immediately afterward 
from 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- 
ately after scarlatina. 
II. Anatomical Changes.—Typhus fever presents no specific ana- 
tomical changes. In general the appearances are merely those of an 
acute infectious disease. 
Rigor mortis lasts but a short time, and decomposition begins 
rapidly. 
In addition to livores mortis, the skin sometimes contains indistinct 
bluish-red patches and petechise. The lips, gums, tongue, and nose are 
covered with sordes. The body appears well nourished. The muscles 
are dry, dark-red, of the color of ham. Neumann found Zenker’s de- 
generation of the muscular fibres, in addition to granular and fatty 
degeneration. The muscles may contain hemorrhages, and the rectus 
abdominis may be the site of hemorrhagic inflammation, as in typhoid 
fever. 
Similar changes occur in the heart muscles. The blood is generally 120 
ACUTE INFECTIOUS EXANTHEMATA. 
dark red, and exhibits little tendency to coagulation. There are evi- 
dences of bronchitis, atelectasis, hypostasis, catarrhal and fibrinous in- 
flammation of the lungs. Larsen also observed small pulmonary hemor- 
rhages. 
The gastro-intestinal mucous membrane is not infrequently swollen 
and hyperaemic. Virchow found fissures in the gastric mucous mem- 
brane which had given rise to hemorrhages. The solitary and agmi- 
nated follicles of the intestines are not infrequently slightly swollen ; 
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 hyperaemic. 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 hemorrhagic 
infarctions, sometimes small abscesses as in relapsing fever (?). 
The liver is usually enlarged, its cells are in 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 periganglionic spaces between the nerve fibres 
and in the adventitious lymph sheaths; also pigment infiltration of the 
ganglion cells. Similar appearances are also found in typhoid fever. 
Small multiple lymphomata were found in two cases. 
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. 
The face is reddened and turgid, the eyes fixed and glassy, the conjunc- 
tiva injected. The tongue has a gray or grayish-yellow 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 spleen 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 symptoms, such as malaise, a feeling of dulness in the head, 
want of desire for mental and physical activity, loss of appetite, etc. ACUTE INFECTIOUS EXANTHEMATA. 
121 
After the prodromal stage has lasted three to five days, 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 limbs. The face does not escape, but in many 
cases the eruption is here distinctly visible 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 first 
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 
hyperaemia has evidently been followed by exudation of serum and dia- 
pedesis of red blood-globules. The patches often number several thou- 
sands. They generally lasts ten days or longer, i. e., into the period of 
convalescence. Their disappearance is followed by very fine desquama- 
tion, rarely by desquamation in larger patches. 
Fig. 19. 
Temperature curve in moderately severe typhus fever, running a regular course. 
In some cases, the roseola presents almost the shape of acuminated 
papules; small vesicles develop occasionally in their centre. 
Petechiae and vi’oices sometimes appear upon and near them. Drasche 
observed herpes labialis in two cases. Miliaria appears as the result of 
sweating, particularly at the crisis. 
The bodily temperature is important in diagnosis. It does not rise 
gradually, as 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 crisis sometimes occurs as early as the eighth or tenth day,, 
sometimes 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 days 
(protracted crisis), and someftmes defervescence occurs almost in a lysis. 
The onset of the crisis may be preceded for a few hours by enormous rise- 122 
ACUTE INFECTIOUS EXANTHEMATA. 
of temperature, chill, vomiting, and other threatening symptoms, but 
the hoped-for symptoms of the crisis soon make their appearance. 
Pseudo-crises are also observed, i. e., the temperature falls at the ordi- 
nary period, but rises to its former height on the following night, and 
then the definitive fall of temperature takes place. Immediately after 
the crisis, the temperature is not infrequently subnormal. 
During the crisis, the majority of the patients fall into a deep, refreshing sleep 
from which they awake with a feeling of relief. In not a few cases, however, it 
is followed by such profound exhaustion that death ensues. After the crisis, the 
urine contains an abundant sediment of urates. 
The temperature sometimes rises very rapidly for a few hours before 
death. 
The pulse is generally increased in frequency (100 to 120), corre- 
sponding to the temperature of the body. If its rapidity exceeds 120 a 
minute the prognosis is very grave. The pulse is sometimes irregular 
and slow; dicrotism is much rarer than in typhoid fever. After the 
crisis, the pulse is generally normal, occasionally subnormal. 
Consciousness is almost always disturbed, partly as the result of the 
high fever, partly on account of the infection. At first there is violent 
headache and occasionally well-developed neuralgia, but soon the senso- 
rium becomes clouded; some of the patients lie quietly in a dreamy 
state, others are violently delirious. The bowels are often evacuated 
involuntarily, or the patients experience no desire to urinate, and the 
bladder is distended to the umbilicus. Tremor of the tongue and face, 
hesitancy in speech, picking at the bed-clothes, and subsultus tendinum 
are not infrequent. 
The lips, tongue, and nares are generally dry and fissured, bleed, and 
become covered with sordes. Mosler found that the parotid saliva, dis- 
charged through a canula, was acid; he recommends catheterization of 
Stenofs duct to prevent parotitis which, in his opinion, is often produced 
by occlusion of the duct with secretion. Conjunctival, nasal, and phar- 
yngeal catarrh are noticeable, and if consciousness is sufficiently clear, 
the patients complain of photophobia, dryness and burning in the nose 
and pharynx. The pupils are generally narrow; according to Schneider, 
often unequal. There is generally impairment of hearing and ringing 
in the ears, partly from tubal catarrh, partly from catarrh of the middle 
ear and inflammation of the drum membrane. 
The thorax almost always presents signs of dry bronchitis. The 
heart is not infrequently dilated towards the right. Occasionally, we 
may hear febrile systolic murmurs; in severe cases, the first sound may 
be inaudible (weakness of the heart). 
The spleen and liver, particularly the former, are enlarged and 
tender on pressure. Slight meteorism and tenderness in the epigastric 
region are observed in rare cases. Nausea, singultus, and vomiting are 
also rare. 
The urine presents the characteristics of febrile urine: small quantity, 
dark-red color, very acid reaction, high specific gravity, increased 
amount of urea, uric acid, and kreatinin, diminution of chlorides. 
Unruh found that the amount of urea was considerable shortly before 
the crisis, fell on the day of the crisis, and became unusually high two 
or three days later. Moderate albuminuria is frequent. Griesinger 
found casts and epithelium of the tubules and bladder in the sediment. 
Frerichs found leucin and tvrosin. ACUTE INFECTIOUS EXANTHEMATA. 
123 
Thirst is always increased, and even apathetic patients will eagerly 
drink water. The appetite is lost, the bowels are generally constipated. 
The skin is said to have a peculiar mouldy smell. It is generally 
dry and hot; in rare cases, there is diaphoresis apart from the crisis. 
Death may occur from excessive rise of temperature before the out- 
break of the eruption, or it takes place at the height of the disease, or 
shortly before or after the crisis. It is generally the result of heart 
failure. 
Among the anomalies may be mentioned typhus without eruption; 
also abortive cases of short duration. In other cases, finally, the symp- 
toms are very mild and brief. 
Complications and sequelae are not uncommon. Eclamptic attacks 
are sometimes observed at the height of the disease. Purulent menin- 
gitis was recently described by Iluguenin, who also observed embolic 
changes in the brain. Impaired memory and imbecility sometimes per- 
sist for a long time after the disease. Paraplegiae have been observed, 
apparently of myelitic origin. Radial neuritis has been described, and 
it is also possible that purely myopathic paralyses may develop. Clonic 
twitchings, aphasia, and neuralgias have been reported as sequelae. 
Chronic purulent inflammations of the ear and deafness may occur; 
the former may extend to the cerebral meninges. Amaurosis has also 
been mentioned in a few cases. 
Moers observed hemorrhages from catarrhal ulcers of the pharynx. 
Epistaxis occurs occasionally. Haemoptysis set in in one case, although 
no pulmonary abnormalities could be discovered. Wojciechowski de- 
scribed 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 
dysenteriform evacuations. Peritonitis is a very rare complication. 
Murchison described acute yellow 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 
heart 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 
veins and arteries. Bed sores may develop, despite the utmost care. 
Among the complications we may also mention furunculosis, multiple 
abscesses, erysipelas, parotitis, pyaemia, septicaemia, suppuration of the 
lymphatic glands, noma, or gangrene of the skin. 
IV. Diagnosis.—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, diarrhoea, ileo-caecal gurgling and pain are rare in typhus. It is 
distinguished from measles by the fact that the latter generally attacks 
children, and that conjunctival, nasal, and pharyngeal catarrh is very 
prominent. 
V. Prognosis.—The disease is 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- 
nosis is so much more grave the highei the fever, the more rapid the 124 
ACUTE INFECTIOUS EXANTHEMATA. 
pulse, the weaker the constitution, the more advanced the age, and the 
severer the complications. As a general thing, a profuse eruption indi- 
cates a severe course. The vigor of the heart's action must be taken 
specially into consideration in regard to prognosis. 
VI. Tkeatment.—The spread of typhus can only be prevented by 
the strictest quarantine. 
If typhus has appeared in a lodging-house, prison, etc., the place 
should be closed, all its utensils which possess only slight value should 
be burned, more expensive ones thoroughly disinfected, and the rooms 
disinfected and aired for a long time. 
The patients should be strictly quarantined, and have their own 
nurses, utensils, and physicians. The latter should visit their typhus 
patients last, then carefully disinfect themselves, and change their 
clothing. The patients may receive no visits, and not enter into com- 
munication with the outside world. Burial should be strictly private. 
Alcohol in large doses (brandy, wine, champagne) or other stimu- 
lants, and antipyretics must be administered. Among the latter, we 
prefer antipyrin ( 3 i.-iss. by enema). Treatment with cold baths pro- 
duces very little good effect. 
In other respects, the treatment is purely symptomatic. 
The rules concerning nursing and diet, which will be laid down in 
discussing typhoid fever, also hold good. 
5. Erysipelas. 
I. Etiology.—Erysipelas may develop whenever, after a wound of 
the skin or mucous membrane, certain bacteria (erysipelas cocci) gain 
access to the lymph vessels, and set up a specific inflammation of the 
skin. The 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- 
ously. 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 
the search the more frequently will lesions be found, so that we must ask our- 
selves whether, in the former event, the primary lesion may not have healed and 
escaped discovery. 
Some writers speak not alone of erysipelas of the skin, mucous or serous mem- 
branes, but also of erysipelas of the viscera, for example, the lungs (vide Vol. I., 
page 303). 
Erysipelas sometimes appears in epidemics, particularly in the spring. 
They may extend over an entire city or only to a few houses. 
It is sometimes found that operations are followed by erysipelas when 
new wards are opened. In some hospitals, certain rooms and beds are 
notorious as the abiding places of erysipelas. 
The introduction of a single case into a hospital may lead to its fur- 
ther spread. In other cases, its frequent occurrence is connected with 
overcrowding and bad ventilation of the wards. Koening described an 
epidemic which took its start from the operating table, inasmuch as the 
pillow had been saturated with blood and secretions from a patient suf- 
fering from erysipelas, and had not been changed in a long time. In- 
struments and bandages may also serve to convey the disease. 
It is generally assumed, but not positively proven, that the virus is 
conveyed only a slight distance in the air; infection takes place very ACUTE INFECTIOUS EXANTHEMATA. 
125 
readily through the agency of intermediate persons and inanimate ob- 
jects. During an epidemic, a very trifling wound (leech bite, hypoder- 
mic injections, etc.) may be followed by erysipelas. 
Erysipelas very often follows chronic inflammations and eczemas of the nasal 
mucous membrane, and is apt to relapse a number of times in the course of a few 
months or years. Inflammations of the lachrymal sac and duct are a frequent 
starting-point of the disease. It is sometimes associated with a gum-boil, eczema 
of the external ear and auditory canal or other parts of the body, and ulcers of 
the leg. 
It occurs occasionally as a puerperal complication, starting from the uterus, 
and, in the new-born, may follow tying of the cord. 
Vaccination erysipelas is a special form which will be discussed later. 
Erysipelas is one of those infectious diseases which, instead of con- 
ferring immunity against a subsequent attack, produces an increased sus- 
ceptibility. It sometimes complicates typhoid and typhus fever, relapsing 
fever, intermittent fever, diphtheria, dysentery, pneumonia, etc. Occa- 
Fig. 20. 
Temperature curve in a moderately severe case of facial erysipelas. 
sionally it exercises a favorable influence on other diseases, for example, 
syphilis. Erysipelas has been known to be followed by the disappear- 
ance or diminution in size of cancer, fibroma, naevi, tumors of the 
lymphatic glands, phagedaenic ulcers, elephantiasis, and lupus. Kopff 
recently described a case of acute articular rheumatism which rapidly 
recovered after an outbreak of erysipelas. 
A number of successful inoculations of animals have been made, partly with 
the contents of vesicles, partly with blood. Felileisen recently inoculated human 
beings with artificial cultures of erysipelas cocci. He found that if a second in- 
oculation was made soon after a successful one, it was attended with negative 
results and only proved successful after a certain lapse of time. Jaenisch and 
Neisser observed a fatal result after inoculation, with erysipelas cocci, of a woman 
suffering from cancer of the breast. 
II. Symptoms.—The duration of the period of incubation varies from 
one to eight days. Heiberg claims that, during an epidemic in Rostock, 
he observed an elevation of temperature two hours after making a surgi- 
cal incision. 
Prodromata are often wanting. Some patients complain of malaise, 
anorexia, and pains in the limbs. 126 
ACUTE INFECTIOUS EXANTHEMATA. 
The symptoms often begin with a chill, or repeated chilly sensations. 
This is followed by fever, which may reach 40° C. or more in a few 
hours. This generally runs a continued course so long as the cutaneous 
changes last, and usually terminates in a crisis (vide Fig. 20). The oc- 
currence of the crisis is sometimes preceded by sudden, marked eleva- 
tion of temperature, delirium, chill, etc. If the disease terminates un- 
favorably. the temperature not infrequently rises very high before death 
and sometimes even for a little while after death. Relapses may be ac- 
companied by another rise of the normal temperature (vide Fig. 21). In 
a few cases mild erysipelas runs an apyrexial course. The elevation of 
temperature is attended with increased frequency of the pulse, anorexia, 
and increased thirst. 
In cutaneous erysipelas, the patients complain of pricking, itching, 
and pain in the affected parts. The skin is cedematous, devoid of folds 
and shining (inflammatory oedema), and is hot and red. The epidermis 
Fig. 21. 
Temperature curve in a moderately severe case of facial erysipelas, with a relapse on the sixteenth 
day. 
is 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 blackish-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 and furrows of the skin. A sallow, yellow cedematous zone 
first forms, and is followed by hypersemia 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 erysiyelas is directly 
visible ; it may be assumed to be taking place on the scalp when the lat- ACUTE INFECTIOUS EXANTHEMATA. 
127 
ter becomes painful, swollen, and hot. Upon separating the hairs, red- 
ness is sometimes visible. Marked swelling of the skin often produces 
great deformity. For example, the eyelids may be swollen to such an 
extent that the patient is unable to open them ; the nostrils are not in- 
frequently narrowed and impermeable ; and the ears and lips may be 
converted into shapeless masses. 
As a rule, the erysipelatous changes reach their highest development 
on the third day after their appearance. The redness and swelling then 
diminish; finally desquamation takes place. The vesicles which have 
been present dry into thin scales and crusts. 
At the height of the disease, the fever and cutaneous changes are ac- 
companied by other symptoms, partly as the result of fever, partly of 
infection. The sensorium is often affected, and delirium or somnolence 
and coma may appear very early. The tongue is often dry, fissured, 
brownish-yellow, or covered with sordes, as in typhoid fever. Catarrhal 
angina is 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, diarrhoea is rare. Febrile albuminuria is common. The urine 
presents the characteristics 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, most abundantly in the 
blood of those parts which were attacked by the erysipelas. 
The disease sometimes lasts only a few days, in other cases several 
weeks or even months. 
Among the rarer complications are changes in the skin itself, such 
as herpes facialis, roseola, or impetigo. In some cases, there are multi- 
ple cutaneous abscesses, after opening which the erysipelatous changes 
may subside in a sort of crisis. In one case, Holms described vaso- 
motor disturbances (bluish-red color and anaesthesia) of the phalanges of 
the fingers, followed during convalescence from the erysipelas by sponta- 
neous 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. Verru- 
cose or ulcerative endocarditis, myocarditis, and pericarditis sometimes 
develop. Jaccoud maintains that pericarditis never occurs without en- 
docarditis, and that the latter attacks only the venous valves. 
Sudden oedema of the glottis occasionally puts an end to existence. 
Bronchitis, pneumonia, pleurisy, and mediastinitis are occasional com- 
plications. Violent epistaxis occurs in some cases as a sort of crisis. 
Icterus, dysenteriform stools, and intestinal hemorrhages are occa- 
sionally observed as the result of round duodenal ulcers or ulceration of 
the intestinal lymph follicles. Peritonitis has been described in a few 
cases, especially in erysipelas of the abdominal walls. 
Acute (hemorrhagic) nephritis may develop, and sometimes termi- 
nates in chronic Bright’s disease. Balide observed glycosuria which 
lasted three days. 
Cicatrices sometimes remain as sequelae, particularly in gangrenous 
erysipelas which has led to deep destruction of the skin. When erysipe- 
las often relapses in the same locality, it is apt to give rise to hyper- 
plastic and hypertrophic changes in the subcutaneous connective tissue 
(elephantiasis Arabum). Anaesthesia or hyperaesthesia is sometimes 128 
ACUTE INFECTIOUS EXANTHEMATA. 
observed on the site of erysipelas. Obstinate neuralgias are sometimes 
left over. In one case, Broadbent described atrophy of the skin associ- 
ated with anaesthesia. Defluvium capillitii is quite a constant symptom 
of erysipelas of the scalp, on account of nutritive disturbances of the 
hair follicles, but the hairs generally grow again after a certain lapse of 
time. 
Joint changes have been described in a number of cases. They con- 
sist of pain, or multiple painful swellings, or of purulent inflammation. 
Ritzmann observed a fatal termination in two of these cases. Puru- 
lent parotitis is mentioned in a few cases. 
The ocular changes are important. Abscesses sometimes form in the 
Fig. 22. 
Erysipelas cocci in the cutis. Enlarged 750 times. Immersion lens. 
lids, or the latter are partially destroyed by gangrene of the skin. There 
may also be inflammation 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 occurs 
most frequently in the pharynx, next in the nasal mucous membrane or 
on that of the lachrymal passages. In the puerperal state, it sometimes acute infectious exanthemata. 
129 
develops on the mucous membrane of the vagina and uterus, whence it 
may pass through the tubes to the peritoneum and give rise to peritoni- 
tis. 
The principal changes are swelling and redness of the mucous mem- 
branes, inflammation of the adjacent lymphatic glands, formation of 
vesicles and abscesses. The diagnosis is rendered positive if erysipelas of 
the skin is also present. The clinical history is the same as that of cuta- 
neous erysipelas. 
III. Anatomical Changes.—There is no longer a doubt that 
erysipelas 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 the lymphatics, and 
the blood-vessels are congested. The changes affect not alone the cutis 
proper, but also extend irregularly into the subcutaneous adjpose 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 
secondarily upon certain toxic substances which are produced by the active 
proliferation of the micrococci, since Fehleisen never found bacteria in 
the blood. 
The changes in the viscera include enlargement of the spleen, cloudy 
swelling of the heart, liver, and kidneys, swelling of the intestinal lymph 
follicles, and, at times, ulcerations of the intestinal mucous membrane. 
Klebs and Reiner have raised the question whether erysipelas is always pro- 
duced by certain definite bacteria. In the erysipelatous skin of patients suffering 
from typhoid fever, they found bacilli, and believe that these bacilli, if carried 
into the lymphatics of the skin, may set up erysipelas. 
IV. Diagnosis.—The disease is 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 cutaneous 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 oedema, the skin 
also exhibits a doughy infiltration, but general symptoms often remain 
absent for a long time. 
V. Prognosis.—In uncomplicated erysipelas the prognosis is not 
very bad, and many individuals survive a large number of attacks. But 
it should not be forgotten that unforeseen complications may arise, and 
that the severity of the general symptoms, particularly in the old and 
decrepit and those addicted to alcohol, sometimes result with astonishing 
rapidity in a fatal termination. Rapidly fatal collapse is not infrequent 
in gangrenous erysipelas, and the disease is also very grave in puerperal 
women. 
VI. Treatment.—As a prophylactic measure, all wounds, however 
slight, must be thoroughly disinfected with carbolic acid (five per cent) 130 
ACUTE INFECTIOUS EXANTHEMATA. 
and kept scrupulously clean. In hospitals, strict attention must be paid 
to ventilation and cleanliness as regards clothing, bedding, bandages, 
walls, and floors. During endemics or epidemics, all operations, even 
vaccination and hypodermic injections, must be avoided. The erysipe- 
las patients should be isolated and have separate attendants. 
Erysipelas requires local and general treatment. The best local ap- 
plication, in our opinion, is carbolic acid dissolved in turpentine (I£ 
Acid, carbolic., 3 ss.; ol. terebinth., 1 i. M. D. S. To be applied ex- 
ternally every hour). It should not be applied in jflaces where vesicles 
have burst, and the skin is deprived of epidermis. The application 
should be 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 gangrene. But if gangrene occurs 
despite our efforts, the part should be dressed with acetate of alumina 
(one to two per cent). 
The patients are kept in bed in a large, airy room, receive fluid 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 (!), aether douche, ice- 
water or lead-water compi-esses. 
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 into thin crusts. The latter fall off without leav- 
ing a scar, but the spot remains red and pigmented for some time. 
Many vesicles are more or less umbilicated. 
Herpes 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 and Etiology.—Zimmerlin observed an instructive 
series of cases of primary infectious herpes facialis in the Basle Citizen’s 
Hospital. Thirty patients—all in the same wing of the hospital—were 
attacked within three months. 
The secondary infectious form is more frequent. It is observed in 
many febrile infections diseases, most frequently in fibrinous pneumonia, 
also in relapsing fever, malaria, meningitis, but only in exceptional cases ACUTE INFECTIOUS EXANTHEMATA. 
131 
in typhoid or typhus fever. The vesicles develop generally at the boun- 
dary between the skin and the mucous membrane of the lips (herpes 
labialis). As a rule, only one-half the lip is affected, more rarely it ex- 
tends over the entire upper or lower lip, or on one side of both lips. 
Occasionally the entire circumference of the mouth is surrounded by 
groups of vesicles; the lips are then swollen, and later become covered 
with more or less thick, gray, brown, or bloody crusts. In certain cases, 
the 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 
herpes of the tongue (glossitis herpetica) has also been observed. 
Herpes nasalis (on the alas nasi), herpes auricularis (on the concha), 
herpes infraorbitalis, palpebralis, conjunctivalis, and episcleralis an 
much rarer than herpes labialis. In a case of pneumonia, Thomas ob- 
served herpes sacro-ischiadicus, in another case herpes facialis and herpes 
manus. 
Herpes facialis also occurs not infrequently in gastric catarrh, also in 
some women at the period of menstruation, and occasionally as the re- 
sult of violent emotions. 
Nothing is known with certainty concerning the relation between herpes and 
febrile infectious diseases. According to Gerhardt, the fever gives rise to dilata- 
tion of the blood-vessels, and thus to mechanical irritation of branches of the 
trigeminus within narrow and unyielding bony canals in the skull. But since 
all febrile diseases do not give rise to herpes facialis with like frequency, it seems 
more plausible to us to assume that a neuritis is associated with the infectious 
process, and that the bacteria of one infectious disease find a more ready entrance 
to the peripheral nerves than those of another disease. 
II. Treatment.—Treatment is hardly necessary. If the entire cir- 
cumference of the lips is affected, painful rhagades sometimes form; 
these may be brushed with ol. amygdalar. every two hours to accelerate 
the exfoliation 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 
chlorate is preferred, it should not be given in too concentrated a solu- 
tion (5:200). 
b. Herpes Zoster. Zona. 
I. Etiology.—It has long been known that some forms of herpes 
zoster are infectious in their origin, since it often occurs in epidemics 
during the spring months, and generally attacks an individual only 
once in a life-time. 
In addition, there are non-infectious forms of herpes zoster. They 
are associated most frequently with nervous diseases (brain, spinal cord, 
and peripheral nerves), either from disturbances of certain trophic 
nerve tracts, as in diseases of the brain and spinal cord, or from direct 
injury to the peripheral nerves. Thus, herpes zoster often occurs in 
cancer or tuberculosis of the spine if the intervertebral ganglia, which 
possess trophic functions, are compressed and inflamed. It appears not 
infrequently in phthisis when it becomes complicated with tuberculosis 
of the vertebrse. Among 1,000 cases of phthisis, Leudet observed 17 of 
herpes zoster. In other cases, affections of the peripheral nerves can be 
demonstrated, for example, in adhesive pleurisy, mediastinal tumors, 
aneurism of the aorta, injury to the peripheral nerves, or compression 132 
ACUTE INFECTIOUS EXANTHEMATA. 
by callus. According to David, dental operations or injuries may 
cause herpes of the cheeks and gums, and this may also be produced by 
the eruption of a wisdom tooth. In two cases, Gerhardt observed 
herpes of the chin after galvanization of the mental nerve. 
The disease has been observed after poisoning with carbonic oxide and after 
the use of arsenic. Hutchinson attributes some cases to syphilis, and maintains 
that this is especially true of bilateral herpes. Hauff observed herpes zoster 
after acute articular rheumatism. According to some writers, pregnancy pre- 
disposes to herpes. 
The disease occurs at every age (Boehm observed it in two infants 
aged 5 and 7 months respectively), but it is most frequent from the 
twelfth to twenty-fifth years. 
II. Symptoms.—In herpes zoster, the herpes vesicles develop along 
the course of certain nerves. It is generally unilateral, but occasionally 
even multiple, i. e., it appears along several distinct nerves. It is most 
frequent upon the trunk. 
It may be divided into different varieties : herpes zoster capillitii, 
faciei, nuchaa, bracliialis, pectoralis, abdominalis, and femoralis. 
The most frequent form is herpes zoster pectoralis. The vesicles 
generally occupy one to four intercostal spaces. In typical cases, they 
begin at the spine, then descend along the course of the intercostal 
nerves, and on the anterior part of the thorax again descend. They 
very often extend a little beyond the median line, both anteriorly and 
posteriorly. In some cases the groups of vesicles are scattered, not 
connected. 
The changes begin with diffuse erythema, upon which develop small 
red papules, which are soon converted into clear vesicles, from the size 
of a pin’s head to that of a lentil. The individual vesicles sometimes 
coalesce. 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. 
In 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 its 
course in two to four weeks. 
The eruption is often preceded by prodromata. In herpes zoster 
pectoralis, intercostal neuralgia develops, and may last four to six weeks. 
Chill, fever, and gastro-enteritic symptoms may appear a few days pre- 
viously. Furthermore, the patients complain 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 neuralgia 
of certain branches of the trigeminus. 
The eruption rarely appears without prodromata. The patients com- 
plain of severe stitches and painful prickling in the skin, and then notice 
the eruption. 
The neuralgia and fever often subside after the appearance of the 
vesicles. In other cases, the neuralgia increases and gives rise to obsti- 
nate insomnia and nocturnal excitement. In the most favorable cases, 
the vesicles heal in one to two weeks. The disease lasts longer if the 
different groups of vesicles follow one another at long intervals, or if 
hemorrhages occur into the vesicles with extensive destruction of the 
skin. 
Herpes of the first branch of the trigeminus (herpes ophthalmicus) is ACUTE INFECTIOUS EXANTHEMATA. 
133 
sometimes attended with severe ocular diseases. In 80 cases collected 
by Cocks, the eye was affected 46 times (left eye 40 times). The ocular 
complications consist of herpes upon the conjunctiva and cornea, anaes- 
thesia 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, but 
several exceptions to this rule have been observed. In herpes zoster of 
the second branch of the trigeminus, vesicles form upon the mucous 
membrane of the cheeks, hard and soft palate. In some cases, the 
herpes of the mucous membrane is primary, and is followed by herpes 
of the face, or the former may exist alone. It is sometimes followed by 
falling out of the teeth and atrophy of the jaw. 
Sequelae are not very rare. They include obstinate neuralgias which 
may not begin until the vesicles have healed. Paralysis of the facial 
nerve or the limbs has 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, 
anaesthesia and paraesthesia, 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. 
II. Anatomical Changes.—In herpes zoster pectoralis, Baeren- 
sprung first observed inflammation of the intervertebral ganglia. In a 
case of herpes ophthalmicus, Wyss found inflammation of the G-asserian 
ganglion. These lesions tally with the theory of the trophic properties 
of the parts in question. 
As a matter of course, herpes zoster will also develop if the trophic 
fibres in the peripheral nerves are inflamed, and this lesion has been 
found in some cases. In the vicinity of the vesicles, however, secondary 
changes may develop in the cutaneous nerves. 
The following are the stages of development in the anatomical struc- 
ture of the vesicles : 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 individual septa consisting 
of compressed epidermis cells)—formation of nests of wandering cells 
within the rete Malpighii by division of the epithelium cells, transfor- 
mation and partial destruction of their protoplasm—drying of the fluid 
contents and regeneration of the stratum corneum through the agency 
of the remaining rete Malpighii. 
III. Diagnosis, Prognosis, Treatment.—The diagnosis is easy 
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 Wvss’ cases, in which it followed panophthalmitis. 
Treatment should not he 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. Sub- 
cutaneous injections of morphine may be made in violent neuralgia. If 
the neuralgia persists after the vesicles have healed, we may order qui- 
nine (gr. 15 to 30), Fowler's solution (5 to 10 drops t. i. d.), the con- 
stant current, or morphine subcutaneously. The faradic current may 
be employed if paralysis and atrophy ensue. 134 
acute infectious exanthemata. 
c. Herpes Progenitalis. 
I. Symptoms and Diagnosis.—In herpes progenitalis, the vesicles 
appear on the genitals. As a rule, they are few in number. In men, 
they are most frequent on the inner surface of the prepuce, but also ap- 
pear on the glans and dorsum penis. They appear rarely on the anterior 
part of the urethra, and may then give rise to blennorrhoic discharge. 
In women, they appear on the prepuce of the clitoris or inner surface 
of the labia minora, rarely on the labia majora. 
The patients complain generally of a peculiar prickling and itching. 
Examination usually shows shallow ulcers but no vesicles, which may 
increase in size if the patients have yielded to the desire to scratch. 
They then form deep, suppurating losses of substance, which may 
readily be mistaken for soft chancre, or, if the base is inflamed, for 
hard chancre. Balanitis, balano-posthitis and oedema of the prepuce 
may also develop. The true explanation would be apparent at once if 
the lesions appeared spontaneously and without previous intercourse, 
but the statements of the patient cannot be relied upon in this regard. 
Enlargement 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. Treatment.—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- 
duction of smegma must receive suitable treatment. 
d. Herpes of the Pharynx. 
(.Angina herpetica.) 
I. Etiology.—Herpes sometimes develops in the pharynx as an in- 
dependent affection. It is attributed to colds and menstrual distur- 
bances (at the onset of the menses). A few years ago, I observed an epi- 
demic of pharyngeal herpes in Goettingen, and at the same time herpes 
praeputialis and erythema nodosum were also remarkably frequent. 
Herzog states that the infectious character of the disease is not demon- 
strable. 
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 first or second day of the disease, the pharyngeal mucous 
membrane is found to contain yellow, slightly elevated patches with 
red borders; 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 
they were situated on the posterior surface of the uvula, and were only 
visible with the aid of the laryngoscope. They are unilateral, and thus 
distinguished from pseudoherpes, which forms a diffuse, irregularly dis- 
tributed vesicular eruption in the pharynx, and is not infrequent in 
inveterate smokers. Herpes pharyngis is sometimes associated with 
herpes facialis, or it may alternate with herpes prseputialis. 
The patients 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 INFECTIOUS EXANTHEMATA. 
135 
or fourth day, the yellow patches are exfoliated, leaving behind shallow, 
cicatrizing ulcers. Great prostration sometimes persists for a very long 
time. In one case I noticed paralysis of the velum palati. Perforation 
of the velum palati or pillars of the palate, and pseudo-membranous in- 
flammation have also been observed in rare cases. 
Treatment; gargles of potassium chlorate (5 : 200). 
e. Herpes of the Larynx. Herpes Laryngis. 
(Laryngitis Phlyctcenulosa.) 
This disease is rare. It generally begins with fever, and is associated with 
herpes of the external skin or other mucous membranes. The laryngeal mucous 
membrane first presents epithelial opacities, later vesicular elevations, which ter- 
minate in shallow ulcers. The latter are surrounded by a red zone, and heal in 
one to two weeks. The diagnosis can only be made with the aid of the laryngo- 
scope. Pseudoherpes may also occur upon the larynx, but, unlike herpes, it is 
not unilateral, and is confined to parts in which the mucous glands are abundant. 
7. Fehris Miliaris. 
Sweating Sickness. 
I. ETIOLOGY.—The existence of febris miliaris has been disputed up to the 
present time. From the reports of others, it appears to us that it is an inde- 
pendent infectious disease. 
The first epidemics appeared in the fifteenth and sixteenth centuries, and then 
not until the eighteenth century. Since then, the disease has appeared from 
time to time in England, France, Italy, and Germany. 
The majority of epidemics occur in the summer. Their development is 
favored by damp, changeable weather, perhaps by a marshy soil. As a rule, 
few epidemics last more than two to six weeks. It occurs most frequently 
between the ages of twenty to forty years. 
Women are affected more frequently than men; also individuals of a strong 
constitution. Tne character of the virus is unknown, but some regard it as 
miasmatic in origin. The circumscribed character of the epidemics is a notable 
feature. The same individual may experience a number of attacks, 
II. Symptoms.—The disease is preceded by general malaise for two or three 
days. 
Patients who went to bed without special local symptoms awake during the 
night bathed in perspiration, together with a feeling of oppression in the prae- 
cordial region, headache, dizziness, palpitation of the heart, occasionally cramps 
in the calves. The temperature is more or less elevated, the pulse accelerated, 
respirations rapid and dyspnceal. The sweating is sometimes so profuse as to 
drench the bed. On the third or fourth day, miliaria appear, at first miliaria 
crystallina, then rubra, finally miliaria alba. The appearance of the eruption is 
often associated with prickling and numbness of the skin. The patients suffer 
from anorexia, increased thirst, nausea, vomiting, constipation, and scanty 
diuresis. The spleen is generally enlarged. 
Death may occur in collapse or from paralysis of the heart or brain, or from 
complications (diphtheria, pneumonia, diarrhoea, dysentery, purpura, and disso- 
lution of the blood). 
When uncomplicated, the disease lasts six to eight days, but the period of 
convalescence is sometimes protracted. The disappearance of the eruption is 
followed by desquamation of the skin. The average mortality is ten per cent, in 
some epidemics as high as fifty per cent. 
III. Anatomical Changes.—There is almost constantly a tendency to rapid 
decomposition of the body in the fatal cases, the blood is thin and black, the 
spleen large and soft. 
IV. Treatment.—The bed covering should be light, the room kept at a tem- 
perature of 15° R., and cold water mixed with claret or brandy given as a drink; 
only fluid food should be allowed. To check the diaphoresis, we may give sul- 
phate of atropia (gr. £ : 3 iij., one svringeful subcutaneously). 136 
ACUTE INFECTIOUS EXANTHEMATA. 
8. Small-Pox. Variola. 
I. Etiology.—Small-pox patients are the most frequent sources of 
infection. In former times, before bovine virus was used in vaccina- 
tion, individuals were often inoculated with the contents of pocks 
taken from patients, because experience taught that the disease, when 
acquired in this way, was more apt to run a mild course than when ac- 
quired accidentally. The scabs left over after the pustules have dried 
possess infectious properties, even if kept for a long time. The physi- 
ological secretions are non-infectious; whether the blood of the patients 
possesses infectious properties still remains doubtful. 
The disease also appears to be infectious even during the period of 
incubation. Schaper reports a case in which a piece of skin was removed 
from an apparently healthy man for the purpose of transplantation. A 
few hours later the prodromata of small-pox appeared. After a certain 
period, the individual upon whom the skin had been transplanted was 
also attacked with small-pox. 
The virus diffuses itself in the vicinity of the patient, and infects the 
air, articles of clothing, and utensils. The danger of infection increases 
the greater the number of patients in one room, and the less the room is 
aired. During the last great epidemics (1870 to 1873) it was noticed in 
some instances that when small-pox patients were placed in quarantined 
houses, cases developed in neighboring, but not immediately adjacent 
houses, particularly if the windows of the sick-rooms were constantly 
kept open. 
Infection may also be conveyed by intermediate persons who escape 
the disease. The virus is generally absorbed through the respiratory 
organs, in exceptional cases by direct inoculation of wounds. Infection 
has also been observed from handling money, rags, etc., witli which 
patients had come in contact. In many cases, it is extremely difficult to 
trace the mode of infection. 
The virus is supposed to consist of bacteria. Colin describes, in the 
contents of the pustules, fine granules which are divided in twos, fours, 
eights, etc., are accumulated in groups of sixteen, thirty-two, or more, 
and form larger zooglcea masses. They are generally immovable, and 
sometimes form rosary-like chains. Klebs states that the tracheal 
mucus contains micrococci 0.5 in diameter, which are partly arranged 
in fours in the shape of a square, but are nevertheless separated from 
one another (micrococcus quadrigeminus). 
The contents of the pustules may not alone infect human beings, but 
also certain animals (cow, calf, horse, ass, sheep, pig, dog, monkey). 
The body of the animal possesses the power of weakening the injurious 
properties of human small-pox (vide remarks on vaccination). 
Almost every individual possesses a susceptibility to small-pox, but it is 
generally abolished or diminished in infancy by vaccination. In many 
persons the efficacy of vaccination does not last longer than ten years, 
so that revaccination should be performed at least every ten years. Very 
few people present permanent immunity from small-pox without previ- 
ous vaccination. 
In others, there is temporary immunity; they escape during one epi- 
demic, but are attacked in the next. 
As a rule, one attack confers life-long, acquired immunity, although 
there are occasional exceptions to the rule. It is said that some indi- 
viduals have suffered from as many as six attacks. 137 
Certain conditions may increase the susceptibility to the disease. 
This is particularly true of pregnancy and the puerperal state, under 
which circumstances the. disease is often of the hemorrhagic variety. 
It is claimed that drinkers, feeble individuals, and those who are ex- 
posed to heat (cooks, firemen) also exhibit a tendency to the hemorrhagic 
form of small-pox. 
Age and sex exert no influence on the frequency of the disease. 
Pregnant women, suffering from small-pox, have been known to give 
birth to children whose skin was covered with small-pox pustules, and, 
on the other hand, the disease has been observed in very old people. 
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 is said that epidemics in large cities are 
apt to recur at definite intervals, which 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 months. The spread of epidemics is sometimes 
favored by external conditions, for example, the crowding together of 
many individuals in wars 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. Symptoms.—The duration of the period of incubation varies from 
ten to fourteen days. After inoculation, the period of incubation is 
generally shorter than in natural small-pox. 
Curschmann states that, in one case, the period of incubation only lasted five 
days, and according to Zuelzer, its average duration in malignant hemorrhagic 
small-pox is six to eight days. 
The majority of patients feel perfectly well during 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, 
anorexia, 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 
pulse becomes very rapid (100, or even 120 beats a minute). The respira- 
tions are increased infrequency, and many patients complain of dyspnoea, 
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- 
ness in the head, of vertigo of such intensity 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- 
junctiva is often injected, and there is photophobia with increased secre- 
tion of tears. The tongue is coated, foetor ex ore is often noticeable. 
Thirst is increased, the appetite is entirely lost. The patients often 
complain of nausea and eructations, and repeated copious vomiting 
occurs with unusual frequency. The bowels are constipated, the urine 
ACUTE INFECTIOUS EXANTHEMATA. 138 
ACUTE INFECTIOUS EXANTHEMATA. 
scanty and saturated. The right ventricle becomes dilated; the first sound 
of the heart is often muffled, blowing, and replaced by a systolic mur- 
mur. The thorax may present evidences of dry bronchitis. The spleen 
is usually enlarged. The liver is often tender on pressure and slightly 
enlarged at a very early period. A very ■ constant symptom is the vio- 
lent pains in the back, which are referred to the loins and region of the 
kidneys. Some attribute these pains to renal congestion, others to 
congestion of the lumbar meninges. The latter view is more probable, 
because the pains often radiate into the lower limbs or abdominal walls, 
and are associated occasionally with anaesthesia, hyperaesthesia, or paraes- 
thesia of the lower limbs. 
Symptoms of pharyngeal and buccal catarrh (diffuse redness or hy- 
peraemia of the mucous membrane in patches) are often found very 
early. Some patients suffer early from hoarseness or a burning sensation 
in the nose; repeated epistaxis may also occur. 
In many cases, a prodromal eruption appears upon the second and 
third day. This may consist of diffuse erythema, as in scarlatina, of 
small circumscribed congestions (roseola variolosa), or of wheal-like 
patches. Simon showed that they are very often found on certain defi- 
nite parts of the body (lower part of the abdomen, the sides of the abdo- 
men and chest as high up as the axillse, and the outer surface of the leg, 
along the extensor hallucis). Their frequency varies according to the 
character of the epidemic. It is not true that the site of these prodro- 
mal eruptions remains free from the small-pox eruption proper. On 
account of the distribution of the prodromal eruptions along certain nerve 
tracts, they have been attributed to paralysis of the vaso-motor cutaneous 
nerves. 
The prodromal stage, on the average, lasts three days. 
It is followed by the stage of eruption. The first cutaneous changes 
appear on the face and scalp, but upon the latter they are only visible if 
the hair is short and thin. At the end of twenty-four hours, they extend 
to the trunk, and finally to the limbs. The eruption also appears in the 
pharynx, larynx, nose, and conjunctiva, opening of the urethra, vagina, 
cervical portion of the uterus. The eruption passes through various 
stages, which will be described later. 
It is a noteworthy fact that the severe general symptoms diminish 
very markedly with the appearance of the eruption, and many patients 
feel so relieved that they consider themselves recovered. The tempera- 
ture falls (vide Fig. 23) and approaches the normal, and the frequency 
of the pulse and respirations also diminishes. 
In the first or papular stage of the eruption, the face contains patches 
like those of measles, particularly upon the forehead and the boundary 
between the nose and cheeks. These patches grow pale on pressure, and 
are hot to the feel. In addition, the integument is cedematous, so that 
the eyelids are swollen and the palpebral fissure narrowed. Small patches 
sprout up very quickly within - the patches, and are very often, though 
not constantly, grouped around the hair follicles or sweat glands. 
Upon the trunk the patches and papules develop later, and are more 
scanty; they are more abundant on the limbs, particularly the extensor 
surfaces and on the fingers. These changes are often attended with 
burning and itching. 
The papular stage has an average duration of two days. On the 
third day of the stage of eruption, i. e., the sixth day of the disease, the 
Vesicular stage begins. At the apex of the papules the epidermis is ACUTE INFECTIOUS EXANTHEMATA. 
139 
raised from the rete Malpighii in the form of a small, transparent vesicle, 
at first upon the face, later upon the trunk and limbs. In the next few 
days, the vesicles increase gradually in size, and many of them become 
umbilicated. 
If a vesicle is punctured, its contents escape gradually. The vesicles 
are often distributed along the folds of the skin or the course of the 
cutaneous nerves. This stage generally lasts three days. 
On the ninth day begins the pustular stage. The temperature and 
the frequency of the pulse and respiration again increase, and chills and 
delirium appear in some cases. At the same time the contents of the 
vesicles become more and more opaque, cloudy, and purulent. Their 
size increases. The edge of the pustule is reddened and infiltrated, and 
around this there generally forms a slightly swollen, reddened zone, pro- 
duced mainly by hyperaemia of the skin. As pustulation increases, the 
Fig. 23. 
Temperature curve of a moderately severe case of small-pox. 
umbilication disappears. Pustulation begins in those parts in which the 
papules first appear, i. 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 the 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-red translucent papules, or large vesicular elevations. 
In about three days, this stage reaches its end, and the stage of de- 
siccation 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 
flabby, and finally is also converted into a crust. The majority of the 
patients experience intolerable itching, scratch the skin, and thus delay 
recovery. 
The crusts gradually fall off at about the sixteenth day of the dis- 140 
ACUTE INFECTIOUS EXANTHEMATA. 
ease (stage of decrustation). Brownish-red pigmented patches remain, 
or, in those places in which the pustules penetrated deep into the cutis, 
brownish-red pigmented cicatrices form, and are converted later into 
white 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 is 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, leaving a subepithelial loss of substance. At the 
same time the patients complain of difficulty in deglutition, and some 
are hardly able to swallow even fluids. 
Annoying salivation generally occurs when the buccal mucous mem- 
brane is affected. If the tongue is involved, it may increase consider- 
ably in size, and appears wedged in between the teeth (glossitis variolosa). 
The eruption may also form on the mucous membrane of the oesophagus. 
In some cases, the changes extend to the Eustachian tube and middle 
ear (giving rise to tinnitus aurium, pain in the ears, etc.), and also to 
the mucous membrane of the air passages. 
The eruption has also been observed upon the urethral meatus, 
vaginal 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 place 
gradually. 
Variola without eruption is a very mild form of the disease. The 
patients, who have been exposed 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 no 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 above description. The milder 
form is called varioloid, in contra-distinction to true variola. The more 
vaccination is adopted the more frequently small-pox occurs as varioloid, 
and the more rarely as variola. As a rule, 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, un- 
sightly cicatrices 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 is 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 as 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 blackish-red and bloody, and hemorrhages also occur upon the 
skin aud mucous membranes. ACUTE INFECTIOUS EXANTHEMATA. 
141 
Renault! states that he lias found decoloration of the red blood-globules and 
haematin crystals in the blood serum in hemorrhagic small-pox. 
Confluent small-pox is another severe form of the disease. It generally 
begins with severe prodromata. The patches and papules are so abundant 
that they coalesce in places. This is true to a still greater extent of the 
pustules 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 mask. The crusts often retain masses of pus 
which exude after rupture or perforation of the crust. The patients 
often emit an unpleasant odor. The general condition is grave: delirium, 
hyperpyrexia, perhaps death from heart failure. Dangerous complica- 
tions often make their appearance. 
The complications of small-pox attack the most various organs. 
Erysipelas of the skin sometimes develops during the stage of pustula- 
tion or desiccation. Gangrene of the skin develops occasionally in the 
vicinity of the efflorescences. Multiple abscesses appear at times in the 
skin, and may be the result of pyaemic infection; this is also true of ab- 
scesses of the intermuscular connective tissue. Inflammatory swelling, 
suppuration, and ankylosis of the joints have been observed, particularly 
in the large joints of the limbs. 
Delirium is one of the most frequent symptoms on the part of the 
nervous system. Marked psychopathic conditions occasionally develop, 
usually of a maniacal, more rarely of a melancholic character, sometimes 
associated with a suicidal tendency. These symptoms may appear 
before the outbreak of the eruption, or they form sequelae and become 
permanent. A combination with purulent meningitis, encephalitis, 
encephalo-malacia, and cerebral hemorrhage is rare. A number of cases 
of aphasia or dysarthria following hypoglossal paralysis have been re- 
ported. Catalepsy, disseminated myelitis, acute ascending paralysis, 
and acute ataxia have also been observed. Peripheral paralyses are rare. 
Gubler and Laborde mention paralysis of the detrusor vesicse at the 
beginning and also at the end of the disease. Diabetes insipidus and 
diabetes mellitus have also been included among the sequelae. 
Very serious changes may develop in the eye. Conjunctivitis is an 
almost constant symptom; this sometimes results in the formation of 
pus, particularly if the lids are swollen and occluded, and the removal 
of inflammatory products thus impeded. Ilirschberg described diphthe- 
ritic patches upon the conjunctiva, which sometimes result in the loss of 
the eye. Small-pox pustules appear occasionally upon the conjunctiva, 
generally on the bulbar 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 skin. They are small, 
and form yellowish papules which are surrounded by a zone of injected 
vessels. Subconjunctival hemorrhages may occur in hemorrhagic 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 hypopion, 
destruction of the cornea, prolapse o£ the iris, and thus in anterior 
synechia, and even phthisis bulbi. This does not often develop before 
the stage of desiccation. Rarer complications are diffuse interstitial 
keratitis and keratomalacia, the latter possessing an unfavorable prog- 
nostic significance. Iritis and irido-choroiditis are rare, and should be 
included among the sequelae rather than among the complications. 142 
ACUTE INFECTIOUS EXANTHEMATA. 
Opacities of the vitreous or the posterior surface of the lens often de- 
velop. Acute glaucoma, retinitis, and neuro-retinitis have also been 
observed. 
Aural changes are very common in small-pox. In one hundred and 
sixty-eight autopsies, Wendt found only two cases in which the auditory 
apparatus 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 hyperaemia often results in hemorrhages, and the circum- 
scribed swelling forms polypoid proliferations of the mucous membrane. 
The petrous portion of 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 be associated with phlegmonous changes in the sub- 
maxillarv 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 sometimes complicated with broncho-pneumonia; 
fibrinous and hypostatic pneumonia or pulmonary gangrene occasionally 
develop. (Edema of the lungs is sometimes the immediate cause of 
death. Pleurisy, very often purulent, is not a rare complication. Dan- 
gerous pulmonary hemorrhages occur in hemorrhagic small-pox. 
Pericarditis may develop independently, or it is secondary to pleurisy. 
Endocarditis, occasionally septic in character, is sometimes observed. 
The frequency of myocarditis lias been greatly 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. 
Iiaematemesis is not infrequent 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 
birth; more frequently they are attacked a few days later. 
It is sometimes found that, in twin births, only one child is attacked, Jases ACUTE INFECTIOUS EXANTHEMATA. 
143 
have also been leported in which the mother was healthy, but the child was 
attacked with small-pox. It is probable that in such cases the disease was over- 
looked in the mother. 
Orchitis has been observed in men; it is either parenchymatous or 
affects chiefly the coverings 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. Haematuria has been observed in hemor- 
rhagic small-pox. 
During the febrile period, the urine presents the ordinary characteristics of 
febrile urine. In one case of hemorrhagic small-pox, Brieger found a very small 
amount of phenol in the urine. Leucin, tyrosin, and fatty acids have been found 
in the urine. 
The complications and sequelae of small-pox cannot be sharply dis- 
tinguished from one another. Cutaneous cicatrices not infrequently 
persist for life, and sometimes cicatricial tumors (keloid) form, and 
must be removed with the knife. The hair often falls out, as after 
other severe diseases, but if the pustules have destroyed the hair folli- 
cles, restoration of the hair does not take place. The nails may be 
exfoliated. 
Pemphigus and acne rosacea have been described as sequelse. Ca- 
chectic oedema may develop, occasionally oedema of one limb from 
marantic thrombosis of the limbs. Paralyses, disorders of the special 
senses, 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 sequelas. Small- 
pox cicatrices in the oesophagus may produce constriction of that organ. 
The disease very rarely attacks the same individual twice, and still 
more rarely do relapses occur. In MichePs two cases, another violent 
outbreak of the eruption appeared upon the eighteenth and twenty- 
second days. 
Small-pox sometimes exercises a favorable influence on other dis- 
eases, for example, chorea and whooping cough. 
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 corium, either arranged in groups or in a tube-like 
shape, and occasionally in the blood-vessels. In the later stages of the 
disease, they disappear. The blood-vessels of the cutis dilate in places 
(patches of hyperaemia). Coagulation necrosis of the epithelium cells 
occurs beneath the groups of bacteria in the deepest layers of the rete 
Malpighii, and the cells are converted into non-nucleated clumps. At 
the same time, there is a circumscribed increase in size of the epidermis 
(papules). Between the necrotic cells are formed cavities, filled at first 
with serous, later with more purulent fluid. The necrotic cells form a 
mesh-work in which the fluid is inclosed. The meshes are often least 
distensible in the centre, so that the surface of the epidermis becomes 
depressed and umbilicated. The umbilication may also be produced by 
the development of the efflorescence 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 Auspitz and Basch, 
swelling of the periphery may also produce apparent depression of the 144 
ACUTE INFECTIOUS EXANTHEMATA. 
centre of the efflorescence. According to Unua, the pock first forms 
between the layers of the stratum lucidum. 
It is only when the efflorescence extends into the cutis that perma- 
nent deep cicatrices are left over. 
Bacteria have also been found in the lymphatic glands, liver, kidneys, 
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 glomeruli). The surrounding cells are either intact or in 
a condition of coagulation necrosis; there is sometimes an accumu- 
lation of round cells in the vicinity. 
The muscles often have the color of ham, and may be in a condition 
of cloudy swelling and wax-like degeneration. 
The blood is sometimes fluid and has a tarry color. 
The spleen is enlarged and soft; on section its follicles are often 
found to be unusually large. 
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 on the mucous membrane 
of the larynx, trachea, bronchi, oesophagus, and stomach. 
In hemorrhagic small-pox, extravasations of blood are found in vari- 
ous organs, even in the medulla of the bones and sheaths of the peri- 
pheral nerves. The cutaneous hemorrhages are the result of diapedesis 
of red blood-globules. 
The corpse remains infectious, probably on account of mechanical 
desquamation of the skin. 
IV. Diagnosis.—The diagnosis is easy, particularly during an epi- 
demic. Under other circumstances, it may be mistaken for impetigo 
contagiosa, but in the latter the general condition is less affected, pain 
in the back and vomiting are absent in the initial stage, and recovery is 
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 back during the prodromal stage favor the 
diagnosis of small-pox, pains in the legs 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 mucous 
membrane of the mouth and pharynx contains vesicles, a positive diag- 
nosis of small-pox may be made. 
V. Prognosis.—The prognosis is best in varioloid, more serious in 
confluent small-pox, most grave in the hemorrhagic form. Old and 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 abolition or diminution of the susceptibility 
to the disease by vaccination with bovine lymph. Revaccination should 
be performed at least every 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 acid, the clothing ACUTE INFECTIOUS EXANTHEMATA. 
145 
and bedding by dry beat or carbolic acid (five per cent). If the patient 
is kept at home, all those dwelling in the house should be quarantined, 
and later the entire house must be disinfected. The patient himself 
may not communicate freely with the outside world until desquamation 
has entirely ceased, and before several warm baths have been taken. 
Small-pox corpses should be placed in hermetically sealed coffins, and 
then buried as quickly as possible in vaults. The funeral should be 
strictly private. 
The treatment of the disease itself is 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 be taken morning and 
evening. 
Disturbances of deglutition may be treated with gargles of potassium 
chlorate (10 : 200) after each meal; acetate of alumina (one per cent) is 
preferable if there is fcetor ex ore. Pieces of ice may be swallowed by 
the patient. 
If there is constant high fever, lukewarm baths (26° R., 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 the head is indicated. 
Hemorrhagic small-pox requires stimulating treatment: large doses 
of alcohol, ether, camphor, or musk, with haemostatics. 
The following measures have been recommended to favor the healing 
of the pustules and prevent the formation of cicatrices: application to 
the face of indifferent fats, collodion, tincture of iodine, carbolic acid 
solution, incision of the pustules and cauterization with nitrate of silver. 
Cold compresses or warm poultices are the most agreeable to the patient. 
9. Vaccination. 
I. Variolation consisted in the inoculation of healthy individuals 
with the contents of small-pox pustules. This was done either through 
means of a puncture or cut beneath the epidermis, or the contents of the 
pustule were applied to the corium, which had been laid bare by means 
of a fly blister. 
But the dangers of this procedure must not be underestimated. Ac- 
cording to Ferro, there was one fatal case among eighteen variolations, 
according to Wilson, one in 6G2 cases. 
A still graver objection was the danger to surrounding individuals. 
A few cases of variolation afforded a favorable opportunity for the out- 
break of an epidemic of small-pox. Hence it was entirely justifiable to 
prohibit variolation by statute. 
II. Exanthemata, like small-pox, also occur in certain domestic an- 
imals, such as sheep, horses, and cows (ovinola, equinola, vaccinola). 
Sheep-pox (ovinola) is very similar in its clinical history to the small- 
pox of the human species. It begins with general febrile disturbances, 
leads to an eruption of pocks on the skin, is conveyed through the air to 
other animals, and often produces great mortality. To diminish its 
dangers, farmers inoculate healthy animals with the contents of the 146 
ACUTE INFECTIOUS EXANTHEMATA. 
pocks, but this is only permitted at the approach of an epidemic, because 
the inoculated flocks may prove a source of infection for healthy ones. 
In horse-pox (equinola), a pustular eruption appears upon the pas- 
terns, and general symptoms are wanting or very slight. 
The mildest course is run by cow-pox (vaccinola). This is localized 
on the udder, especially on the dug. The infectious matter is present 
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 inoculated successfully in man, 
monkeys, the camel, ass, pig, goat, dog, cat, and rabbit. 
The contents of human pocks, when inoculated into animals, always 
produce that form of the disease which is peculiar to the animal in 
question. If a cow is inoculated with variola-lymph, a pustular exan- 
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. 
This has been denied by Chauveau and other physicians of Lyons. They in- 
oculated cows with variola, and, on revaccination, produced variola in children. 
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 
pox. 
III. The inoculability of man with cow-pox has long been known. 
Farmers were long aware that milkmaids were 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 proved 
scientifically that vaccination guards against variola. On May 14th, 
1796, he inoculated James Phips with the contents of cow-pocks taken 
from the arm of the milkmaid Sarah Nelmess. After the cow-pox pus- 
tules had healed, he inoculated the boy witli 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.: humanized lymph, primary bovine lymph, and retrovaccina- 
tion lymph. 
Humanized 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 artificially preserved, 
humanized bovine 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 tubes, which pos- 
sess a spindle-shaped dilatation in the middle. The lymph is collected 
in a carefully cleaned watch glass, the two closed ends of the tube are 
then broken off with the fingers, and the tube held almost horizontally, 
with one open end in the fluid. The tube 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 ACUTE INFECTIOUS EXANTHEMATA. 
147 
upon for more than six to twelve months, and it should be kept in a 
cool, dark place. The lymph is ineffective if it contains opacities and 
clouds. 
It should be taken only from healthy children who come of 
healthy families. Special attention must be directed to the presence of 
phthisis, scrofula, or syphilis in the family. The pustules, whose con- 
tents are gathered, must possess all the characteristics of a regularly de- 
veloped cow-pox pustule. Those which possess a very broad zone of in- 
flammation must be avoided, since vaccination with their contents 
sometimes causes extensive inflammation, and even erysipelas. The 
pustules should be taken from children who are vaccinated for the first 
time, since the lymph from pustules of revaccinated persons is less cer- 
tain in its effects, and often produces doubtful efflorescences. The best 
time for collecting the contents of the pustules is the eighth or ninth 
day after vaccination. Under no circumstances may lymph be employed 
which contains macroscopic amounts of blood. If the child unfor- 
tunately happens to be syphilitic, the simple contents of the pustule will 
not convey syphilis, while this may be 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. He recommended that the 
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 parts of glycerin and distilled water. This is kept 
in glass tubes. An addition of sulphate of soda, salicylic acid, or thy- 
mol has been recently recommened 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 
vaccination 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 is true that 
some children suffering from hereditary syphilis present no signs until 
the age of three months, but danger in this regard is avoided by employ- 
ing children who are past the age of six months. Experience in no 
wise justifies the fear of the gradual impairment of the efficiency of the 
lymph. 
The employment of primary bovine virus is also not free from objec- 
tions. In the first place, the disease itself is not very common, so that 
the lymph cannot be obtained whenever desired, and in addition, the 
primary lymph may produce violent symptoms in man; often great 
swelling of the arm, erysipelatous redness, and not inconsiderable 
febrile movement. If the animals suffer from garget, the inoculation 
of tuberculosis is possible, so that the animal should be killed, and the 
healthy condition of its organs rendered certain before vaccination is 
performed. The symptoms are milder if the animal has been inocu- 
lated by vaccination with primary bovine lymph. 
In retrovaccination, the bovine lymph is revaccinated from man 
upon the udder of calves, and vaccination in man is then continued 
with the contents of the pustules produced in the animals by the vacci- 
nation. In this case, also, only those animals should be employed who 
present healthy viscera after death. 148 
ACUTE INFECTIOUS EXANTHEMATA. 
The 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 the 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 the cicatrix 
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 who 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. 
YI. 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 may 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: ACUTE INFECTIOUS EXANTHEMATA. 
149 
During the tirst few days after vaccination, hardly any change is 
noticeable. On the fourth day, a red papule appears on the site of vac- 
cination. On the fifth day, serum accumulates beneath the epidermis 
of the papule, so that a small vesicle appears. On the sixth day, this 
increases in size, its contents become cloudy, and its periphery is sur- 
rounded by a red zone. On the seventh day, the vesicle is converted 
into a pustule; its contents are purulent, its red border slightly infil- 
trated, around it is a hyperaemic zone shading gradually into the healthy 
parts. The pustule increases in size in the next few days, and attains 
its greatest development on the tenth day. On the twelfth day, the 
contents of the pustule begin to dry, and a crust forms which falls off 
on the twenty-first day. At first its 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 are 
made, the bodily temperature will be found slightly elevated during the 
first three days (prodromal fever) and from the seventh to ninth days 
(suppurative fever). If the temperature rises to 40° C. or more, other 
febrile symptoms also develop: increased thirst, anorexia, a tearful 
mood, restless sleep, and even convulsions and delirium. 
The anatomical characteristics of vaccine and variola efflorescences are, in 
the main, identical. 
VIII. The pathological accidents of vaccination may be local or 
general. 
In a very few cases death has resulted from hemorrhage from the site 
of hemorrhage. Strongmeyer and Henoch observed this in a hcemophilic 
child, Polk in a leukaemic child. As a rule, however, vaccination is well 
tolerated in haemophilia. 
A painful furuncle, attended with febrile movements, sometimes de- 
velops at the site of vaccination, especially if the incision has been made 
too deep. 
Vaccine ulcer is the term applied to those cases in which the pus- 
tule develops normally until the tenth day, after which it ruptures and 
discloses a painful ulcer. This is accompanied by general febrile dis- 
turbances. It is relatively frequent after vaccination with primary 
bovine lymph. 
The term vesicular pocks is applied to those cases in which large vesi- 
cles with watery contents are formed. Thin crusts are produced, and 
fall off without leaving a cicatrix. 
In eczema pocks, a senes of vesicles form around the site of vaccina- 
tion, and terminate in a weeping eruption. This is observed with rela- 
tive frequency in anaemic, rachitic, and scrofulous children, especially if 
they have suffered previously from eczema. 
In two cases, 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 to twenty-first days. 
The erysipelas is the result of the wound, and extends over the arm, and 
even the larger portion of the trunk. It is often fatal. Its production 
is favored by uncleanliness in vaccination, vaccination in the hot months, 
the epidemic occurrence of vaccination erysipelas, the removal of lymph 
from pocks which are surrounded by a broad zone of inflammation, or 150 
ACUTE INFECTIOUS EXANTHEMATA. 
from erysipelatous children, and vaccination with primary bovineflymph. 
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 exceptional 
cases they undergo suppuration, or become swollen in distant parts, or 
the salivary glands enlarge. Lymphangoitis is occasionally observed. 
Bednar states that he has observed peritonitis after vaccination in sev- 
eral cases. 
10. Varicella. Cliicken-pox. 
I. 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 set. 11 days. Among 
584 cases collected by Baader, 
382 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 
endemically 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 in 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 and Anatomical Changes.—The period of incuba- 
tion averages thirteen to sixteen days, occasionally it is as short as eight 
days or prolonged to nineteen days. ACUTE INFECTIOUS EXANTHEMATA. 
151 
Kroenlein describes the following case which illustrates the length of the 
period of incubation. January 4th, 1884, a child was received into the surgical 
ward of the Zurich Hospital, and on January 6th, was attacked with varicella. 
January 20th, at noon, two other children were taken sick, and the first efflores- 
cences appeared on the evening of the same day. In vaccinations, the period of 
incubation is generally short (about eight days), and in one case, Fleischmann ob- 
served the eruption on the second day after inoculation. 
A prodromal stage is entirely absent in many cases, but some chil- 
dren suffer from irritability, anorexia, eructations, vomiting, and irregu- 
larity in evacuations from the bowels. Canstatt mentions tenesmus of 
the bladder and pale urine; disturbances of deglutition.have also been ob- 
served. Delirium and convulsions occur in rare cases. As a rule, the 
bodily temperature is unchanged; but occasionally it rises to 39° C. or 
even more. This stage lasts only a day or two, the elevation of tempera- 
ture only a few hours. 
The stage of eruption begins, in rare cases, with a fleeting erythema. 
The specific 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 
gradually 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 litre 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 
by a red zone (hyperaemia of the cutaneous vessels). The 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 experience, the 
vesicles may be umbilicated. The contents of the vesicles are clear and 
watery, but after the second day they become cloudy from the admix- 
ture of cellular elements. Vesicles with purulent contents may develop 
in rare cases and are exactly similar to well-developed pustules of small- 
pox. 
If a vesicle is punctured with a needle, a clear fluid slowly escapes, 
of an alkaline or neutral reaction, and poor in cells. Hence the vesicle 
is multilocular. If this were not so, the contents would be discharged 
at once. 
When the vesicles 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 off without leaving anything beyond a red pig- 
mented patch which persists for a few days. In rare cases, a few vesi- 
cles extend to the deeper layers 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 
severe itching, so that the children scratch the vesicles and produce ex- 
coriations even in their vicinity. Very tense vesicles may burst sponta- 
neously, and dry up after partial discharge of their contents. 
The vesicles are generally distributed irregularly; they are sometimes 
arranged in groups, as in herpes. Their number varies greatly (from 
ten to eight hundred or even more); they are most abundant upon the 152 
ACUTE INFECTIOUS EXANTHEMATA. 
trunk. Confluence of adjacent vesicles occurs very rarely. The patches 
and vesicles appear by fits and starts in the course 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 that 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, also 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 witli 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 Comby, 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 r&les. 
The disease almost always runs a henign course. Its average dura- 
tion is one to two weeks; occasionally it is protracted for six weeks, lie- 
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 sequelse. 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 Tkeatment.—The 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 itching diminished by baths at 28° K. 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. INFECTIOUS DISEASES INVOLVING THE MOTOR APPARATUS. 
153 
PART II. 
INFECTIOUS DISEASES IN WHICH THE MOTOR APPARATUS 
(JOINTS OR MUSCLES) IS CHIEFLY INVOLVED. 
1. Acute Articular Rheumatism. 
(Polyarthritis acuta.') 
t 
I. Etiology.—The view that this is an infectious disease, produced 
by specific bacteria, is gradually gaining ground. In our opinion, the 
term articular rheumatism should be discarded, and the disease should 
be called infectious arthritis or polyarthritis. 
In furnishing grounds for our view as 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 rheumatism; nor upon that of 
Thoresen, who claims to have observed the spread of the disease by per- 
sonal 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, 
so that I have repeatedly had more than a dozen cases in my wards at 
one time. These epidemics are more frequent in the cold, changeable 
weather of winter and spring. As is true of other infectious diseases, 
the character of the individual epidemics varies greatly, but cases occur- 
ring during the same epidemic present great similarity to one another. 
Edlefsen found that, in Kiel, acute articular rheumatism is a 
“ house disease,” like fibrinous pneumonia and typhoid fever, so that, 
for example, 728 cases occurred in 492 houses. 
This writer also found that the frequency of the disease does not 
depend upon the temperature or variability of the weather, but upon 
the amount of rain-fall, increasing with diminished rain-fall, diminish- 
ing with increased rain-fall. 
According to Thoresen, the disease does not flourish above certain 
levels. Its proper habitat is the temperate zone, especially on the sea- 
coasts. 
Another circumstance indicative of its infectious nature is its inti- 
mate relation to other infectious diseases, especially endocarditis and 
meningitis. Autopsies in cases of this disease also produce the impres- 
sion of an infectious process; hemorrhages into various organs, cloudy 
swelling of the heart, liver, and kidneys, soft large spleen, etc. 
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 
proportion of cases in which this is probable. Not that we deny the in- 
jurious effects of a cold, but, in our opinion, this is secondary, and 
merely preparatory for the bacteria. 
Some patients mention bodily or mental exertion as the cause of the 
disease. 
Heredity sometimes appears to play a certain part. Perhaps, in such 
cases, the power of resistance of the joints is diminished. 154 
INFECTIOUS DISEASES INVOLVING THE MOTOR APPARATUS. 
Males are attacked more frequently than females. It is also more 
common in those who work a good deal in the open air. 
The disease occurs most frequently between the ages of 15 and 30 
years. 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 distinguish primary and secondary articular rheumatism. The former 
occurs independently, the latter follows other infectious diseases (scarlatina, 
gonorrhoea, diphtheria, syphilis, dysentery, typhoid and relapsing fever, erysipe- 
las, puerperal fever, erythema nodosum). In our opinion, however, we have to 
deal, in secondary rheumatism, with true metastases. 
f 
II. Symptoms.—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 tongue 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 arytasnoid 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 left 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 oedema of the surrounding soft parts. The slightest movement of 
the parts is attended with the most violent pain. The patients keep the 
joints slightly flexed, and if the disease is extensive, are rendered help- 
less. The situation is especially distressing if the joints of rotation and 
flexion of the head and of the jaws are also attacked. 
Creaking is sometimes felt on passive movement of the joints. This INFECTIOUS DISEASES INVOLVING- THE MOTOR APPARATUS. 
155 
does not always originate in the joint cavity, but results occasionally 
from inflammation of adjacent sheaths of tendons. 
Drosdoff states that, in examination with moist electrodes, the electro- 
cutaneous sensibility over the affected joints is diminished or even abolished. 
Abramowski found the sensibility increased when dry electrodes were used. 
Drosdoff observed diminished pressure sensibility, and increased temperature 
and tactile sensibility over the inflamed joints. The local rise of temperature 
varies from 2 to 3° C. 
The duration of the disease varies from a few days to four, eight, or 
twelve weeks. There are frequent remissions and exacerbations, the 
latter being produced especially by too early or incautious use of the joints. 
The disease may confine itself to a certain joint in which it continues 
with great obstinacy. The longer it lasts the less marked the fever, 
cutaneous and urinary changes become. Recovery generally occurs 
gradually, rarely in a sort of crisis. The epidermis over the swollen 
joints often becomes wrinkled, and desquamates actively. 
Attention has been called to latent articular rheumatism which 
occurs as neuralgia, often periodical, usually of the trigeminus; it is as- 
sociated with endocarditis, and leaves the joints free, but rapidly dis- 
appears under the use of salicylic acid. 
Complications are remarkably frequent in this disease. 
Endocarditis often develops, sometimes even the ulcerative form. 
It is so much more apt to occur the greater the number of joints affected 
(vide Vol. I., page 69). 
Pericarditis is somewhat rarer (endocarditis in about 20#, pericarditis 
in 14# of the cases). Both diseases are not infrequently combined. 
Dilatation of the right ventricle is often observed, and systolic febrile 
murmurs are frequently audible. The heart muscle is sometimes sub- 
ject to embolism, secondary to endocarditis (embolic myocarditis). 
Some authors also assume the development of non-embolic myocarditis. 
Others speak of rheumatism of the heart, to which they attribute sud- 
den, sometimes fatal attacks of cardiac pain and heart failure. 
Cerebral complications are the result, in some cases, of the high 
fever which gives rise to disturbance of consciousness and delirium ; or, 
the fever rises so rapidly that death occurs from hyperpyrexia. The 
temperature sometimes rises above 43° C., and may even continue to 
rise for a short time after death. Meningitic symptoms may appear, 
although the autopsy may show merely congestion, hemorrhages, or oede- 
ma of the meninges. Cerebral embolism may give rise to paralysis and 
aphasia. The cerebral symptoms are sometimes the result of uraemic 
poisoning. Psychopathic conditions have often been observed as se- 
quelae. All the symptoms mentioned were formerly called cerebral rheu- 
matism. 
The complications sometimes start in the joints themselves. The 
inflammation may become purulent, and terminate in rupture, pyaemia, 
or ankylosis. Abscesses of the muscles have been observed in a few cases. 
Myalgia is more common, and may occur in the muscles adjacent to the 
inflamed joints or in remote parts. 
Roseola, urticaria, erythema, facial herpes, erysipelas, and gangrene 
of the skin have been observed. Purpura and ecchymoses have also 
been described; upon the latter are sometimes found vesicles with 
serous, sero-purulent, or sanguinolent contents. Ilautf observed herpes 
zoster at the level of the lower angle of the scapula. Papules some- 156 
INFECTIOUS DISEASES INVOLVING THE MOTOR APPARATUS. 
times form upon the skin, especially of the forehead and occiput, and 
disappear with 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 with 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 hsematuria develop at times ; 
anuria may be produced, and may lead to uraemic symptoms. Ilaematuria 
is sometimes the result of renal embolism, not of acute nephritis. Op- 
pert described hemorrhages from the intestines and uterus. 
An unfavorable termination in acute articular rheumatism is always 
the result of complications, such as rapid rise of temperature, pulmo- 
nary embolism, meningitis, pericarditis, heart failure, pyaemia, etc. 
Many complications pass directly into sequelae, 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 develops. Chorea and psy- 
choses merit special attention. Both begin not infrequently during the 
course of the disease as a complication, 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 cases 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 
psychopathic, condition. Recovery generally occurs in two weeks to four months. 
The insanity seems to result from anaemic changes dependent on complicating 
heart affections (?). 
III. An-atomical Changes.—Little is known concerning the ana- 
tomical changes of acute articular rheumatism, because the majority of 
patients recover. In one of my patients, in whom death resulted from 
hyperpyrexia, 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 addition, 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, 
fiocculent, 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, large 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). INFECTIOUS diseases involving the motor apparatus. 
157 
IV. Diagnosis.—As a rule, the diagnosis is easy. The disease is 
distinguished from gout by the fact that the latter generally runs an 
apyrexial course, and affects the great toe joint. In pyaemic joint dis- 
eases, the articular changes are secondary. 
V. Prognosis.—The prognosis is good, inasmuch as there is rarely 
(in hardly 3% of the cases) any immediate danger to life. It may be 
rendered unfavorable by the complications and sequelae. 
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. When the pains have subsided—and the swelling 
of the joints usually disappears with surprising rapidity at the same time 
—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 such cases, I have obtained good effects from local 
warm baths containing a pound 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 fixation 
of the joints by splints or bandages, but this plan meets with practical 
difficulties, if many joints are attacked. 
We have often obtained good effects from Davies’ plan of treatment. 
A fly blister (if the joint is large, two blisters) is placed upon the 
affected joint, the blister opened, the surface covered with carbolized oil, 
and then inclosed in salicylated wadding. Poisoning with cantharides 
occurs very rarely. 
We may mention the following other methods of treatment: a. Derivatives : 
leeches, cups, moxa, actual cautery, alcoholic inunctions, veratrine ointment, 
ichthyol ointment (15 : 50), nitrate of silver, faradic current, b. Antiphlogistics : 
ice-bags, ether spray, elayl chloride, c. Narcotic inunctions with chloroform, 
chloroform liniment, ointments of belladonna, opium, etc. d. Subcutaneous 
injections of morphine or carbolic acid (one to three per cent), e. Absorbents : 
tincture of iodine, iodoform ointment. /. Antirheumatics: aconite, colchicum, 
potassium iodide, g. Antipyretics: digitalis, tartar emetic, veratrine, quinine, 
benzoic acid, salicin, antipyrin, kairin, etc. h. Diaphoretics: pilocarpine, hot-air 
chamber, i. Laxatives, k. Mercurials (internally and externally). 1. Alkalies: 
potassium nitrite, sodium nitrite, potassium carbonate, sodium bicarbonate. 
m. Astringents: acetate of lead, ergotin. n. Narcotics, opium, morphine, chloral 
hydrate, ammonium bromide, potassium cyanide, o. Specifics: propylamin 
(useless in many of my cases), tincture cynarne, tincture guaiac, permanganate 
of potash. 
Iodine and iron may be employed in persistent anaemia. 158 
infectious diseases involving the motor apparatus. 
Complications must be treated according to general principles. In 
hyperpyrexia we should use protracted lukewarm baths (26° R., thirty 
minutes* duration) and large doses of antipyrin ( 3 i.-iss. by enema). 
2. Chronic Articular Rheumatism. 
(Chronic Polyarthritis.) 
I. Etiology.—In many cases, this is a sequel of the acute form. 
But the disease may also he chronic from the start, and is then generally 
attributed to colds, to repeated wetting, and living in damp rooms. As 
a rule, the patients are past the age of 40 years. Heredity is sometimes 
said to play its part in the etiology. 
II. Symptoms.—The chief symptom is pain in the joints, which 
develops spontaneously, on pressure, 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, and wrists are 
attacked most frequently; but similar changes may also appear in the 
fingers and toes. 
After the inflammation has lasted for some time, creaking of the 
joints may develop, motion becomes difficult, and even ankylosis may be 
produced. The capsule, ends of the bones, and the inserted fasciae may 
be permanently thickened. 
Fever is absent. As a general thing, there are no complications on 
the part of the heart or other organs. 
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 symptoms of acute articular rheumatism are 
produced. 
The complications and sequelae 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 Changes.—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. 
IY. Diagnosis.—The diagnosis is evident from the symptoms. 
The disease is distinguished from gout by the fact that it runs a more 
gradual course, and that the great toe is not attacked with special fre- 
quency or severity. The differential diagnosis from arthritis deformans 
is more difficult; chronic rheumatism is often preceded by acute attacks, 
and inflammatory changes prepare the way for deformities of the joints. 
Y. Prognosis.—While there is no danger to life, the disease can 
only be improved, not cured, by medical interference. 
YI. Treatment.—Trial may be made of salicylic acid or salicylate 
of soda, but the effects are uncertain, and can only be looked for if large 
doses are continued for a sufficiently long time (gr. xv. every hour until 
tinnitus aurium is produced repeatedly). Potassium iodide (gr. xv. 
t. i. d.) may be given; also tincture of aconite, colchicum, or other 
remedies employed in acute articular rheumatism. INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
159 
During the summer the patient may be recommended to take a course 
of indifferent thermal baths, sodium chloride, or sulphur baths. Bene- 
fit may also be derived from mud baths, Russian or Turkish baths, and 
cold-water cures. The poor must be satisfied with ordinary warm baths 
(30° R.), perhaps, with the addition of salt or sulphur. Trial may also 
be made of sweat cures. 
The local measures include leeches, cups, alcoholic and narcotic in- 
unctions, subcutaneous injections of morphine or carbolic acid, massage, 
and electricity. Seeligmueller recommends the faradic brush (strong 
current, the brush as the negative pole). 
3. Muscular Rheumatism. 
I. Etiology 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 disease is apyrexial, and 
elevation of temperature only occurs when many muscles are attacked. 
The usefulness of the limbs may be considerably impaired. Pain and 
difficulty in respiration, cyanosis and dyspnoea may be produced by rheu- 
matism of the chest muscles. In one of my cases the rheumatism of all 
the muscles of the back was so violent as to give rise to marked opis- 
thotonos. When the neck muscles are attacked, the head is held stiff; 
if the affection 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 days, 
the latter lasting weeks and months, and often presenting remissions and 
exacerbations. Muscular contractures or fibrous thickenings sometimes 
develop. 
Endocarditis and myocarditis have been observed in a few cases as 
complications of muscular rheumatism. 
The disease generally develops beyond the age of thirty years, and is 
attributed, as a rule, to colds, living in damp rooms, etc., sometimes to 
hereditary influences. 
II. Anatomical Changes are not discoverable. The diagnosis is 
easy, the prognosis favorable, except in old cases. The treatment is 
similar to that of chronic articular rheumatism. 
PART JII. 
INFECTIOUS DISEASES IN WHICH THE BLOOD AND HEMATO- 
POIETIC ORGANS ARE CHIEFLY INVOLVED. 
1. Relapsing Fever. 
{Recurrent Typhus.) 
I. Etiology.—The mode of infection and spread of relapsing fever 
is similar to that of typhus fever. As a rule, the disease is contracted 
by direct personal contact, more rarely through the medium of inter- 
mediate persons, still more rarely by various utensils, clothing, or bed- 
ding. In hospitals, the nurses, laundresses, and physicians are often 
attacked, and the disease sometimes spreads to adjacent beds, when the 
patients are placed in general wards. 160 
INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
The disease occurs chiefly among poor people and tramps. An epi- 
demic often spreads from a single imported 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 foetus 
in utero. It is rare beyond the age of forty-five years. 
Sex, occupation, and constitution exercise no noteworthy influence 
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 only a few days. 
The virus is undoubtedly 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 days in capillary 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 almost 
seems as if the animal body possesses the power of modifying the poison. At 
least Carter states that in monkeys suffering from the disease 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 
paroxysm, but they are not the carriers of the infectious matter. The 
latter 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 (0.1$). 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 (F). Carter believes that the spores develop into spirilli in 
the walls of the splenic veins. 
The corpse retains the infectious power for a short time. Peris 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 3G.80 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, INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
161 
more rarely typhoid fever. The individual is sometimes attacked by 
relapsing fever, and immediately afterwards by typhus, or vice versa. It 
has also been found on several occasions, that when relapsing fever and 
typhus were prevalent at the same time, the former attacked 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 
fever, or that the former developed immediately after the latter. 
II. Anatomical Changes.—Rigor mortis develops early and is very 
prolonged. The skin often , has a slightly yellowish color, and may con- 
tain petechi8e. In some cases there is intense icterus, and then the 
internal organs are also jaundiced. The body is not emaciated to any 
noteworthy extent. As a rule, the muscles are dry and have a deep-red 
color. Hemorrhagic inflammation and softening of the rectus abdominis 
are observed occasionally, as in typhoid and typhus fever. Small hemor- 
rhages are often found in the muscles and viscera. 
The microscope shows cloudy swelling and fatty degeneration of the muscular 
fibres and proliferation of the muscle nuclei. 
The heart muscle is pale, brittle, and flaccid, and in some cases 
hardly a muscular fibre can be found which is not in a 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 are 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 
perisplenitic deposits. The splenic pulp is intensely red and diffluent. 
The Malpighian corpuscles are enlarged, and visible as gray or yellowish 
nodules. Their centre is often necrotic or contains an abscess. Larger 
abscesses also occur with relative frequency, and generally develop from 
wedge-shaped or simple hemorrhagic infarctions. 
Rupture of the spleen has also been described, either as the result of 
excessive swelling or of previous suppuration (in 5.9 per cent of all cases, 
according to Petersen). The rupture is said to occur most frequently 
on the surface directed towards the stomach. 
The enlargement of the spleen depends partly on congestion, partly on hyper- 
plasia of the cellular elements. A striking phenomenon is the appearance of 
large fatty cells, which pass from the spleen into the general circulation, and are 
also found in the blood of the splenic vein and portal vein. 
The changes in the follicles start from the central arteries, in which round 
cells accumulate and undergo rapid fatty degeneration; this results in the forma- 
tion of central cavities. Granulo-fatty cells are found in the parenchyma of the 
splenic follicles, and in the adventitia and muscular coat of the arteries. The en- 
dothelium of the splenic veins also undergoes fatty degeneration and desquama- 
tion, so that spindle-shaped cells are found in the circulation during life. 
It has been suggested that the frequent infarctions may be the result of occlu- 
sion of the vessels by masses of spirilli, but this has not been substantiated by 
microscopic examination. Spirilli have been found in the necrotic splenic folli- 
cles, and in the blood of the splenic vessels. 
As a rule, 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 mu- 162 
INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
cus. The mucous membrane of the ductus choledochus is often swollen 
at its entrance into the duodenum, or is occluded by a plug of mucus. 
In the bilious typhoid variety of relapsing fever, the hepatic changes 
are similar to those of acute yellow atrophy of the liver. 
Gastrointestinal 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 hemorrhages. Ac- 
cording to Ponfick, these are found particularly in the convoluted tubes 
and Henle’s loops. The epithelium of the tubes is in a condition of 
cloudy swelling and fatty degeneration. Small hemorrhages and slight 
inflammations are also noticeable on the mucous membrane of the uri- 
nary passages. 
Meningeal hemorrhages and oedema of the brain have often been 
noted. 
Fig. 34. 
Blood in relapsing fever with spirochaete Obermeieri. Immersion. Enlarged 1150 times. 
Ponfick found changes in the medulla of the bones similar to those 
in the follicles of the spleen; they are manifested macroscopically by 
branching 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. Symptoms.—The duration of the stage of incubation is five to 
seven days. 
A prodromal stage is absent in many cases. In others, general dis- 
turbances (malaise, anorexia, etc.) are felt for a few hours or days. 
The disease generally begins with a violent chill or repeated chilly 
sensations. Very high fever 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- 
plain of pain in the back, especially the loins, and shooting pains in the 
legs. True neuralgias may also develop. The feeling of prostration is 
especially pronounced. The conjunctiva is injected, the sclera slightly 163 
yellow, the face often very pale and almost cachectic in appearance. 
Some patients experience, at the onset of the disease, a distressing feel- 
ing of oppression in the epigastrium, with or without vomiting. 
In the further course of the affection, the chief symptoms refer to 
the blood, bodily temperature, spleen, and liver. 
The blood obtained by pricking the finger often has an intense black- 
ish-red color. Under the microscope it is found to contain corkscrew- 
like, rapidly moving structures (spirocfnete Obermeieri, vide Fig. 24). 
These so-called spirilli are so constant in relapsing fever that the diag- 
nosis cannot be made if they are permanently absent. 
Heydenreich noticed that they are sometimes present a few hours before the 
attack of fever, and when the axillary temperature is below 38° C. As a rule, 
they occur only with the beginning of the fever, sometimes even several hours 
later. Towards the crisis their movements become slower, and they usually dis- 
appear before the crisis is over. In two cases, however, they were found upon 
INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
Fig. 85. 
Temperature curve in relapsing fever with one relapse. 
the second and third days after the cessation of the fever. With the next attack 
of fever they reappear in the blood. Their number varies greatly. Motschutk off- 
sky noticed that they are most abundant before the crisis of a third attack of 
fever. 
In examining a specimen of blood, we should look for any apparently sponta- 
neous movement of red or white blood-globules, which is found not infrequently 
to be conveyed by spirilli. They often dart rapidly across the field, pushing 
aside everything that comes in their way. Sometimes they are arranged in coils 
or one above another. 
The spirilli form fine threads, 16-40// (1//=0.01 mm.) in length, and with 5-18 
corkscrew-like twists. Their forward movement is attended with rotation around 
the long axis, forward and backward movements in toto, and 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 fine granules. 
They may be preserved alive for a long time outside of the body. Motschut- 
koffsky found them alive in the blood at the end of thirty-seven days. Muellen- 
dorf preserved them for eight to ten days in capillary tubes. They are very 
sensitive to reagents, and are killed by everything which alters protoplasm, for 164 
INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
example, distilled water, glycerin, sodium chloride, potassium iodide, permanga- 
nate of potash, creasote, sugar, and white of egg. They are more resistant to solu- 
tions of strychnine, bicarbonate of soda, salicylic acid, and hydrochloric acid; 0.5 
per cent solution of sodium chloride acts like the serum of the blood. In human 
milk their movements continued eight hours, in perspiration two hours, in saliva 
one to four hours, in cow’s milk one hour; urine and bile exercise a very unfavor- 
able effect. According to Heydenreich, a temperature of 43-46° produces death in 
one and three-quarters to three and a half hours. At a temperature of 0° they be- 
come rigid, but recover if the low temperature has not continued too long. Vapor 
of chloroform, carbonic acid, oxygen, jand the electrical current also produce rapid 
death. Koch found that, in cultures, the spirilli developed into long threads 
which were interlaced among one another, but always retained their twisted 
shape. 
The spirilli are found in none of the secretions and excretions of the body. 
The white blood-globules are increased in number during the febrile 
paroxysms. The blood also contains large, granular, in part fatty cells 
—so-called protoplasm cells—which disclose several nuclei on the addi- 
tion of acetic acid, and are capable of amoeboid movements. These cells 
are also found in the spleen in which they probably originate. Spindle 
shaped fatty cells (endothelium of the splenic veins) are also found. A 
few of the protoplasm cells may also contain one or more vacuoles or red 
blood-globules. Finally, we may mention the granules—so-called proto- 
plasm granules—which are supposed by some writers to be the germs of 
the spirilli. 
The initial chill is followed by rapid rise of temperature, which soon 
reaches 40, 41, or even 42° C. The fever generally runs a continued type 
for five to seven days. Then follows a critical 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 symptoms as before, and even 
a third, fourth, or fifth relapse may occur. But the later relapses are 
usually shorter and less typical. After the disease has run its course, 
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 disease. More frequently relapsing fever terminates, as it were, in 
intermittent fever. 
The crisis is sometimes preceded by critical perturbation; in such 
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. Friedreich noticed that 
the splenic enlargement appears before the onset of the first paroxysm 
of fever. After the paroxysm, the size of the organ diminishes consid- 
erably, and again enlarges in the next paroxysm. 
The liver also increases in 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 temperature. It is generally hard and full, rarely 
dicrotic at the height of 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. INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
165 
The sensorium is generally unaffected, and delirium is decidedly 
rare. Many patients complain of obstinate insomnia. There is gen- 
erally ringing in the ears and difficulty in hearing, partly from tubal 
catarrh, partly from 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 infrequently 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 complaint of dryness and burning in the nose and throat, and diffi- 
culty in deglutition. 
The skin often has a light grayish-yellow color. Roseola is often 
seen upon the abdomen and chest, occasionally herpes labialis, more 
rarely herpes nasalis or auricularis. Extensive erythema, or petechiae 
and urticaria are observed at times. Litten described bluish-red patches, 
which do not grow pale 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 usually takes place during convalescence, sometimes in larger 
shreds. 
Dry bronchitis is 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 pulsations of the carotid 
and temporal arteries in several cases. 
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- 
tity, dark-red color, very acid reaction, and high specific gravity. At 
times, 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 
tubular epithelium; the formed elements may also be present without 
albuminuria. 
So long as the bodily temperature is elevated, the amount of urea is in- 
creased; this increase is not so great in the subsequent attacks. According to 
Bock and Wyss, the amount of uric acid is diminished during the paroxysm; ac- 
cording toother writers, it is increased. During the febrile period, there is also 
increase of ammonia and sulphuric acid in the urine. The chlorides diminish to 
a mere trace, and gradually increase in amount during the intermissions. In a 
diabetic patient suffering from relapsing fever, the sugar in the urine disap- 
peared, according to Semon and Traube, during the febrile period, and the spe- 
cific gravity of the urine diminished 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 
the greater the number of febrile paroxysms. Complications and 
sequelae are not uncommon. 
In addition to delirium, nervous symptoms sometimes appear in the 
shape of epileptiform convulsions and trismus. In rare cases, conscious- 
ness is impaired to such an extent that urine and faeces are passed invol- 166 
INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
untarily or the bladder becomes distended to the level of the umbilicus. 
All these symptoms occur during the febrile period. There may be con- 
siderable rigidity of the back of the neck* which is not always due to 
meningitis, but to pain in the muscles of the nape. Violent delirium 
sometimes appears immediately after the crisis (inanition delirium). 
Temporary insanity develops occasionally during convalescence. Para- 
lyses are sometimes left over, for example, atrophic paralysis of the arm 
and ocular paralyses. Griesinger mentions diabetes mellitus as a sequel. 
The eye is often attacked by sequelas, 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 the vitreous are observed not infrequently, and may be combined 
with iritis, irido-choroiditis, and irido-cyclitis. The posterior surface 
of the cornea sometimes contains fine light dots (Descemetitis) and 
hypopion. Keratitis may also develop. Retinal hemorrhages, phlyc- 
taenular conjunctivitis, transitory amaurosis, and paresis of accommoda- 
tion have also been observed. 
Catarrhal and purulent inflammation of the middle ear has been 
described in a number of cases. 
Stomatitis, pharyngitis, and swelling of the follicles of the tongue 
have been observed. Purulent parotitis and inflammations of the sub- 
maxillary gland sometimes develop as sequelae. Croupous 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 bronchi; ulcers like those of typhoid fever have been seen 
upon the posterior wall of the larynx. (Edema of the glottis also occurs. 
Bronchitis is sometimes complicated with atelectasis, hypostasis, catar- 
rhal or fibrinous pneumonia, rarely with abscess or gangrene of the lungs. 
Huff observed haemoptysis. Pleuritis, pericarditis, and endocarditis 
occur rarely; inflammations of the serous membranes are sometimes 
hemorrhagic. 
Peritonitis is equally rare. Rupture 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, pericardium, muscles of the loins, stom- 
ach, or intestines. 
Haematuria 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 a sequel. 
Pseudo-menstrual discharges of blood from the genitals is observed at 
times. 
Abscesses or furuncles of the skin may occur as sequelae. In rare 
cases erysipelas or bed-sores develop. 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, bullous, or liche- 
noid eruptions, or inflammation and suppuration of the lymphatic glands 
may develop during convalescence. Desquamation of the skin has been 
observed in a number of cases. 
The patients are sometimes anaemic long after recovery from the dis- 
ease, and oedema 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. INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
167 
Hepatic complications include catarrhal jaundice with its well-known 
symptoms. In some cases these terminate in the symptomatology of 
bilious typhoid, which is undoubtedly a variety of relapsing fever, 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 
grave jaundice, the latter being hsematogenous in origin, and resulting 
from the severe infection. The jaundice becomes very intense, conscious- 
ness is clouded, hemorrhages occur into the skin and mucous membranes, 
and many patients die from collapse in the first attack. 
In uncomplicated, moderately severe cases, the duration of relapsing 
fever varies from four to five weeks. Death may occur in the first attack 
of fever from excessive rise of temperature, paralysis of the heart, col- 
lapse, or cholsemia; it may also be produced by the sequelse. 
IV. Diagnosis.—The diagnosis is rendered certain by the discovery 
of spirilli and by the characteristic temperature curve. 
V. Prognosis.—In uncomplicated cases the prognosis is good, and 
the mortality often does not exceed two per cent. It is rendered grave 
by complications, and is very serious in bilious typhoid, in which the 
mortality may reach sixty per cent. 
VI. Treatment.—The prophylactic measures are the same as those 
employed in typhus fever. This is also true of treatment (vide page 124). 
In bilious typhoid, Griesinger 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 the spirilli from the blood 
and shortens the fever, but other writers have used this remedy without 
benefit. Oks claims that no relapses occur in 60$ of the cases, if calomel 
is administered. 
2. Malaria. 
I. Etiology.—Malarial diseases are also known as marsh fever, aaid 
are especially frequent in marshy regions. 
Endemic malaria is often found near the banks of large streams and 
the 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- 
gerous in which the waters of rivers and seas mingle, and the waters 
become brackish. 
Foci of malaria are sometimes formed in an accidental manner, 
for example, 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 when previously 
cultivated districts are allowed to fall into disuse, or if barren districts 
again are subjected to cultivation. Malaria has also been known to de- 
velop in vessels as the result of stagnation of bilge water. 
The conditions necessary to the development of malaria always ob- 
tain where decomposition of vegetable matter is associated with a certain 
degree of moisture in the soil. The richer the superficial strata of the 
soil 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 is sometimes found at high levels. 
Malarial poisoning is a prototype of miasmatic infection. Whoever 
enters the malarial region is in danger of infection; as a general thing, 168 
INFFCTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
infection does not result from personal contact with diseased individuals. 
Whether infection occurs through the medium of drinking-water is still 
an unsettled question. The poison seems to be propagated with greater 
facility near the surface of the ground. 
According to some accounts, the disease may be produced by personal contact. 
Sawyer states that he visited a district which was entirely free from malaria, 
was there attacked by malaria which he had contracted in his own home, and 
at the end of nine days infected his nurse who lived in the non-malarial region. 
Buchner claims that the perspiration of the patients may convey the disease to 
those sleeping in the same bed. 
Malaria occurs endemically, epidemically, pandemically, or sporadi- 
cally. In regions in which the disease is endemic, the cases increase in 
such numbers at times as to constitute an epidemic. The majority of 
epidemics begin in the spring and autumn. The temperature is also 
important. The higher it rises, and the more the swamps are dried up, 
i. e., the more the decomposition in them increases, 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 the bog, while the laborers in the bog 
itself were not attacked. It has also been found that a wall 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 
sometimes recover spontaneously after a stay in a non-malarial region. 
The first signs sometimes appear after removing to a healthy region. 
Sleeping on the 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 and 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 the present time, the malarial poison is supposed to consist of bacteria. 
Klebs and Tommasi-Crudeli have described rod-shaped structures—bacillus ma- 
lariaa—which thev cultivated and successfully inoculated in rabbits. Gerhardt 
recently succeeded in producing intermittent fever in healthy individuals by sub- INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
169 
cutaneous injections of blood which he had taken during the febrile paroxysm 
from patients suffering from intermittent fever. Dochmann had obtained posi- 
tive results by inoculation with the contents [of herpes vesicles obtained from 
patients suffering from intermittent fever. 
II. Symptoms.—There are several forms of malarial disease which are 
known as intermittent fever: latent intermittent, pernicious inter- 
mittent, remittent and continued fever, and malarial cachexia (pri- 
mary and secondary). 
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 larynx, a feeling of dryness 
and constriction; and, soon after, by other manifest symptoms of malaria. 
On the other hand, 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, malaise, chilliness, somnolence or disturbed sleep, gastrointes- 
tinal disturbances (anorexia, foul taste in the mouth, fgetor ex ore, eruc- 
tations, womiting, diarrhoea, etc.). 
The form of malaria depends partly on the locality. In our 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 regions. 
Intermittent fever is the most frequent form of malaria in our climate. 
It consists of febrile paroxysms, occurring at certain definite periods, 
with apyrexial intervals. 9 
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 octava), and the interval is sometimes said to 
last thirty days (?). 
The successive attacks of fever sometimes recur at a little earlier period, so that 
a tertian may be converted gradually into a quotidian, etc. The opposite condi- 
tion is also observed at times. A second attack sometimes occurs before the first 
has entirely run its course. 
Double intermittent fever is a special variety. In double quotidian, two at- 
tacks occur daily at certain definite times. In double tertian, an attack occurs 
daily, but the attacks vary in severity, those occurring on alternate days being 
alike. In double quartan, an attack occurs on two successive days, then follows a 
day without fever, then two febrile days, etc. 
The temperature curves generally suffice to permit a positive diagnosis 
(vide Figs. 26-28). 
The different 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 stages, viz., the cold, 
hot, and sweating stage. 
In some cases, the stages appear in an inverse order; in others, intervals of 
hours elapse between the different stages. In erratic intermittent fever, the 
aroxysms follow no definite order with regard to time. 170 
INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
As a rule, the cold stage begins gradually. The patients feel weak, 
grow pale, yawn frequently, and stretch themselves. A slight chilly 
sensation is soon felt along the back, and extends into the limbs. This 
sensation is gradually intensified into a well-marked chill. The teeth 
chatter, and the patients sometimes shake with such violence as to move 
Fig. 26. 
Temperature curve in a case of quotidian intermittent. 
the bed. The skin 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 blackish-red color (con- 
Fig. 27. 
Fig. 28. 
Temperature curve in tertian intermittent 
Temperature curve in quartan intermittent. 
traction of the cutaneous vessels, and slowing of the circulation). The 
skin loses its turgor, the eyes are surrounded by blue rings, the pupils are 
large, and their reaction slow. Many complain of dizziness and a feeling 
of syncope, flashes of light before the eyes, and ringing in the ears. The 
tongue is often coated. Eructations or obstinate vomiting are occasion- 171 
ally observed. The pulse and respirations are accelerated. The patients 
often, though not always, discharge a large amount of pale, watery urine. 
The spleen increases in 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 very rarely much 
longer (six hours or more). 
The hot stage begins with a gradually 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 the same as at the end of the cold stage, 
more rarely, it rises a little. The skin becomes turgid, feels dry and 
burning. 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 ears, 
pain and throbbing in the head continue. The temporal arteries are 
usually very sinuous and pulsate vigorously. The right ventricle is not 
infrequently dilated, and the first (systolic) sound of the heart often has 
a blowing quality. A systolic murmur may be heard over the carotids, 
and a systolic arterial sound over the large peripheral arteries. The 
physical signs of bronchitis are sometimes present. The spleen in- 
creases in size, and continued or systolic vascular murmurs are heard 
occasionally over the organ. There may also be pain and tenderness over 
the spleen. The stomach and liver remain sensitive, and the latter is 
occasionally enlarged. The urine is scanty and saturated (febrile urine). 
The amount of urea increases considerably 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. But A. 
Fraenkel has shown that a smaller amount is sometimes excreted in the 
febrile paroxysm than in the apyrexial 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 appeared. 
Uric acid is very little, if at all, increased ; the phosphoric acid is increased. 
While the chlorides diminish in febrile conditions, they increase in intermittent 
fever, pari passu with the urea. 
In one of Riegel’s patients, in whom the pulse was not accelerated during the 
febrile paroxysm, the radial pulse was very dicrotic at this period. Ziehl ob- 
served bacilli in the blood, about 4 in width, and varying in length from 
that of a red blood-globule to one-quarter of its length. Behlen also observed 
cocci in the blood, partly free, partly in the red globules. 
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 in the axillas) becomes moist, and very 
large, sour-smelling drops of sweat appear on the forehead and face, and 
finally on the entire body. Tbe temperature falls, and may even be 
subnormal at the end of this stage. The pulse becomes full, soft, and 
slow. The spleen diminishes in size. The urine often, though not 
constantly, deposits a brick-red sediment of urates. Many patients fall 
INFECTIOUS DISEASES INVOLVING TIIE BLOOD, ETC. Temperature curve in quotidian intermittent fever. Measurements every fifteen minutes. Duration of disease, four weeka 
Fig. 29. INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
173 
into a profound, refreshing sleep from which they awaken with a feeling 
of relief. As a general thing, the patients recover very rapidly, espe- 
cially during the first period of the disease. 
As a rule, the sweating stage lasts two to four hours. The attacks 
generally begin between midnight and noon, although there are note- 
worthy exceptions to this rule. Da Costa Alvarenga reports the case of 
a woman who was unusually pale, without any apparent cause. Exami- 
nations with the thermometer showed that paroxysms of intermittent 
fever began towards midnight. 
Careful examination shows that the rise of temperature during an 
attack is more rapid than the fall, and the course of both parts of the 
temperature 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 hundred and fifty pounds; a week 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 
very protracted. If the patient passes from a malarial to a healthy 
region, the disease sometimes recovers spontaneously in one or two 
weeks. Relapses 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. Castro-enteric disturbances are also prominent in children. 
Curtmann mentions as a constant symptom, a leaden gray coating on the 
tongue from its tip to the circumvallate papillae. Rupture of the spleen 
was 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, haematuria, and haematinuria have been noticed in a few 
cases. Herpes often develops on the lips or other parts of the face; 
urticaria-like or erythematous eruptions are also frequent. 
Among the sequelae, malarial anaemia occupies a prominent part. 
Many patients grow pale very rapidly, and the lips and mucous mem- 
branes assume a waxy, pale color. Kelscli 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 haemoglobin 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. Melanaemia is one of the sequelae (vide 
page 11), and leukaemia may also be associated with intermittent fever. 
Endocarditis, 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 albuminuria. Glycosuria has also 
been observed, and terminates occasionally in diabetes mellitus. Paro- 
titis, noma, multiple hemorrhages, chronic dyspepsia, and psychopathies 
must also be mentioned among the sequelae. 
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 174 
INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
elevation of the temperature of the skin. The spleen is often, though 
not always, enlarged. 
The disease occurs most frequently as intermittent neuralgia, espe- 
cially of the supraorbital nerve. It also occurs as intercostal, sciatic, 
and occipital neuralgia, clavus, ciliary neuralgia, mastodyuia, and 
neuralgia of the testicle. The pain occasionally passes from one nerve 
to another. 
Intermittent paralyses, spasms, hyperaesthesia, anaesthesia, hysteria, 
psychopathy, delirium, aphasia, agrypnia, and contractures have also 
been described. 
Hydrops articulorum intermittens and intermittent arthralgia (espe- 
cially coxalgia) are occasionally observed. 
The skin may present local or general intermittent oedema or inter- 
mittent eruptions (erythema, erysipelas, urticaria, pemphigus, hemor- 
rhages, even gangrenous changes). 
Among other symptoms may be mentioned intermittent deafness, 
blindness, paralysis of the vocal cords, or periodical attacks of sneezing, 
coughing, asthma, vomiting, eructations, gastric pain, meteorism, hem- 
orrhages from various organs, painful swelling of the breast and testi- 
cles, dysuria, constipation, and diarrhoea. 
In some cases these symptoms are preceded or followed by manifest 
evidences of malaria. 
In pernicious intermittent fever, otherwise mild symptoms of malaria 
are intensified to a dangerous degree, or certain unusual organic diseases 
develop. 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 start, but 
pernicious symptoms appear in the subsequent attacks. 
The following is a brief resume of the more frequent varieties: 
Algid pernicous intermittent. After a violent chill, the hot stage re- 
mains absent, the patients gradually grow colder, the pulse becomes 
small, and finally death occurs in collapse. 
Sweating pernicious intermittent. In the sweating stage, the dia- 
phoresis becomes so excessive that the patients become comatose, 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. 
Comatose pernicious intermittent. The patients grow more and more 
comatose, especially during the hot stage; sometimes remain in a state of 
coma for one or two days, and may die in this condition. 
Apoplectic pernicious intermittent. Apoplectic attacks occur, fol- 
lowed by transitory or permanent paralysis. 
Epileptic, tetanic, hydrophobic, delirious, and eclamptic pernicious in- 
termittent are sufficiently characterized by their names. A trance condi- 
tion occasionally develops, and Trousseau states that a patient in this 
condition had been brought into the dissecting room where signs of 
life were noticed. 
In bronchitic pernicious intermittent, there is violent bronchitis, as- 
sociated occasionally with dyspnoea and asthma. 
Pneumonic pernicious intermittent gives rise to the intermittent de- 
velopment of pneumonia during the febrile paroxysms; pleuritic and per* 
icarditic pernicious intermittent has also been described. infectious diseases involving the blood, etc. 
175 
Cardiac pernicious intermittent produces dangerous attacks of pal- 
pitation and heart failure, often associated with violent pains in the re- 
gion of the heart. 
Finally, we may mention cardialgic pernicious intermittent (severe in- 
termittent gastric pains), choleraic intermittent (diarrhoea, rice-water 
stools, and collapse), dysenteric intermittent (bloody stools and tenesmus), 
icteric and peritonitic pernicious intermittent, hemorrhagic intermittent 
(hemorrhages from the nose, lungs, stomach, intestines, kidneys, gen- 
ital organs), amaurotic, erysipelatous, and lymphangitic 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. Gastric symptoms 
are prominent, likewise enlargement of the spleen, and often of the liver. 
Icteric symptoms, bloody stools, and heematemesis are sometimes so prom- 
inent as to rouse the suspicion of yellow fever. In other cases dysen- 
teric symptoms develop, or the patients lie in a typhoid state, and not in- 
frequently die in collapse. 
Fievrebilieuse-hematurique i3 the term applied to cases in which severe jaun- 
dice and hsematuria occur. Remittent or continued fever may last from several 
days to a few weeks. 
Malarial cachexia develops 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, 
suffer from palpitation of the heart, shortness of breath; the heart is 
dilated, and systolic murmurs are heard over the heart and cervical 
veins. Coated tongue, anorexia, vomiting, and eructations are often no- 
ticed; the spleen and liver are often enlarged. 
Diarrhoea is frequent, and may even be dysenteriform. Tremor, 
chorea, paralysis, spasms, contractures or grave psychopathic conditions 
are occasionally produced. Borelli described atrophy of the male sexual 
organs and gradual approximation to the feminine type. 
The sequelae are similar to those of simple intermittent fever. 
III. Anatomical Changes.—The splenic enlargement is the result 
at first, of excessive hyperaemia. Hemorrhagic infarctions are sometimes 
observed, more rarely abscesses and perisplenitis. At a later period the 
spleen becomes hard, and hyperplastic changes develop. 
The liver may also present diffuse and miliary hyperplastic changes, 
in addition to melanaemic processes. 
At the present time, most writers are inclined to believe that, while the spleen 
perhaps acts as a sort of reservoir for the malarial poison, the latter chiefly at- 
tacks the nervous system, especially the heat-regulating centres. The periodical 
recurrence of the attacks and the genesis of latent forms of the disease are unex- 
plained. 
IY. Diagnosis.—The chief diagnostic features are the periodical oc- 
currence of the symptoms, the opportunity for malarial infection, and 
the usually prompt effects of quinine. 
Simple intermittent fever may be mistaken at times for pyaemia, ul- 
cerative endocarditis, and pulmonary phthisis. In doubtful cases we 176 
INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
must search for wounds, or changes in the lungs and heart (vide Vol. L, 
page 75). 
Remittent and continued fever may be mistaken for grave jaundice, 
yellow fever, and dysentery. 
Y. Prognosis.—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 is the prognosis. Perni- 
cious, remittent, and continued fevers are especially dangerous when 
their nature is unrecognized. 
VI. Treatment.—The prophylactic measures are partly general, 
partly individual in character. Marshy regions should be 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 should 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 closed at night. 
The prophylactic 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 light. Pieces of ice or carbonated 
waters may be given in cases of vomiting. 
Quinine is the best remedy in all forms of malaria; gr. xv. to xxx. of 
the hydrochlorate may be given for two or three days about three hours 
before the expected attack. One-half or one-quarter the amount may 
then be continued until the enlargement of the spleen has subsided, and 
the danger of a relapse has passed. If the quinine is vomited, it may be 
given subcutaneously (quinia hydrochlorate, glycerin, puri, aq. destil., 
aa. M. D. S., warmed, two syringefuls) or as an enema with some starch 
and lukewarm water. 
Fowler’s solution (five to eight drops t. i. d. after meals) is useful in 
some cases. 
After the febrile paroxysms have subsided, the existing anaemia may 
be treated with iron and arsenic (tinct. ferri chlorid., 3 v.; liq. potass, 
arsenit., 3 iss.; gtt. xxv. t. i. d. after meals). 
A large number of other remedies have been employed, but all are much less 
reliable than quinine, a. Cinchonia, chinidine, chinoidine, cinchonidine: b. Tinct. 
eucalypt. globuli; c. Carbolic acid, salicylic acid, resorcin; d. Salicin, berberine, 
lupinin, apiol, picric acid, strychnine, santonine, buxine sulphate; e. Potassium 
bromide, potassium iodide, sodium chloride, nitrate and acetate of potash; /. Liq. 
ferri sesquichlorid., mercurials; g Chloroform; h. Gelsemium sempervirens; i. 
Pilocarpine; j. Faradization of the spleen and galvanization of the sympathetic. 
Hearty eating is considered an effective remedy in certain malarial regions. 
3. The Plague. 
I. Etiology.—Epidemics of plague appeared long before the Christian era. 
In the great epidemics of the Middle Ages, sometimes more than a fourth of the 
inhabitants fell victims to the disease. Europe has escaped its ravages since the 
middle of the fourteenth century, but in 1878-79 there was renewed danger of its 
introduction from the shores of the Volga. INFECTIOUS DISEASES INVOLVING THE BLOOD, ETC. 
177 
The disease has also become less prevalent in the Orient. India and Anterior 
Asia are supposed to be its habitat. 
If the plague breaks out in places in which it is not epidemic, it is always in- 
troduced from without, so that strict quarantine is the best means of prevention. 
The disease acquires a so much firmer hold the poorer the surroundings and hygi- 
enic conditions of the inhabitants. A single attack does not prevent subsequent 
infection, 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 held that the plague 
may develop autochthonously, but this is not probable. The majority of writers 
do not believe that simple contact with a patient will produce infection, but there, 
is no doubt that it is conveyed chiefly 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 bodies were found in the blood, perhaps also in 
the pus of the buboes. 
II. Symptoms.—The plague is an acute infectious disease, in which the exter- 
nal and internal lymphatic glands undergo inflammation, with a tendency to 
suppuration. 
The stage of incubation lasts two to seven days, but longer and shorter periods 
have also been mentioned. 
Hirsch describes three forms of the disease. 
In the mildest form, the patients sometimes feel well enough to walk about. 
Prodromata are absent. The disease often begins with a chill. Then headache, 
vomiting, and constipation set in. At the same time the glands (inguinal, crural, 
axillary, submaxillary, cervical) become painful and swollen. In three to six 
days, some of the glands discharge pus, profuse diaphoresis occurs, and then 
convalescence. The scars of the buboes are always superficial. 
In the moderately severe cases, all the symptoms are more marked. The con- 
junctiva is injected, and subconjunctival' hemorrhages are occasionally found. 
Delirium and unconsciousness frequently occur, and the temperature of the body 
is increased. Carbuncles and petechiae appear on the skin. Tongue thickly 
coated. Then acute buboes ; the escape of pus is often looked upon as a favora- 
ble sign. Death in four to six days, or recovery in one to three weeks. 
In the gravest form, the patients complain of violent terror, but sometimes 
retain consciousness until death. The disease may run such a rapid course as to 
prove fatal before the glands enlarge. There is obstinate 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, 
stomach, intestines, kidneys, and lungs. Rapid death from collapse. 
Convalescence is sometimes protracted for a long time ; relapses are not un- 
common. Furuncles of the skin and muscles, parotitis, pneumonia, paralyses, in- 
sanity, otitis, and dropsy have been mentioned as sequelae. 
III. Anatomical Changes.—The lesions in the lymphatic glands (external 
and internal) consist of congestion, inflammatory oedema, and hyperplasia of the 
parenchyma and periglandular connective tissue; hemorrhages into the glands 
may also occur. Later, circumscribed necrosis and suppuration of the glands. 
The spleen is always enlarged, the liver and kidneys swollen and in a condition 
of cloudy swelling. There are numerous hemorrhages in the viscera. 
IV. Diagnosis, Prognosis, Treatment.—The diagnosis is not always easy. 
The disease may be mistaken for typhoid fever, malaria, splenic fever, and 
syphilis. The prognosis is grave, and the mortality may exceed 90 per cent. 
The spread of the disease can only be prevented by the strictest quarantine. 
The disease itself is treated symptomatically, 178 
INFECTIOUS DISEASES INVOLVING THE KESFIKATOEY OEGANS. 
PART IV. 
INFECTIOUS DISEASES IN WHICH THE RESPIRATORY ORGANS 
ARE CHIEFLY INVOLVED. 
1. Whooping-Cough, Tussis Convulsiva. 
(Pertussis.) 
I. Etiology.—Whooping-cough is an infectious and contagious dis- 
ease. It generally appears in epidemics, and in most cases it can be 
shown 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 vims 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 year. In some 
large cities, they are said to recur at different intervals. The epidemics 
are sometimes so mild that hardly any fatal cases occur; in others, 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-cough 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 wrorse 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 maintain 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 modern doctrines. 
The nature of the virus is unknown. Successful attempts at inoculation in 
animals have been reported by some, but denied by other writers. INFECTIOUS DISEASES INVOLVING THE EESPIEATOEY OEGANS. 
179 
The susceptibility to the disease depends very materially upon the age 
of the individual. It is a disease of childhood, and occurs rarely in 
adults, though even old people have been attacked in rare cases. It is 
most frequent from the age of seven months to seven years, and is rare 
in infants before the age of six months. A few cases have been reported 
in which mothers suffering from whooping-cough bore children who pre- 
sented the symptoms of the disease at birth. 
It has also been held that whooping-cough in the mother during pregnancy' 
confers immunity upon the foetus after birth, because it has been infected in 
utero. 
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 affections 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 
favor the deposit of the virus of pertussis. 
The children of the poorer classes are attacked more frequently than 
those of the well-to-do (overcrowded dwellings, imperfect isolation of the 
patients, insufficient care, and frequency of catarrhs of the air passages). 
Some individuals enjoy permanent immunity, others only temporary 
immunity. A single attack confers 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 symptoms are produced. The duration of this period may 
vary according to the power of resistance of the patient and the virulence 
of the poison. 
The clinical history maybe divided into the catarrhal, convulsive, and 
decreasing stages. The duration of the disease varies from four or six 
weeks to as many months or more. On the average, the catarrhal stage 
lasts two to four weeks, the convulsive stage four to six weeks, and the 
decreasing stage four to six weeks. 
The catarrhal stage not infrequently begins with mild general symp- 
toms. The children lose appetite, grow pale, sleep is disturbed, and 
there is slight fever. The conjunctive 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 mucus. At times, slight burning in the throat and 
difficulty in deglutition indicate mild pharyngitis. Cough and slight 
hoarseness appear, associated with a 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 becomes 
spasmodic, and the disease thus passes into the convulsive stage. 
The catarrhal stage is sometimes absent, especially in nurslings. 
The convulsive stage manifests itself in characteristic paroxysms of 180 
INFECTIOUS DISEASES INVOLVING THE RESPIRATORY ORGANS. 
coughing. They begin with a deep, whistling inspiration, followed by 
uninterrupted, short, expiratory coughs. Sometimes twenty to thirty 
expiratory coughs follow one another before another long-drawn, whis- 
tling inspiration takes place, to be again followed by expiratory coughing. 
A single paroxysm lasts from one-fourth to one minute, and a series of 
them may continue from ten to fifteen minutes. At the end of the pa- 
roxysm, tough, glassy mucus fills the mouth and pharynx, and is expec- 
torated by a combination of coughing, strangling, and vomiting move- 
ments. In infants, this must often be removed from the mouth with 
the aid of the fingers. 
The paroxysms are often provoked by fright, joy, laughter, crying, 
etc. In very many patients an attack may always be produced by de- 
pressing the tongue with a spatula, until gagging movements ensue. 
Mimicry also plays an important part. If a paroxysm appears in one of 
a number of children, the rest very often are also attacked in a short 
time. In other cases, the paroxysm is preceded by the rattling of mu- 
cus in the trachea or larynx, and the irritation of the laryngo-tracheal 
mucus membrane evidently provokes the attack. 
Intelligent patients complain not infrequently, before the paroxysm 
begins, of intolerable tickling in the larynx, trachea, or beneath the 
sternum. The desire to cough can rarely be repressed by an effort of 
the will. The children grow more and more terrified, hold fast to a firm 
object, or to the nurse, and ask that their head be held between the 
hands. 
During the attack, the face presents evidences of increasing venous 
stasis. It becomes more and more cyanotic, the eyeballs protrude, 
the lips and cheeks become swollen, the jugulars appear as blue cords 
as thick as the finger, the face and limbs are bathed in perspiration, the 
pulse is felt with difficulty, partly on account of the violent concussion 
of the body, partly because the heart’s action intermits, and the pulse 
becomes smaller. There is sometimes involuntary evacuation of urine, 
flatus, and faeces. 
During the expiratory coughing, the thorax is dull on percussion, on 
account of the unusual compression of the thorax. During the whis- 
tling inspiration, the percussion sound becomes very loud. The respira- 
tory murmur is not audible during the long-drawn inspiration because 
the rima glottidis is spasmodically narrowed, so that the air enters the 
lower air passages very slowly. Feeble respiratory murmur is heard 
during the expiratory cough. 
According to Gueneau de Mussy, there is dulness over the manubrium sterni 
on account of swelling of the tracheo-bronchial glands (?). 
The patients suffer intolerable fear of suffocation during the attacks. 
But they often recover with surprising rapidity, and return to their oc- 
cupation as if nothing had happened. Others suffer from exhaustion, 
dulness in the head, and slight vertigo for some time. There is frequent 
complaint of pain in the abdominal walls on account of strain in cough- 
ing. 
In moderately severe cases, twenty to twenty-five attacks occur daily; 
in severe cases, as many as one hundred may occur in a day. They are 
always more frequent at night, because mucus is then more apt to accu- 
mulate in the air passages. According to Hanke, the attacks are more INFECTIOUS DISEASES INVOLVING THE RESPIRATORY ORGANS. 
181 
frequent if the air is polluted with carbonic acid and ammonia, while 
exercise in the open air acts favorably. 
The convulsive stage gradually passes into the decreasing stage. The 
paroxysms of coughing become less frequent, and lose their spasmodic 
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 
convulsive seizures again make their appearance. 
The laryngoscopic changes readily 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 
spells rather than to the specific influence of the pertussis virus. 
As a rule, 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 cavity, as far as the true vocal cords, is 
sometimes not at all, always very little affected. The region between 
and beneath the arytsenoid cartilages, and the anterior wall of the larynx 
and trachea below the true vocal cords, are inflamed with special in- 
tensity. 
Croup and spasm of the glottis, which may prove fatal, are very rare compli- 
cations on the part of the larynx. 
Bronchitis is a frequent complication, and is present in the majority 
of cases. The situation becomes serious when this is complicated with 
pneumonia, as shown by accelerated, short, groaning respirations, and 
great 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, and subcutaneous cellular tissue of 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. 
Struma, pleurisy, pericarditis, and endocarditis are rare complications. 
There is often obstinate vomiting. The patients vomit after each 
spell of 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 the anterior edge of the frsenum linguae, 
more rarely on the inferior surface of the tongue. These are the result 
of mechanical injury by the teeth during the coughing fits. 
The excessive strain of the abdominal muscles may result in hernia 
and prolapsus ani. 
It is said that sugar is sometimes found in the urine. Steffen observed albu- 
minuria during and immediately after violent coughing spells. 
Characteristic cutaneous changes are often produced. On account 
of the pronounced venous stasis during the coughing fits, subcutaneous 
hemorrhages develop and occasionally attain considerable size. 182 
INFECTIOUS DISEASES INVOLVING THE EESFIEATOEY OEGANS. 
Cutaneous oedema has been observed, 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 right heart, i. e., of stasis, and attributes 
to it a very unfavorable prognostic significance. 
Hemorrhages of the mucous membranes are also observed frequently. 
Subconjunctival hemorrhages are very common; hemorrhages may also 
occur from the nose, air passages, and gastro-intestinal tract. Hemor- 
rhages from the external auditory canal are sometimes observed as the 
result of rupture of the drum membrane. 
Otitis media is present in rare cases; if bilateral, it may produce deaf-mutism 
in children under four years of age. In one case, Landesberg noticed optic neuri- 
tis and bloody infiltration of the lids; in another, exophthalmus of one eye from 
retrobulbar hemorrhage; in a third, hemorrhages into the retina and optic nerve, 
and in a fourth, dislocation of the lens. 
In a few cases, there is marked change in the mental condition, 
amounting even to insanity. In rare instances, hemorrhages occur within 
the skull from venous stasis. Barrier reports a fatal case of subdural 
hemorrhage. Convulsions sometimes occur during a coughing spell 
from excessive venous stasis within the skull. 
In some cases, grave sequelae follow, and prove fatal at an early age. 
General marasmus is occasionally observed, and the children succumb 
after a longer or shorter period. They grow pale, emaciate, and finally 
die of exhaustion. Signs of scrofula sometimes develop. Chronic dis- 
eases of the respiratory tract (chronic hoarseness, bronchitis, or tuber- 
cular processes in the lungs) are not infrequently left over. Tuberculous, 
cheesy, bronchial glands may give rise to miliary tuberculosis, especially 
to tubercular meningitis. Pulmonary emphysema is sometimes produced 
by the acute distention of the lungs observed during the paroxysms, but 
as a general thing it soon disappears. Epilepsy and chorea are rare 
sequelae. Certain complications (hernia, prolapsus ani, valvular lesions 
of the heart, auditory or visual disturbances) persist as sequelae. 
III. Anatomical Changes.—Specific anatomical changes in per- 
tussis are unknown. 
The mucous membrane of the air passages is generally swollen and 
congested, and covered with abundant secretion. These changes may 
rapidly disappear in the dead body. 
The tracheo-bronchial glands are often enlarged and congested. The 
congestion may also extend to the pneumogastric, which is embedded in 
the glands. 
Pulmonary lesions are frequent 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 
patches which are the result partly of atelectasis, partly of catarrhal 
pneumonia. Fibrinous pneumonia and fibrinous inflammation of the air 
passages are observed in rare cases. 
The liver, spleen, and kidneys are congested and often slightly swollen. 
Similar changes are found in the mesenteric glands, the solitary glands 
and Peyer’s patches of the intestines, and the follicles of the stomach. 
Ulcerations of the follicles of the intestines have also been mentioned. 
Meningeal and parenchymatous hemorrhages may be present in the 
brain. 
In our opinion, whooping-cough is the result of a general infection, i. e., one 183 
starting from the blood. This gives rise to increased irritability of the vaso mo' 
tor and cough centres in the medulla oblongata. The former causes increased 
secretion of the mucous membrane of the air passages, the latter increased excit- 
ability of the nerves of coughing, especially the superior laryngeal. 
The theory that the disease is an ordinary central or peripheral neurosis is con- 
tradicted by its infectious character. This also disproves the opinion that it is 
an ordinary bronchitis with unusual irritability of the mucous membranes. 
IV. Diagnosis.—During the convulsive stage the diagnosis is easy; 
and the laity properly lay great stress on the prolonged whistling in- 
spirations. Obstinate coughing spells, attended with frequent vomiting 
and subconjunctival 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 fraenum linguae. 
In doubtful cases, it should be remembered that deglutition or depression 
of the tongue not infrequently produces an attack of coughing. 
In the first and third stages of the disease, it is often difficult to make 
a differential diagnosis from ordinary bronchitis. The opportunity for 
infection is an important factor in diagnosis. 
V. Prognosis.—This is usually good; the average mortality is about 
three per cent. The younger the patient the greater is the danger. 
The disease is also serious in anasmic, rachitic, and scrofulous children. 
As 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 insuf- 
ficient nursing, overcrowding, and poor ventilation of the rooms. Spora- 
dic cases are more favorable than epidemic ones. Grave complications 
on the part of the respiratory organs are more frequent in cold weather. 
The prognosis also depends on the daily number of coughing spells. Ac- 
cording to Trousseau, the prognosis is serious if thirty to fifty attacks 
occur daily, and unfavorable if they exceed sixty. In pregnant women 
there is a possibility of premature delivery from the violence of the cough- 
ing movements, but the frequency of this event is often greatly overes- 
timated. 
VI. Treatment.—The spread of the disease can be prevented only 
by the strictest prophylaxis. The patients must be isolated, and the 
healthy children in the family are safe only when sent to another house. 
Half-way measures are useless. Isolation should be continued until the 
cough and catarrh have disappeared. 
The children should have their own table service, their bedding and 
clothing should be cleaned separately, and they should be allowed to ex- 
pectorate only in vessels containing carbolic acid (5$) or corrosive sub- 
limate (1 :1000). The physician should visit these patients last, in order 
that he may not convey the disease to other families. 
Specific remedies against whooping-cough are unknown. The pa- 
tient's room should be large and sunny, and well ventilated. Every two 
hours the air should be sprayed with a three-per-cent solution of car- 
bolic acid. In winter, a vessel containing water and a half teaspoonful 
creasote should be placed on the stove. The air is kept at a uniform 
temperature of 15° E. If the weather is not windy, daily exercise should 
be taken in the open air. The diet consists of milk, eggs, soup, boiled 
meat, stewed fruit, and wine. Older children should be directed to 
repress the desire to cough as much as possible. In obstinate cases, re- 
moval to another locality sometimes produces favorable results with sur- 
prising rapidity, but the danger of producing infection in the new sur- 
roundings must be kept in mind. 
INFECTIOUS DISEASES INVOLVING THE RESPIRATORY ORGANS. 184 
INFECTIOUS DISEASES INVOLVING THE RESMRATORY ORGANS. 
Specially prominent symptoms must be treated according to general 
principles. If the number of coughing spells is very great, or their du- 
ration protracted, we may order narcotics, such as Aq. amygdal. 
araar., 3 iij. ; morphin. hydrochloric., gr. ss. M. D. S. 5 to 10 drops 
every three hours. 
If there are numerous sonorous and sibilant rales, we may give 
expectorants, such as 1$ Sol. Apornorphin. hydrochlorat. gr. iss. : 3 iiiss.; 
acid, hydrochloric., gtt. v.; syr. simp., 3 v. M. D. S. 3 i. —ij. every two 
hours; if there are numerous moist riiles, we may order ipecac. 
A combination of different, dry and moist rales may be treated with 
ipecac and iodide of potassium, etc. 
We may mention the following other remedies which have been employed 
in this disease, a. Nervines: valerian, musk, asafoetida, camphor, nitrate of sil- 
ver, bismuth, arsenic, zinc and copper preparations, etc. b. Narcotics: chloral hy- 
drate, chloroform, ether, croton chloral, veratrine, hyoscyamus, nux vomica, 
conium, ergotin, pulsatilla, cocaine, etc. c. Expectorants of all kinds, d. Anti- 
parasitics: carbolic acid, salicylic acid, creasote, benzin, petroleum, quinine, 
breathing the air of gas houses, e. Balsamics: turpentine, ol. petrae italicum. 
f. Emetics, in repeated doses, g. Tonics: iron and quinine, h. Astringents: 
tannic acid, acetate of lead. i. Purgatives, k. Absorbents : potassium iodide 
and tincture iodine, applied to the manubrium (to disperse enlarged glands). 1. 
Constant current to medulla and pneumogastric. m. Inspiration of compressed 
air. o. Derivatives to the chest, p. Specifics : cantharides tincture, propyla- 
min, pilocarpine, powdered vaccine pustules internally, etc. 
2. Influenza. 
I. Etiology.—Influenza almost always occurs epidemically or pan- 
demically, more rarely sporadically. The disease has 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 less, 
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 which 
individuals travelling to localities in which influenza was epidemic es- 
caped the disease. 
Whether the disease is conveyed from one individual to another is 
still 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, 
sometimes reappearing towards the end of the influenza epidemic. 
The nature of the virus is unknown. Letzerich described influenza-micrococci INFECTIOUS DISEASES INVOLVING THE RESPIRATORY ORGANS. 
185 
in the blood (?). Seifert also described cocci in the nasal secretion and sputum, 
but they were absent in the blood and tears, and could not be conveyed to ani- 
mals. 
II. Symptoms.—The symptoms generally begin suddenly, more rarely 
they are preceded for a few hours or days by prodromata (malaise, pains 
in the limbs, somnolence or insomnia, gastrointestinal disturbances, 
headache, etc.). 
It is often maintained that the disease has no stage of incubation, 
but this is an open question. 
The manifest symptoms are catarrh of various mucous membranes, 
fever, severe impairment of the cerebral functions, and striking weakness. 
All 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, and the rapidity of the pulse is increased. The 
patients often complain of severe pain in the forehead near the glabella, 
more rarely of occipital pain. This may be associated with confusion of 
mind, delirium, convulsions, cramps in the calves, subsultus temdinum, 
tremor of the limbs, and a striking degree of prostration. 
Hypersemia of the conjunctivse and epiphora 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- 
velops. Attacks of nervous dyspnoea occur not infrequently. Coated 
tongue, a bad taste in the mouth, anorexia, vomiting, constipation, 
or more rarely diarrhoea indicate gastro-intestinal catarrh. If meteor- 
ism is 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. 
Unusual prostration is generally left over for a considerable period. 
The following complications have been observed: broncho-pneumonia, 
more rarely fibrinous pneumonia, pleurisy, even pericarditis, exceptionally 
croup. Erythema, roseola, urticaria, miliaria, p'etechise, and aphthae of 
the mucous membrane have also been described. Ptyalism and parotitis 
have been observed in exceptional cases. 
Phthisis, secondary to chronic broncho-pneumonia, may develop as 
a sequel. 
III. Anatomical Changes.—The lesions are similar to those of the 
corresponding disturbances when independent of influenza. 
IV. Diagnosis and Prognosis.—In view of the sudden and epi- 
demic occurrence of the disease, the diagnosis is easy. The prognosis is 
good in middle life, but is serious in adults and when complications 
develop. It often aggravates previously existing diseases. Pregnant 
women are exposed to the danger of premature delivery. 
V. Treatment is purely symptomatic. Many recommend quinine 
almost as a specific. Narcotics may be given to relieve the cough, expec- 
torants to facilitate expectoration, emetics if gastric symptoms are 
prominent, etc. 
3. Hay Fever. Summer Catarrh. 
I. Etiology.—This disease occurs as catarrh of the air passages, con- 
junctiva and lachrymal canal, and as asthma (so-called hay asthma). 186 
INFECTIOUS DISEASES INVOLVING THE RESPIRATORY ORGANS. 
It is most frequent between the ages of fifteen and thirty years, rarer 
in childhood; it never develops after the age of forty years. Men are at- 
tacked about twice as often as women. 
The educated classes are almost always attacked, the laboring classes 
rarely. A distinct predisposition is necessary to the development of the 
disease; this may be congenital or acquired. The patients generally 
come of neuropathic families, or have been rendered nervous by various 
causes. They present increased irritability of the vaso-motor system, in 
consequence of which slight irritation of the mucous membranes pro- 
duces hyperaemia and inflammatory changes. According to Hack and 
Roe, abnormal swelling of the mucous membrane over the inferior tur- 
binated bone, also over the middle turbinated bone and the septum, 
often give rise to hay fever. 
In many persons, the symptoms occur periodically at definite times, 
usually between May and September. As a rule, the cases are more 
frequent between May and July. 
It has long been recognized that the outbreak of the disease coincides 
with the flowering of grasses, and individuals are often attacked imme- 
diately after approaching a mowed lawn, a field of grain, etc. It is now 
held that the disease is produced by the pollen of flowering grasses. As 
the pollen is diffused far and wide, it is not astonishing that individuals 
should be attacked, although not exposed apparently to the exciting 
cause. 
This theory is confirmed by the fact that the symptoms coincide in 
point of time with the first and second crops of hay ; that the secre- 
tion of the inflamed mucous membranes has been found to contain grains 
of pollen, and that the application of the latter to the nasal mucous 
membrane of predisposed individuals will produce the disease. The de- 
velopment of the disease is favored by drought and winds, and pre- 
vented by steady rains. People living in the country generally escape the 
disease, but this is probably owing to the absence of the predisposition. 
I. Symptoms.—The symptoms not infrequently begin immediately 
after a walk across a meadow, i. e., the cause is immediately followed 
by its effect. Prodromata (malaise, anorexia, slight fever, etc.) are ob- 
served occasionally for several hours or days. 
In the catarrhal form of hay fever, the first symptoms are those of acute 
coryza: burning and pricking in the nose, frequent sneezing, increased 
nasal secretion; olfactory hyperaesthesia is sometimes noticeable. Then 
follow symptoms of conjunctival catarrh, “ foreign body ” feeling in the 
eyes, increased lachrymal secretion, photophobia, injection of the conjunc- 
tiva, oedema of the lids. Then scratching and dryness of the throat, 
and slight difficulty in deglutition. These symptoms may or may not be 
followed by catarrh of the larynx, trachea, and bronchi. There is some- 
times slight fever, often mental depression, and severe pain in the fore- 
head or occiput. The patients sometimes have an annoying sensation of 
coldness in the nose, especially its tip, which maybe cold to the feel. In 
one of my colleagues, the integument of the nose always became red and 
contained dilated vessels. Extensive erythema and urticaria have also 
been observed. The symptoms often last three to eight weeks, rarely 
only a few hours or days. As a rule, relapses occur. 
Pollen of graminae has been found in the nasal and lachrymal secre- 
tions, either intact or swollen and ruptured. The contents are described 
as very fine, moving granules, often arranged in chains. 
Hay asthma corresponds in its clinical history to a full-developed asth- INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
187 
matic attack. In 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 marked congestion, swelling, and hypersecretion of the af- 
fected mucous membranes. The disease rarely terminates fatally, and 
only one fatal case (in an old man) has come to my knowledge. 
The diagnosis is easy, in view of the causation and regular recurrence 
of the symptoms. The prognosis is unfavorable so far as regards per- 
manent recovery. 
IY. Treatment.—The treatment should be chiefly prophylactic. If 
the individual suffers from excessive erectility of the nasal mucous mem- 
brane, the galvano-cautery should be employed. Predisposed individuals 
should live during the summer at the sea-shore, or on high mountains. 
Existing nervousness should be combated by a rational mode of life, 
cold rubbings, baths and douches ; when exposed to infection, the nose 
should 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 as 
possible. 
Irrigation of the nasal cavity with a solution of quinine (1:740), car- 
bolic or salicylic acid, and other disinfectants, may be performed when the 
disease is fully developed. 
In one of my cases, good effects were obtained from the following snuff 
powder: R Hydrarg. chlorid. mite, alumin., aa gr. xlv.; morphin. 
hydrochlorat., gr. ivss. M. D. S. A portion as large as a pea to be 
snuffed up t. i. d. 
Nervines (bromide of potassium, arsenic, strychnine, and camphor) and 
central galvanization have been employed in order to relieve the general 
nervousness. Narcotics may be administered internally and locally if 
the symptoms of irritation are violent. 
PART y. 
INFECTIOUS DISEASES IN WHICH THE DIGESTIVE APPARATUS IS 
CHIEFLY INVOLVED. 
1. Epidemic Parotitis. Mumps. 
I. Etiology.—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 is sometimes preva- 
lent at the same time as epidemics of scarlatina. 
Parotitis is said to be endemic in certain places (coasts of Holland, France, and 
England, certain parts of the United States,) 
The male sex is affected more frequently 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 
is most frequent between the second and twentieth years. 188 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPAEATUS. 
It develops very often in crowded institutions. Among L31 pupils 
in the Cadet Academy at Ploen 118 (90$) were attacked. 
The contagious character of the disease has been demonstrated in a 
number of cases. For example, an'apparently healthy individual travels 
from a locality in which parotitis is epidemic to another district. Here 
he is attacked by mumps at the end of a few days, and soon infects those 
living in the same house, and then those in neighboring houses. 
Epidemic parotitis is probably a general infectious disease, character- 
ized in the main by a local affection of the parotid gland. This opinion 
is supported by its epidemic character and contagiousness, and the fact 
that a single attack generally confers immunity in subsequent epidemics. 
The general symptoms are often very slight, but cases occur, on the 
other hand, in which internal organs are seriously affected, while clouded 
consciousness, 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 
through the excretory duct of the parotid, and that the general symp- 
toms depend upon the unobstructed passage of the virus into the gen- 
eral circulation. 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-shaped bacteria 1 n broad and 2 long, but 
attempts at inoculation in animals proved fruitless. 
II. Anatomical Changes.—According to Virchow, the lobules of 
the parotid gland are hypersemic, the excretory duct is filled with muco- 
pus, and the periglandular connective tissue is in a condition of inflam- 
matory oedema and infiltrated with round cells. 
III. Symptoms.—The duration of the stage of incubation is variously 
estimated at nine to twenty-one days. The characteristic symptoms are 
sometimes preceded by proaromata for one to three days. The patients 
complain of fever, prostration, and anorexia. In children the 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- 
gion of the parotid gland. Violent pains sometimes occur, and may ra- 
diate into the auricular region, and between the shoulder blades. The 
movements of the jaw are interfered with. 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 oedematous. In rare 
cases, it presents inflammatory redness. It is hot to the feel, of a 
doughy 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 gives to the patients a peculiarly stupid appearance. If the disease 
is unilateral, the head is generally held immovable towards the affected 
side, and attempts at rotation produce extremely violent pains. In bi- 
lateral mumps, the head is held peculiarly stiff, and is somewhat bent 
over forwards or backwards. The movements of the lower jaw are 
almost entirely abolished, and sometimes only a narrow fissure is left INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
189 
between the rows of teeth. Hence the patients are restricted almost 
exclusively to fluid food. Articulation is rendered indistinct, and foetor 
ex ore is often produced on account of the inability to keep the mouth 
clean. 
The latter symptom is intensified when stomatitis and ptyalism 
develop. The secretion of saliva is often diminished at the outset, and 
is only increased in the later course 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 is said that these glands may alone be swollen during on epidemic of 
mumps. The adjacent lymphatic glands generally take part in the 
swelling. 
After the swelling has formed, the fever generally falls and remains 
below 39° C. Some cases run an apyrexial course. 
An uncomplicated case 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. Granier found 
that among 495 cases in an epidemic among soldiers, orchitis developed 
115 times. Children 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 pains 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 be enlarged and tender on pressure; the 
scrotum is generally red and oedematous. The testicle itself, not the 
epididymis, is inflamed. 
The frequent complication with orchitis depends on the character of 
the epidemic. Blondeau reported a case in 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 the appearance of or- 
chitis, or both lesions present repeated variations in severity. In some 
cases of parotitis, a gonorrhoea-like discharge takes place from the 
urethra. 
Pains and even enlargement of the ovaries, swelling, and haematoma 
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 externally through several fistulae or into 
the mouth, pharynx, or external auditory canal; or it destroys the facial 
nerve and produces permanent facial paralysis; or erodes the large vessels 
in the neck and causes fatal hemorrhage; or ruptures into the air pas- 
sages, pleural or pericardial cavities, etc.; or finally it produces pyaemia 
or septicaemia. 
Among other complications we may mention : a. Cferebral congestion 
(from pressure of the parotid on the jugular vein) and meningitis, b. 190 
infectious diseases involving the digestive apparatus. 
Delirium and maniacal attacks, which always have an unfavorable prog- 
nostic significance, c. Visual disturbances (amblyopia and color blind- 
ness) have been observed a number of times by Fairy, who attributes 
them to congestion of the papilla. Conjunctivitis, epiphora, and photo- 
phobia may also occur, d. Laryngeal stenosis, resulting from compres- 
sion of the larynx, was observed in some epidemics, e. Acute albumin- 
uria, uraemia, and death were described by Colin. Ilaematuria and 
persistent albuminuria have been observed. /. Gastro-intestinal disturb- 
ances are very frequent; the bowels are generally constipated. Obstinate 
vomiting is observed in some cases, g. Isham claims to have observed 
endocarditis (?). 
Sequelae are sometimes left over. The inflammatory swelling may 
not be entirely absorbed, certain portions persisting for many months or 
even for. life. This is observed with special frequency in scrofulous 
children. Suppuration of the parotid is also apt to follow in them, and 
this may be followed by the formation of a fistula, burrowing of pus, 
pyaemia, or erosion of large vessels. In one case I noticed severe ptyalism 
which lasted three months and was cured by atropine. Burton observed 
absence of salivary secretion and relieved the condition by the applica- 
tion of the constant current. Facial paralysis may be produced by pres- 
sure on the facial nerve. Atrophy of the testicle sometimes occurs in 
males who have suffered from orchitis. In Grauier’s 115 cases of 
orchitis, 51 suffered from atrophy of the testicle. Jaloux described a 
case in which the healthy testicle underwent hypertrophy. Deafness has 
been observed, preceded by noises in the ears and vertigo. It seems to 
depend on primary or secondary affection of the labyrinth or on secondary 
catarrh of the middle ear. 
IV. Diagnosis.—The diagnosis is easily made from the presence of a 
swelling between the mastoid process, external auditory canal, and zygo- 
matic process, and from the epidemic character of the affection. 
V. Prognosis.—The prognosis is almost always favorable. It is only 
in rare cases that life is endangered or that serious sequelae persist. 
VI. Treatment.—Oily inunctions and the application of cotton bat- 
ting are almost always sufficient in the way of treatment. The bowels 
should be opened daily, and the diet consist chiefly of fluid food. Lestor 
recently recommended the administration of jaborandi. If orchitis de- 
velops, the patient must remain in bed and keep the testicle elevated. 
If suppuration of the parotid occurs, it should be poulticed and opened 
as soon as possible. Indurations are treated by applications of iodine 
tincture or ointment, iodoform ointment, and iodide of potassium or 
iron given internally. 
2. Ephemeral Infectious Fever. 
{Herpetic Fever.') 
I. Symptoms.—Every physician probably meets cases in which a 
general febrile condition suddenly develops, often without any known 
cause, and disappears in a short time. The scene opens not infrequently 
with a single violent chill, or the patients complain of repeated chilly 
sensations, great prostration, apathy, and a feeling as if a severe illness is 
impending. In children, convulsions may develop. The bodily temper- 
ature soon rises to 39°, 40° or more. The pulse and respirations are 
accelerated, thirst increased, diuresis diminished. The tongue generally infectious diseases involving the digestive apparatus. 
191 
presents a thick, gray, yellow, or brownish coating, and there is often a 
disagreeable fcetor ex ore. Eructations and vomiting are not uncommon. 
There is sometimes tenderness over the stomach, and meteorism. 
Herpes often develops very rapidly on the lips, rarely on the ala 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 
consciousness and delirium may set in. 
The disease often terminates in the following night. Profuse dia- 
phoresis occurs, and the temperature becomes normal or even sub-normal, 
an abundant sediment appears in the urine, 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 sutler from a large number in the course of their 
lives. They are most frequent in middle life. They are generally 
attributed by the patients to a cold, but, in the majority of cases, without 
justification. Others attribute the disease to excesses in eating ordrink- 
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. Plessing has recently reported a case 
in which several patients were attacked in the same ward of a hospital. 
III. Diagnosis, Prognosis, Treatment.—The diagnosis is easy. 
Apart from the febrile and gastro-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 is 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 German 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 consists of certain 
low organisms (vide Fig. 30). Gaffky found typhoid bacilli in the intes- 
tinal ulcers, mesenteric glands, 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 faeces. They have never been found in the blood. 
The length of typhoid bacilli is about one-third the diameter of a red blood- 
globule, their width about one-third their own length. The ends are rounded. 
They are readily stained with aniline, for example, methyl blue, gentian violet, 
Bismarck brown, and fuchsin. They occasionally contain spores, which do not 
stain with aniline colors. The spore3 are as broad as the bacilli, and are always 
situated near one extremity of the bacillus. Each bacillus contains only one 192 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPAEATUS. 
well-developed spore. If two bacilli are adherent, the spores are found only at the 
adjacent extremities. 
Gaffky cultivated the bacilli in meat extract, peptone-gelatin, and slices of 
potato, but inoculations in animals did not produce positive results. Hence the 
results of his investigations may only be regarded as probable, not as certain. 
Clinical experience indicates that the virus is contained in the fasces, 
so that the danger of infection arises only from contact with the intestinal 
contents. The virus is not diffused in the exhalations of the patient, so 
that it is not conveyed to those who come in contact with him. Hence 
the patients may safely be kept in the general wards of a hospital, if care 
be taken to disinfect the faeces, bed-pan, and soiled articles of clothing. 
Fig. 30. 
Typhoid bacilli from the juice of the mesenteric glands. After Eberth. Enlarged 1,980 times.- 
Oil immersion. 
The virus may enter the intestinal tract through the anus or mouth. 
If the infection occurs through the agency of water-closets or bed-pans 
which have been soiled by typhoid stools, infection takes place in the 
former method ; but sometimes the virus is introduced in the ingesta, or 
it is diffused from the faeces into the air, enters the pharynx, and then is 
swallowed. Some assume the possibility of infection through the respir- 
atory organs. Certain cases in which the disease begins with severe in- 
flammation of the lungs would seem to indicate that the virus may first 
produce its injurious effects at its site of entry (the lungs) before exercis- 
ing its full deleterious influence on the intestinal canal. 
Drinking-water undoubtedly plays a prominent part in infection. 
Epidemics often affect only those houses or streets whose inhabitants INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
193 
obtain their drinking-water from a certain well. In a number of such 
cases, it has been found that the water supply communicated with water- 
closets, dung heaps, ditches, etc., which contained infected faeces. 
A number of cases have been observed, particularly in England, in 
which the disease was confined to families who received their supply of 
milk from a certain milkman. In the majority of these cases the milk 
had been diluted with infected water. 
In the canton of Zurich a number of epidemics have been observed, which 
have been attributed to the ingestion of spoiled meat. These generally occurred 
at festivals, the spoiled meat being used in the preparation of special popular deli- 
cacies. In the Kloten epidemic (1878), among 700 singers 500 were attacked by 
typhoid fever. These epidemics have given rise to much controversy, especially 
upon'the following points: a. Was the disease really typhoid fever ? b. If so, was 
it produced by meat which was simply spoiled ? Or c. By infection with the meat 
of typhoid animals ? My colleagues in Zurich are agreed as regards the typhoid 
nature of the epidemics, and the statements of Wyss will hardly admit of any 
doubt. Huguenin states that the Kloten epidemic was produced by eating the 
flesh of a calf which suffered from typhoid fever, but fails to prove the truth of 
this assertion. Positive evidence that typhoid fever occurs in animals has not 
been furnished hitherto. But to assume that the disease was produced by the 
mere ingestion of spoiled meat contradicts the theory of the specific nature of the 
typhoid virus. Moreover, we know that the ingestion of spoiled meat produces 
symptoms (hemorrhagic gastro-enteritis) 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 some cases infection is attributable to certain occupations, for 
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 be kept in mind that the virus may retain 
its potency for many years, and thus it often becomes difficult to ascer- 
tain whether typhoid stools have ever been emptied into the closets. 
The outbreak of an epidemic is sometimes caused by an imported case, 
but in other cases the mode of infection cannot be discovered. In our 
opinion, there are mild forms of the disease in which the patients walk 
about. The faeces 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 individuals 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 summer, 
while the spread of the disease is antagonized by a very cold winter. 
According to Buhl and Pettenkofer, typhoid fever increases the lower the 
level of the subsoil water. They assume that the typhoid virus then proliferates 
more abundantly in the upper, dry strata of the soil, and are thus conveyed to the 
lower strata of the atmosphere. This theory, however, is opposed by numerous 
experiences. 
To explain the occurrence of typhoid cities, we must assume that, in the course 
of years, the subsoil becomes saturated with typhoid germs which are constantly 
proliferating. As a matter of course, the level of the subsoil water may be im- 
portant, but only because the higher its level the more apt it will be to contami-, 
nate the wells. J 194 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
Typhoid fever very often occurs in house-epidemics (barracks, pris- 
ons, etc.). In large cities, certain houses and streets are apt to be no- 
torious as the habitat of the disease. Extensive epidemics are sometimes 
found to consist of a number of house-epidemics. 
The disease is most frequent from the fifteenth to the thirtieth years 
(maximum from twenty to twenty-five years), although it also occurs in 
childhood and old age. 
Charcelay claims to have observed it twice in the new-born. Hastelius re- 
ported the case of a pregnant woman suffering from typhoid fever, who had a 
{>remature delivery in the eighth month. In the still-born child were found en- 
argement of the spleen and lymphoid infiltration of the intestinal follicles and 
mesenteric glands. Typhoid fever is rare in the first year of life. During child- 
hood, it is especially frequent from the age of five to ten years. 
Sex exerts no special influence on the frequency of the disease, 
though, on the whole, more men are attacked than women. 
Robust individuals are often attacked, and some physicians believe 
that weak aenaemic individuals, and those suffering from cancer, heart- 
disease, syphilis, or phthisis, possess almost complete immunity.. 
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, premature delivery is produced in two-thirds of the cases which occur in 
pregnant women. The child is generally still-born, or dies soon after birth. As. 
a rule, pregnancy does not affect the course of typhoid fever, and complications 
often remain absent, even after premature delivery. The latter may be the re- 
sult of the high fever, the severity of the infection, or disturbances of respira- 
tion. 
Pfeiffer believes that typhoid fever is unusually frequent in certain families, 
and assumes that this fact is owing to the diminished power of resistance of the 
intestinal follicles. 
The disease is most frequent among the poor. A predisposition may 
also be created by certain occupations. For example, the physicians 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. 
As a rule, only a single attack is experienced, although exceptions 
have been observed, and in a few cases individuals have suffered even 
three attacks. 
Typhoid fever is sometimes associated with, or followed by other in- 
fectious diseases. 
The combination with measles, scarlatina, typhus fever, variola, acute articu- 
lar rheumatism, and intermittent fever has been reported. 
During an epidemic, the individual cases often resemble one another 
very closely in their symptoms and general course. 
II. Anatomical"Changes.—The specific lesions of typhoid fever 
affect the lymph follicles of the intestinal mucous membrane, the mes- 
enteric glands, and the spleen. 
The intestinal changes generally begin with catarrhal inflammation, 
not alone of the lymph follicles, but also of the mucous membrane, and 
the latter persists in greater or less degree during the entire course of INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
195 
the disease. The catarrhal follicles at first project more strongly from 
the surface, and are generally surrounded by a zone of hyperaemic ves- 
sels. 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 oedema. 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 may 
exceed five mm. The edges of the infiltration usually are steep, but oc- 
casionally 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 infrequently greatly 
exceeds that of the interfollicular connective tissue, so that its surface 
presents a latticed appearance. In some places the infiltration is con- 
fined to certain 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 a cer- 
tain extent. This is observed with relative frequency on the ileo-caecal 
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-red, 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 
fatty detritus enters the lymphatic channels. This is shown macroscop- 
ically by the yellow color of the parts. In Peyer’s patches, it is found 
not infrequently that the cellular elements in the follicular substance 
undergo fatty degeneration and absorption earlier than in the interfolli- 
cular connective tissue, so that the patch presents a furrowed appear- 
ance, the follicles being depressed, and the interfollicular bands 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 converted into blackish pigment detritus. The 
Peyer’s patches may then present a black speckled appearance. These 
changes generally persist for many years. Extravasations may also form 
in the hyperaemic 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 least this is true of the majority of the infiltrated 
lymph follicles. As a general thing, the necrosis takes place about the 
middle of the second week of the disease. This is evidently owing to the 
fact that the cellular elements increase in such numbers as to compress 
the blood-vessels, and thus deprive the cells of nutriment. A thin layer 196 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
of necrosis first forms on the surface of the follicle, and assumes a yel- 
lowish or brownish color from imbibition of bile pigment. But the ne- 
crosis may extend so deeply as to lead to perforation of the serous layer- 
The mucous 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 visible. Ulcers of the 
solitary follicles are usually round, those of Peyer’s patches are oval in 
shape. Unlike tubercular ulcers, their long diameter is parallel to that 
of the 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. As a 
general thing, however, this is 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 ulcer (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 in the process, as is evident from the 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 is sometimes lined merely with a layer of 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 microscopical changes in the follicles affect all their constituents. The 
vessels are dilated, their walls in a condition of vitreous swelling. In places they 
are plugged with white blood-globules. 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 Rindfleisch). In the connective-tissue 
stroma are found swelling of the tissue, proliferation of the branching cells, and 
infiltration with round cells. Typhoid bacilli probably form an integral part of 
the changes. Heschl observed that the changes extended far beyond the lymph 
follicles. In the capillaries of the intestinal walls he found swelling and prolifer- 
ation 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 of 
the intestines, where they had produced, in places, nests of round cells. 
The typhoid changes in the follicles begin and are most marked in 
the lower end of the ileum and upon the valve. They are no longer found 
in the duodenum, although some authors claim to have found typhoid 
changes even upon the mucous membrane of the stomach. The vermi- 
form appendix is sometimes attacked with special severity, and in 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 affection of the intestinal lymph follicles is attended with change* INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
197 
in the mesenteric glands. These appear earliest and are most marked 
near the lower part of the ileum. Some of the mesenteric 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 substance. Ex- 
travasations of blood may occur in places. The cut surface is moist 
and juicy, the consistence soft. Later, the congestion diminishes, the 
succulence partly disappears, and a condition of medullary infiltration 
develops, as in the lymph follicles of the intestines. In teased 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, and may give use to perforation 
with subsequent peritonitis. Or caseation and calcification may develop; 
this may terminate finally in infection with tubercle bacilli and in general 
miliary tuberculosis. 
The spleen begins to enlarge about the middle of the first week, and 
reaches its 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 is 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 the cut sur- 
face as small gray infiltrations. In advanced cases, there is often an un- 
usual 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 
changed red blood-globules or with their detritus. Typhoid bacilli have 
also been found in the spleen. Wedge-shaped and simple hemorrhagic 
infarctions, and even abscess of the spleen are not very rare complica- 
tions. 
Jit would appear as if almost the entire lymphatic gland system may be affected 
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 
(cervical and inguinal). Similar changes have been observed in the tonsils, the 
follicles of the tongue, and the thyroid gland. The medulla of the bones is often 
of a red color, its parenchyma cells increased in number ; it contains an unusual 
number of nucleated blood-globules and cells which contain blood-corpuscles. 
The specific lesions mentioned above are always associated with 
changes in other organs, partly as the result of infection, partly owing 
to the increased bodily temperature. 
If the patients have died at the height of the disease, rigor mortis is 
apt to develop very quickly and to be very marked. Livores mortis are 
usually very abundant upon the back and dependent portions of the 
body. 
The panniculus adiposus is often well retained, even if the disease has 
lasted two or three weeks. The muscles are generally dry, and have a deep 
red color. Here and there they contain pale-gray or yellowish patches, 
which are most frequent in the recti abdominis and adductors of the 
thigh, but are also found in other muscles (even the heart, tongue, and 
diaphragm). In such places the microscope shows that the contents of 198 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
the muscular fibres have a dull shining, vitreous, coagulated appearance, 
and are converted into fibrillated clumps (Zenker’s degeneration). Iq 
other places the muscular fibres contain very fine granules, which partly 
disappear on the addition of acetic acid (albuminoid), but partly persist 
and turn black on the addition of hyperosmic acid (fat granules). Pro- 
liferation of the muscle nuclei is observed not infrequently. 
The heart muscle is often flaccid, brittle, and pale. On section, it is 
found to contain numerous pale-gray and light-yellow spots, which show 
under the microscope cloudy swelling of the muscular fibres, fatty and 
wax-like degeneration. The fibres often contain an unusual amount of 
brownish pigment. Nuclear proliferations within the fibres are also ob- 
served. 
The larynx may contain ulcers, 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 fatal oedema 
of the glottis. Bronchitis is observed in almost every case. 
The salivary glands are often enlarged, especially in the first stages 
of the disease. The microscope shows proliferation and cloudy swell- 
ing of the cells within the acini. The signs of pharyngitis, which are 
usually present during life, disappear in great part after death. Catar- 
rhal gastritis is found not infrequently. The pancreas presents similar 
changes to the salivary glands. 
The liver is often enlarged, its cells in a condition of cloudy swelling 
or fatty degeneration. Wagner observed lymphomata in the liver and 
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 degeneration 
of the tubular epithelium. There is sometimes slight catarrh of the 
mucous membrane of the urinary passages. 
The brain may present meningeal hemorrhages and oedema of the pia 
mater. Meynert found distention of the cortical capillaries, granular 
degeneration of the ganglion cells, increase of their nuclei, and fibrilla- 
tion of the protoplasm. Popoff observed infiltration of the ganglion 
cells with round cells, and an accumulation of round cells in the peri- 
ganglionic lymph spaces, adventitious lymph spaces of the blood-vessels, 
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. Symptoms.—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 mentally or physically. Not 
infrequently there are shooting pains in the muscles, generally in the 
legs, more rarely in the back. 
The disease proper generally begins with repeated chilly sensations, 
more rarely with a single chill. As a rule, this is followed by rapid ele- INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
199 
vation of temperature. The manifest symptoms depend chiefly on the 
anatomical changes in the intestines. 
Typhoid fever is almost always associated with increased bodily tem- 
perature, and the curve is so characteristic as to enable us to make a 
diagnosis from it in doubtful cases. In the first week (catarrhal swell- 
ing and beginning medullary infiltration of the intestinal lymph folli- 
cles) the temperature rises gradually. Every night it is usually about 
1° C. more than 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 
week the fever has generally reached its height, and then remains ap- 
proximately continuous during the second week (completed medullary in- 
filtration and beginning ulceration of the follicles). In the third week 
greater variations of temperature occur, the type of fever becoming re- 
Fig. 31. 
Typical temperature curve in moderately severe typhoid fever. 
mittent. Gradual defervescence occurs 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 is sometimes observed, i. e., exacerbations in the morning, remis- 
sions in the evening. 
The elevation of the bodily temperature is attended with other fe- 
brile symptoms, viz. acceleration of the pulse, diminished appetite, in- 
creased thirst, and diminished diuresis. 
At the beginning of the first week, the tongue is sticky, moist, 
and covered with a thick, gray, grayish-yellow, or grayish-brown 
coating (desquamated epithelium, debris of food, and schizomycetes). 
In the second half of the first week, the dryness of the tongue in- 
creases, and its edges, as far as the tip, become unusually clean, and 
almost brick red. As the second week approaches, the coating is 
gradually exfoliated (beginning at the tip and gradually passing back- 
ward). This often occurs in the shape of a triangle, the apex of 200 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
which is situated at the tip of the tongue. The tongue is generally 
entirely clean in the first part of the second week. It is unusually 
dry and red, often rough and papular from swelling of the fungiform 
papillae. 
Towards the end of the first week, a peculiar eruption often appears 
in the shape 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 the 
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 generally disappear in three to five days, but occasionally persist 
for more than a week. In the latter event, I have sometimes found 
that the paling of the patches is 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 varies 
according to the epidemics, but they may be so numerous as to remind 
us of measles. I have never seen typhoid fever without roseola, but 
some authors state that this ocours in rare cases. Fine vesicles some- 
times form at the apices of the patches. 
The abdomen is generally prominent, especially in its lower half, 
and in the ileo-caecal region. 
The ileo-caccal region is almost always tender on pressure, and even 
unconscious 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 is 
often felt in the ileo-caecal region. This merely indicates the presence 
of fluid mixed with bubbles of gas beneath the compressing fingers, and 
while it is unusually frequent in 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 is 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 
results than palpation. In our opinion, however, the possibility of feeling the 
spleen is one of the most constant symptoms 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. 
Diarrhoea 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 
speeific gravity is about 1.005, the proportion of solid constituents about 
4 per cent. The typhoid stool is very poor in albuminoids. As reeov- 201 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
ery progresses, the stools become more consistent and scanty, and finally 
normal. 
Microscopical examination of the stools shows intestinal epithelium, round 
cells, debris of food, fat cells and crystals, necrotic tissue from the mucous 
membrane, round and rod-shaped schizomycetes, and triple phosphates (vide Fig. 
32). Pfeiffer reports that he has succeeded in cultivating typhoid bacilli from 
the stools. 
Typhoid fever rarely runs the simple course indicated above, and 
its symptoms are unusually manifold. 
Among the different varieties we will first refer to those in which tha 
Fig. 32. 
Typhoid stool, containing round cells, debris of food, granular detritus, and crystals of triple 
phosphates. Enlarged 20 times. 
affection of other organs is so prominent as to give rise to the liability 
of overlooking the typhoid fever. We refer chiefly to pneumotyphoid, 
renotyphoid, and meningotyphoid. 
Pneumotyphoid often creates the impression of an ordinary but 
severe fibrinous pneumonia. But we will generally be struck by the 
unusual degree of impairment of consciousness, the unusually large 
size of the spleen, and the presence of roseola on the integument. It is 
sometimes found that, despite the occurrence of absorption, the critical 
defervescence 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 
that in this variety of the disease infection does not take place through 202 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
the intestinal tract, but through the respiratory organs, so that the first 
and most violent morbid phenomena are noticed in the lungs. 
The terms bronchotyphoid and laryngotyphoid are sometimes applied to 
cases which are characterized by violent symptoms of bronchitis or inflamma- 
tion and ulceration of the laryngeal mucous membrane. We regard these terms 
as misnomers. , 
Renotyphoid is characterized by prominent urinary symptoms from 
the very beginning of the disease. The urine contains albumin, casts 
and blood. The kidneys show parenchymatous or interstitial changes, 
eccasionally merely a condition of cloudy swelling. In these cases, there 
is danger of overlooking the typhoid fever and regarding the disease as 
nephritis. 
In meningotyphoid (cerebral typhoid), the suspicion of meningitis is 
aroused by rigidity of the nape, marked impairment of consciousness, 
sometimes by temporary inequality of the pupils. 1 have often observed 
such cases in conditions of high fever, and the meningitic symptoms 
often disappeared as soon as the temperature was lowered. AVe suspect 
that these symptoms depend on liyperaemic and cedematous conditions 
of the meninges. 
A second group of varieties of the disease may be designated, accord- 
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 absent. In such mild 
cases, we may be 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 Aveek. Such attacks often assume the character 
of an acute disease ; they begin with a chill, followed by continued high 
fever, and quite 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 frequent 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&les, more rarely by moist r&les. As a rule, 
the symptoms are most marked in the posterior and lower portions of 
the lungs. 
Eisenlohr described acute bronchial croup which appeared at the beginning 
of typhoid fever, and disappeared at the end of the second week. 
Pulmonary complications are not infrequent. Patients who occupy 
the same position for a long time are apt to develop pulmonary hypo- 
stasis, characterized by more or less dulness (occasionally by a tym- 
panitic note), feebleness, sometimes absence of \Tesicular breathing, and 
non-consonant moist r&les. If the position of the patients is frequently INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
203 
changed, it is often found that the dull parts become resonant. If this 
is not done, hypostatic pneumonia is apt to develop. The dulness then 
becomes more marked, bronchial breathing is heard and the r&les be- 
come consonant. These complications are so much more apt to develop 
the higher the fever, the more profound the unconsciousness, the greater 
the impairment of the heart's action. Fibrinous pneumonia sometimes 
develops in quite a latent manner. Apparently spontaneous rise of tem- 
perature, accelerated respiration, cyanosis, and slight clouding of con- 
sciousness should always lead to careful examination of the lungs. This 
complication develops most frequently after the second week. 
In several cases, I have observed “foreign body” pneumonia; lobular ca- 
tarrhal pneumonia is not uncommon. Hemorrhagic infarctions are sometimes 
produced, secondary to thrombosis of the riglit auricle, or marantic thrombosis of 
the veins. This is sometimes followed by abscess Pulmonary gangrene may 
occur, but rather as a sequel. Embolism of tiie pulmonary artery may give rise 
to sudden death. Pleuritis is a rare complication. 
The bronchial glands sometimes undergo suppuration. This may be followed 
by mediastinitis, which Fraentzel also observed after inflammation of the oesopha- 
gus and peri-oesophageal connective tissue ; the pus may rupture into the cesoph- 
gus, bronchi, pleural or pericardial cavities. 
Typhoid ulcers develop not infrequently in the larynx, sometimes as 
early as the second week of the disease. They often give rise to no 
symptoms and are found only after laryngoscopic examination. In 
other cases, the patients are hoarse and complain of pain in swallowing 
and on pressure over the larynx. The ulcers are so deep at times as to 
give rise to perichondritis and necrosis of the laryngeal cartilages, even 
to perforation of the laryngeal walls and cutaneous emphysema. The 
ulcers may also be the starting-point for fatal cedema of the glottis. 
According to Dittrich, laryngeal perichondritis may also develop in typhoid 
fever independently of specific ulcerations. Diphtheritic and croupous laryngo- 
tracheal inflammation has been observed at times, usually associated with similar 
changes in the pharynx. 
In Zurich I often observed purulent or hemorrhagic inflammation of goitres ; 
in some cases death from suffocation occurred, despite tracheotomy, as the result 
of laryngeal stenosis. 
Nasal catarrh is a very frequent complication, accompanied by red- 
ness, swelling, and hence impermeability of the nose. Repeated epistaxis 
sometimes occurs in the prodromal stage or the first week of the disease, 
and may become dangerous from its profuseness. The patients often 
feel easier after the hemorrhage. Epistaxis occasionally does not develop 
until a later period, associated at times with signs of. blood dissolution 
(petechise on the skin and mucous membranes, intestinal hemorrhage, 
haematuna, etc.), and is then an unfavorable prognostic sign. 
The respiratory complications are sometimes nervous in character. Heckylei 
reports a case in which Cheyne-Stokes breathing and stuttering developed on 
the fourteenth day of the disease. In one of my cases, sudden hoarseness was 
produced in the third week by paralysis of the internal thvro-arytaenoid and 
arytaenoid muscles. In another case, complete unilateral paralysis of the recur- 
rent laryngeal set in. 
Pericarditis and endocarditis are rare complications on the part of 
the circulatory organs. There is often slight dilatation of the right side 204 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
of the heart, as in other febrile or exhausting diseases. The first 
(systolic) heart-sound is not infrequently soft and blowing, usually most 
markedly over the apex. Paralysis of the heart-muscle may set in 
Fig. 33. 
Seventh day of the disease. Temperature, morning, 38.5°; evening, 39.7®. 
gradually or suddenly, at the height of the disease or during convales- 
cence ; in the former event, it is the result of the high fever, the 
severity of the infection, or both. 
Fig. 34. 
Eighth day of the disease. Temperature, morning, 38.4°; evening, 39.5*. 
Cardiac thrombi may also form and, according as they affect the left or right 
side of the heart, will give rise to embolism of the spleen, kidneys, etc., or of the 
pulmonary artery. 
Marantic thrombosis of the veins occurs rather as a sequel of typhoid 
fever. It is most frequent in the saphenous vein at its entrance 
Fig. 35. 
Eleventb day of the disease. Temperature, morning, 38.0®; evening, 38.6°. 
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 character- 
ized by pain, numbness, coldness, and oedema of the limb; the throm- INFECTIOUS DI8EASES INVOLVING THE DIGESTIVE APPARATUS. 
205 
bus is sometimes felt as a hard cord below Poupart’s ligament. Palpa- 
tion must be performed very cautiously, since particles are apt to be 
broken off and carried into the circulation as emboli. The thrombus 
Fig. 36. 
sometimes extends into the inferior vena cava and then into the other 
crural vein. 
Thrombosis in other localities is rarer. In a number of cases in Zurich, I ob- 
served thrombosis of the vena saphena magna from the knee to the middle of the 
Sixteenth day of disease. Temperature, morning, 36.8°; evening, 38.4°. 
Fig. 37 
Twenty-second day of disease. Temperature, morning, 35.7°; evening, 36.2°. 
thigh, unattended with oedema, but followed by ulceration and discharge of a 
purulent, bloody fluid; termination in recovery. Cole described a thrombus of 
the innominate vein. I have observed several cases of periphlebitis in women 
suffering from varicose veins in the legs. 
Fig. 38. 
Thirtieth day of disease. Temperature, morning, 36.2°; evening, 36.4°, 
Figs. 33-38.—Pulse curves from a typhoid fever patient, set. 24 years. 
The pulse is accelerated, but often less than would be anticipated from 
the height of the fever. As a rule, it varies from one hundred to one 
hundred and twenty beats a minute. A more rapid pulse indicates great 206 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
gravity. The pulse is sometimes unusually slow, without any ascertain- 
able cause. It is generally full and soft, often distinctly dicrotic, or 
acquires the latter quality during the stage of recovery. If the hitherto 
regular pulse becomes irregular, small, and occasionally intermittent, 
there is danger of the occurrence of heart failure. 
In Figs. 33-38 we furnish the sphygmographic tracings in a case of 
typhoid fever, taken on those days in which a change in the pulse was 
manifested. It is evident that during the course of the disease the pulse 
becomes more and more dicrotic, i. e., the blood pressure gradually 
sinks. 
No specific changes have been found in the blood. Occasionally there is a 
slight increase in the number of white blood-globules, or an unusual abundance 
of elementary granules, especially during convalescence. In one case, I found in 
the blood large granular cells which contained as many as seven red blood- 
globules. 
The lips are generally dry ; rliagades are apt to form upon them, and 
the epithelial layers are exfoliated in part in the shape of yellowish and 
brownish scales. Hemorrhages are not infrequent. The blood dries into 
brownish-red or black crusts, and the lips look as if covered with soot. 
They are sometimes inflamed, thickened, and painful. 
/The gums are often swollen and red, and not infrequently covered 
with sordes. Abscess of the gums develops at times, and may form the 
starting-point for extensive ulcerations. 
Fissures, sordes, and hemorrhages are often noticeable on the tongue, 
and its edges often contain the impressions of the teeth. These may give 
rise to extensive ulcerations. The tongue is often 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 
general weakness, dryness, and stickiness of the tongue, but it must not 
be 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. Follicular angina may also develop. The 
condition becomes more serious when necrotic or diphtheritic changes 
appear in the pharynx, and extend, as they sometimes do, to the larynx 
and oesophagus. 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 mouth to Steno’s duct and occlusion of the latter, or 
from typhoid changes which occur not infrequently in the parotid glands. 
If suppuration ensues, death may occur from exhaustion or pyaemia, 
or the pus burrows, erodes blood-vessels, destroys the facial nerve, rup- 
tures into the external auditory canal, etc. These changes are late com- 
plications, and do not appear before the end of the third week of the 
disease. 
Mosler states that only a few drops of saliva can be obtained from the parotid 
in typhoid fever, and that its reaction is acid. 207 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
In rare cases, sprue develops on the buccal mucous membrane and 
may even extend into the oesophagus. 
Thirst is always increased, though apathetic patients do not ask for 
drink. The appetite is poor, but boulimia may be observed during con- 
valescence. The taste in the mouth is generally said to be pasty, some- 
times nauseous. Vomiting is not infrequent. Griesinger 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 suffer from an annoying feeling of nausea. 
Catarrhal inflammation, necrosis, and ulceration, and sprue have been observed 
in the oesophagus. The inflammation sometimes extends to the peri-oesopliageal 
tissue, and then to the mediastinum. In one case, Lindner observed uncontrol- 
lable oesophageal spasms 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 oesophagus. 
Haematemesis has been described in a few cases, and is secondary to 
round gastric ulcer or to excessive congestion of the gastric mucous 
membrane. 
Serious intestinal complications are not infrequent. Thus, the diar- 
rhoea may become very severe (more than twenty evacuations daily), and 
is often attended with tenesmus. The faeces 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 starting- 
point of severe inflammations of the skin, gangrene, and bed-sores. In 
some cases, on the other hand, constipation continues during the entire 
course of the disease. It may then happen that the thick and dry fasces 
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 that 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, but 
soon recurs, 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 oedema of the malleoli. In one case 
of relapsing intestinal hemorrhage, Traube observed extensive oedema and 
death from oedema of the glottis. Rapid 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 
by means of a canula, and the point of escape of the injection mass sought 
for. In rare cases, 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 anus. 
The occurrence of latent intestinal hemorrhage maybe assumed if great 
pallor 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 in 208 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
certain parts, corresponding to the site of hemorrhage, there is a feeling 
of increased resistance on palpation, and a dull tympanitic percussion 
note. Blood which is passed in the stools is usually dark-red, sometimes 
blackish-brown, usually coagulated, more rarely fluid. Several litres 
may be discharged, and death has been known to occur in an hour. In- 
testinal hemorrhage is unusually frequent 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 
have extended deeply, so that the thin portion of the intestine is rup- 
tured 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 abdomen is distended and tender on pressure; hepatic and 
splenic dulness disappear when gas enters the peritoneal cavity and 
separates the organs from the abdominal walls. Dulness soon sets in, 
corresponding to peritonitic exudation. Vomiting of grass-green, 
watery, or porridge-like masses is not infrequent. 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. Recovery is exceptional. 
In one case, Tschudnowsky observed amphoric breathing over the abdomen, 
synchronously with the movements of respiration. It appeared to be caused by 
escape of gas through the site of perforation into the peritoneal cavity, owing to 
rhythmical compression of the loops of intestines. Intestinal perforation is 
more frequent in men than in women, generally affects the small intestine, more 
rarely the vermiform process or colon. There may be several perforations at the 
same time. 
Hepatic and splenic dulness does not disappear if the organs are fixed in their 
position by old peritonitic 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 be 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 in 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 rupture of that 
organ in very rare cases. Splenic infarctions develop much more 209 
frequently ; they are often secondary to thrombi of the left heart, more 
rarely to recent endocarditic deposits. These may induce peritonitic 
symptoms, or lead to suppuration and the formation of a splenic abscess, 
which ruptures into the peritoneal cavity or other organs. 
The liver is very often swollen and slightly painful. Abscess or 
acute yellow atrophy of the liver develops in rare cases. As in many 
other febrile diseases, slight jaundice of the sclera is not at all uncommon. 
Haematogenous icterus, associated with haemoglobinuria, appears to have 
been present in a case reported by Immermann. 
Necrotic or diphtheritic processes sometimes form on the wall of the gall- 
bladder, and may give rise to perforation, with subsequent diffuse peritonitis. 
The urinary changes depend entirely on the fever. 
Its amount is diminished, reaction very acid, specific gravity increased ; a 
brick-red sediment of acid urate of soda is found not infrequently. The urea is 
increased, especially during the first week, but diminishes during convalescence. 
If the temperature is reduced by treatment, the amount of urea generally in- 
creases. The quantity of kreatinin and ammonia is increased. Salkowsky 
showed that the amount of potassium sinks very considerably upon the occur- 
rence of convalescence. 
Leucin and tyrosin have been found in the urine, occasionally bile pigment, 
although jaundice is not present. Haemoglobinuria has been reported a number 
of times. Gerhardt observed peptonuria. 
Albuminuria is not uncommon during the course of typhoid fever. 
It is generally pyrexial 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 uraemia may take place during the 
course of typhoid fever. Wedge-shaped infarctions are found occasionally 
in the kidneys. 
The symptoms of mild cystitis or pyelitis soon become noticeable. 
In unconscious patients, the bladder is often distended and may reach 
to the umbilicus. 
Diphtheritic changes develop very rarely on the mucous membrane of the 
urinary passages. 
Menstruation often becomes irregular, and amenorrhoea is almost always 
noticed for two or three months after recovery from typhoid fever. 
Orchitis and epididymitis have been observed in men. Phlegmonous inflam- 
mation and gangrene of the genitals may occur in both sexes, and may be the 
cause of death. 
The functions of the nervous system are always more or less impaired 
in this disease. Headache begins very early. The pain is either diffuse 
or localized in certain nerve tracts on one side of the head. In addition, 
there is often hyperaesthesia. In some cases, there is very early hyper- 
aesthesia or anaesthesia of the entire skin or certain parts; partial or 
general convulsions and trismus have also been observed. Conscious- 
ness is soon impaired. The patients feel incapable of thinking, com- 
plain of dulness in the head, they are sleepless and restless at night, 
somnolent during the day. At first delirium is apt to set in just before 
falling asleep. Gradually the patients become more and more apathetic, 
mutter to themselves, or move the lips and tongue in a trembling man- 
ner. If they are still able to answer questions, the words are spoken in 
INFECTIOUS DISEASES INVOLVING TIIE DIGESTIVE APPARATUS. 210 
INFECTIOUS DISEASES INVOLVING TUE DIGESTIVE APPARATUS. 
a jactitating, 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 recovery begins, consciousness slowly clears 
and the patients awake as if from a long sleep. The memory of events 
which occurred shortly before and during the 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. The 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 the facial nerve. 
The following ocular complications have been described: ulcers of the cornea, 
mydriasis, paresis of accommodation, transitory and permanent amaurosis (optio 
atrophy). Galezowsky 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. Petechiae sometimes 
develop upon roseolae 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 
seen most frequently upon the sacrum, next upon the trochanters, mal- 
leoli, elbows, occiput, etc. It may 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 INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
211 
position and folds in the bedding will produce it. But in some cases it 
forms despite the best of care, and is then the result of trophic disturb- 
ances of the skin, partly from the accumulation of abnormal products 
of disassimilation in the blood, partly from the enfeebled circulation in 
the cutaneous vessels. Erysipelas occasionally develops without apparent 
cause; it generally begins near the nose, but not infrequently extends 
to the neck and chest. 
Muscular pains are a frequent complication and are attributed by 
many to the anatomical lesions found in the muscles. Hemorrhages, 
abscess, 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 
sequelse. Furuncles and abscesses may develop in the skin, are often 
of pyaemic origin, and sometimes cause a fatal termination by the loss 
of vitality entailed. Petechise or oedema of the lower limbs, pains or 
cramps in the muscles sometimes appear after the first attempts at 
standing. The lymphatic glands may also be affected and give rise to 
slow processes of suppuration. 
In one case, Litten observed extensive pigmentation of the skin in the shape of 
blackish patches which he attributed to an affection of the sympathetic ; in an- 
other case, he observed an eruption like erythema. 
Necrosis and spontaneous gangrene sometimes develop in peripheral 
portions of the body, such as the nose, genitalia, toes, etc. Arterial 
thrombosis has 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 
extensive necrosis of the skull from thrombosis of a branch of the 
middle meningeal artery. According to Paget, post-typhoid periostitis 
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 has 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 may be so extensive as to produce almost complete baldness. This 
condition disappears after a while. 
Valvular lesions of the heart and Basedow’s disease have been ob- 
served as sequelae. Nothnagel mentions neurosis vasomotoria. 
Pulmonary abscess and gangrene may also be included among the 
sequelae. Chronic pulmonary phthisis and miliary tuberculosis develop 
occasionally. 
Necrosis of the laryngeal cartilage may be left over. There may also 
be functional paralysis 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 
the evacuations from the bowels remain thin and frequent for life. 
Suppuration of the perirectal cellular tissue (periproctitis) occurs in rare 212 
cases. Slight enlargement of the spleen persists permanently in som(' 
cases. 
Chronic Bright's disease is rare as a sequel of typhoid fever. Polyuria 
often sets in during convalescence. 
Nervous disturbances are often left over. Many patients exhibit, for 
a long time, lack of desire for mental activity, indifference, 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 frequency appears to depend 
on the character 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 
Gerhardt 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, typhoid 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 rareiy followed by sequelae. 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 11.3 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, %t e., brief rises of temperature during the period of conva- 
lescence. 
IV. Diagnosis.—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 between typhus and typhoid fever, chief stress 
must be laid on the abundance and character of the eruption, the more sudden 
onset and critical termination in typhus, and the shorter duration of the latter 
disease. 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
213 
In measles, the face is particularly affected by the eruption. 
Scarlatina begins more acutely and leads to desquamation of the skin. 
Typhoid fever may be mistaken for variola in the prodromal stage, but in the 
latter pains in the loins predominate. 
In doubtful cases, the diagnosis of pneumonia is favored, apart from the 
pneumonic sputum, by the presence of herpes labialis. 
In meningitis, there are rigidity of the nape, paralytic and irritative symptoms 
in the limbs, and changes in the fundus of the eye. 
In miliary tuberculosis, special attention should be paid to the fundus of the 
eye (choroideal tubercles). 
Septic endocarditis requires careful examination of the heart for murmurs, 
and search for embolic processes. 
Florid syphilis is associated with changes on the genitals. 
Acute gastro-enteritis runs a shorter course than typhoid fever, and the 
febrile movement is generally less. 
V. Prognosis.—The prognosis is always serious, but the mortality 
varies remarkably in different epidemics. The disease runs a more 
favorable course in children than in adults, because true ulceration of 
the intestines rarely occurs in the former, and complications are much 
less frequent. The danger is so much greater the higher and the more 
protracted the fever. 
Severe clinical symptoms do not always correspond to extensive 
intestinal changes and vice versa, and the severity of the general 
infection is an essential feature in prognosis. 
YI. Treatment.—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 enter adjacent streams, etc. 
Care must be taken to secure good drinking water and to clean the soil 
of excrementitious matters as much as possible by suitable canalization. 
When typhoid fever breaks out in a house, we should endeavor to 
ascertain its cause in order to protect the other inhabitants. The safest 
plan is removal from the infected house. The treatment of typhoid 
fever itself is purely symptomatic. 
The patient’s room should be large, airy, and kept constantly at a 
temperature of 15° R. It should be aired several times a day. Too 
bright light should be avoided. 
The bedding must be carefully smoothed, and this must be seen to 
several times a day. The position of the body, especially if the patient 
is 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 be rubbed every morning and evening with 
lukewarm water, to which alcohol, vinegar, or eau de cologne has been 
added. If possible the patient should have a separate bed for day and 
night use. lie may drink water, to each glass of which a teaspoonful of 
brandy or two or three tablespoonfuls of white or 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 au 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 boiled 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 may be 
given (calomel, gr. vij. at one dose). 214 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPAEATUS. 
Finally, the patient should receive two lukewarm baths (26° R.) daily, 
one at 9 a.m., the other at 4 p.m. They must be kept under constant 
supervision, especially if they are delirious. 
These measures are entirely sufficient in many cases, though we are 
often forced 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 long time at an unusual height (above 40.5° 
C.); or if the patient is old, feeble, or a drunkard, or in pregnant wo- 
men, in whom the fever may produce abortion. Opinions differ as to 
whether the antipyretic should be administered in the evening, during 
the night, or in the morning (9-11 a.m.). We prefer the latter method. 
In some cases, antipyretics produce increase of the bodily temperature. Dif- 
ferent patients react differently to this or that plan of treatment. 
The antipyretics include cold baths, antipvrin, quinine, salicylic acid, 
benzoic acid, kairin, thallin, 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 15° 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. 
Riess 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 § ij. of lukewarm water. The remedy may be continued, despite the 
production of antipyrin eruption. During the 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 enema, but sometimes causes disagreeable tenesmus. If the 
stomach and rectum are very irritable, it may be given subcutaneously 
(R Quiniae hydrochlor., glycerin., aq. destil., aa. 3 i. M. D. S. One 
syringeful, warmed). 
Salicylic acid or salicylate 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. every hour until the 
temperature has become apyrexial, and is again administered when the 
temperature reaches 38.0° C. INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
215 
Thallin is also a certain antipyretic, but produces similar, though 
less severe, disagreeable incidental effects. In one of my cases, its admin- 
istration was followed by marked albuminuria. Gr. iv. are given every 
hour until the temperature becomes normal. 
Digitalis and veratrine have very little antipyretic action. 
Profound unconsciousness and delirium disappear not infrequently 
under antipyretic treatment; in addition, an ice-bag may be applied to 
the head, and large amounts of stimulants given if the patient is very 
feeble. 
If the mouth is very dry, it should be wiped every two hours with a 
piece of wet linen; dry, fissured lips are anointed with cold cream or 
vaseline. 
In conditions of cardiac weakness, large doses of alcohol must be 
given from the start. If necessary, coffee, tea, champagne, camphor 
(subcutaneously), 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 diarrhoea, we may order Dover’s 
powder (gr. iij. every two hours) or Bismuth, subnitrat., gr. vij.; 
pulv. opii, gr. every two hours. 
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 our opinion, puncture of 
the intestines with a fine trocar is dangerous, because the intestinal 
contents may escape through the opening and set up perforation-perito- 
nitis. 
In intestinal hemorrhage, an ice-bag is applied to the ileo-caecal region 
or to the part in which the 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 writers. 
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 
patient should be placed in a permanent water-bath. 
4. Dysentery. 
I. Etiology.—Dysentery is an inflammatory affection of the mucous 
membrane of the large intestine, which is generally epidemic and depends 
on 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 and 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, dysentery is one of the most danger- 
ous diseases during wars, and also puts an end to many an exploring 
expedition in the tropics. 
The outbreak of epidemics is favored by certain circumstances, for 
example, climate. The spread of the disease is favored by hot seasons, 
and winter epidemics occur much less frequently than those in the sum- 216 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
mer. Hot days*followed by very cold nights are regarded as especially 
dangerous. This is also true of protracted rains and absence of winds. 
The spread of the disease also seems to be favored by marshy 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 the 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 observed. 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 
despondent 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 faeces 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 which 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 m hospitals, if 
the dysentery patients are placed in general wards. These patients 
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. 
ii. Symptoms.—The duration of the period of incubation varies 
from three to eight days. 
Prodromata are absent in many 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. 
In a few cases, the disease begins suddenly with a chill or repeated 
chilly sensations. Intestinal disturbances are often present from thebe- 
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. INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
217 
The daily amount of the stools generally varies from 3 xxv.-xxxv. Some- 
times only three or four drachms are passed at a time. 
The evacuations consist of faeces, mucus, pus, and blood in varying 
proportions. At first the intestinal contents are passed in a fluid condi- 
tion. Masses of mucus then appear, partly adherent to faeces, partly 
separate. They often contain small, vitreous clumps, looking like 
swollen sago. These are not always composed of mucus. Virchow 
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 is supposed that the secretion of the mucous glands is pressed out upon the 
mucous membrane on account of follicular ulcerations, then assumes a round 
shape, and is 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 fiocculi or larger shreds. The stool sometimes contains 
hardly anything but pure pus, especially if abscesses have formed in the 
submucous 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 such amounts, and is so intimately mingled 
with the other constituents, that the stool has a uniform bloody color, 
in which the mucous and purulent flocculi are easily recognized. The 
intimate mixture of mucus and blood often gives to the stool the ap- 
pearance of the rusty sputum of fibrinous pneumonia. 
The stool sometimes 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 vessels. 
The stool sometimes has a cadaverous odor and a blackish color, 
and contains exfoliated shreds of mucous membrane. Such cases are 
known as putrid or gangrenous dysentery, and generally run a fatal 
course. 
The evacuation sometimes loses the faecal odor and occasionally 
smells somewhat like semen. Its reaction is generally alkaline or 
neutral, rarely acid. It contains a large amount of albumin, and this 
explains the fact that the patients rapidly grow pale and often assume a 
cachectic appearance. 
Under the microscope the passages are found to contain round cells, red blood- 
globules, more or less altered epithelium, drops of fat, crystals of triple phos- 
phates, bile pigment, debris of food, and innumerable schizomycetes of various 
shapes. 
The majority of patients complain, before the evacuations, of bor« 
borygmus, colicky pains (tormina), and very soon of violent, almost un- 
controllable 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 
pulse imperceptible. The anus is often retracted, and inspection 
reveals spasmodic twitchings of the sphincter. In men, the cremaster is 
often strongly contracted, and the left testicle drawn upwards against the 
inguinal ring. After dysentery has lasted for some, the anus and sur- 218 
INFECTIOUS DISEASES INVOLVING TIIE DIGESTIVE APPAEATUS. 
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 the bladder is often noticeable. Slight ten- 
derness on pressure over the stomach, vomiting, and singultus are occa- 
sionally observed. The tongue presents a gray or yellowish coating. 
Thirst is generally increased, the appetite lost. 
Uffelman investigated the digestive secretions in a dysentery patient who 
also suffered from a biliary 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 salivary cor- 
puscles, but contains numerous epithelium cells, granular detritus, and fungi. 
The gastric juice becomes more acid, and, in mild cases, 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 bile produced 
in the beginning 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 faecal 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 also run a chronic course. The patients have purulent 
evacuations for months, and finally die of marasmus. Chronic ulcers 
and submucous abscesses or fistulae 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 the 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 fistulas. Cicatrices of the INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
219 
intestinal mucous membrane sometimes give rise to stenosis and symp- 
toms of ileus. A tendency to diarrhoea persists for life in some individ- 
uals. Dysentery may be associated with hepatic abscess, especially in 
tropical countries. The hepatic changes sometimes 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 cases, 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, as the result of previous malaria. Pylephlebitis 
has also been observed. Chronic Bright’s disease is a rare complication, 
but cachectic oedema 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 pyaemic or septicaemic condition occa- 
sionally 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 be regarded as a metastasis of the dysentery virus. Among 
the sequela? must be mentioned paralyses, generally of a spinal charac- 
ter, and which were shown by Leyden to be the result of an ascending 
neuritis starting from the intestines. During violent diarrhoea, 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 surrounded by rings, and the skin clammy, 
while the internal temperature of the body is elevated. Signs of blood- 
dissolution (cutaneous hemorrhages, swollen gums) sometimes make their 
appearance. 
III. Anatomical Changes.—The intestinal lesions of dysentery are 
generally confined to the large intestine, in rare cases they extend to the 
small intestines (usually the ileum). The lesions are most pronounced 
in the rectum, and gradually diminish upwards. The points of flexion 
of the large intestine are usually attacked with special intensity. This 
is attributed by Virchow to the fact that masses of faeces are apt to re- 
main for 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 infrequently very hy- 
peraemic, and in places small subserous hemorrhages are visible. Its sur- 
face often looks opaque, and may be covered by a thin, veil-like mem- 
brane (beginning peritonitis). 
The changes in the mucous membrane are sometimes catarrhal, some- 
times diphtheritic. 
In the catarrhal stage of dysentery, the mucous 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 parts 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 
punctate or cover a large surface. The mucous membrane is also swollen 
and its secretion increased; the surface is covered with an unusually 220 
INFECTIOUS DISEASES INVOLVING TIIE DIGESTIVE APPARATUS. 
large amount of glassy mucus, often dotted or streaked with blood. The 
submucous tissue is also very succulent, congested, and swollen. 
In the further course of the disease, the swelling of the mucous and 
submucous layers increases, while the hypersemia diminishes. The secre- 
tion of the mucous membrane becomes opaque, and assumes a more 
purulent character. In some cases, the solitary lymph follicles take part 
in the swelling. They are enlarged, surrounded by a hyperaemic zone of 
vessels, and often undergo disintegration, at first in the centre, later at 
the periphery. The cavities of the follicles often contain mucoid, sago- 
like masses, such as are observed in the stools during life. 
The microscope at first shows marked dilatation and congestion of the vessels 
of the mucous membrane and submucous tissue, with oedematous infiltration. 
The epithelium of the mucous membrane is intact, and the interstices between 
the individual Lieberkuehn glands appear broader than normal. At a later period, 
there is active emigration of white blood-globules, which accumulate in great 
numbers on the walls of the vessels. They are so densely 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 blood-vessels are narrowed and the hyperaemia diminishes. White 
blood globules are also found on the walls of the vessels in the muscular coat 
At first the enlargement of the follicles depends chiefly on congestion.and 
oedema, later upon hyperplasia of the cellular elements; if the latter becomes ex- 
cessive, necrosis 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 mucosa and especially the submucosa are 
very much thickened. The surface of the mucous membrane forms a 
nodular, greenish or blackish mass, the changes 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 fistulas develop. The extension of the inflammation may 
lead to peritonitis and perforation-peritonitis. Suppuration may also 
take place in the perirectal cellular tissue and terminate in rectal fistulae. 
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 con- 
gested; they sometimes undergo necrosis or caseation. 
The other organs present no characteristic changes. 
IY. Diagnosis.—A diagnosis is easily made, especially during an 
epidemic, from the character of the stools, the tenesmus, tormina, bor- 
borygmi, the tenderness on pressure and dulness in the left ileo-csecal re- 
gion. The disease may possibly be mistaken for: a. Rectal syphilis; syphi- 
litic changes are found in other parts of 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 felt. INFECTIOUS DISEASES INVOLVING TIIE DIGESTIVE APPARATUS. 
221 
d. Paramoecium, distomum, or anchvlostomum; the ova of the parasites 
or the worms themselves are found in the stools. 
V. Prognosis.—The average mortality is seven to ten per cent, but in 
some epidemics it may reach sixty or seventy per cent. Cases of putrid 
and scorbutic dysentery have an unfavorable prognosis. Many patients 
die, after recovery from the dysentery, from marasmus or other compli- 
cations. 
VI. Treatment.—The prophylaxis is similarto that of typhoid fever. 
The patients must be kept in bed and, apart from wine (especially 
astringent red wine), may take only soft-boiled eggs, meat broths, milk, 
and glutinous soups. A large cataplasm (not too heavy) is placed over 
the abdomen. So long as solid particles of faeces are found in the stools, 
mild laxatives (castor oil, calomel, etc.) should be given, and in mild 
cases these will produce 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.; sacch. alb., gr. v. One 
powder every three hours). 
In addition, one to two litres ice-water, to which salicylate of soda has 
been added (two to four per cent), should be injected two or three times 
a day by means of Hegar’s funnel. Carbolic acid should not be employed, 
inasmuch as poisoning with this remedy has been reported. Severe 
tenesmus may be treated with suppositories of opium or morphine; per- 
haps better still with cocaine. 
Cures in Carlsbad, Marienbad, Kissingen, or Tarasp may be very 
useful in chronic dysentery. 
Otherwise symptomatic treatment. 
The following remedies have also been recommended: a. The various astrin- 
gents (internally or by enema); b. narcotics: opium, strychnine, chloral hydrate, 
ergotin; c. laxatives; d. emetics; e. antiseptics (carbolic and salicylic acids, etc.); 
/. balsams: oil of turpentine; g. acids ; h. potassium nitrate, potassium chlo- 
rate, etc. 
5. Asiatic Cholera. 
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 Koch’s celebrated investigations, that 
the cholera virus consists of the so-called comma bacilli. These are 
found constantly in the intestinal contents and walls. 
They never appear in other organs or in the blood, urine, perspiration, 
lachrymal fluid, or inspired air. In one case, Nicati and Pietsch found 
them in the ductus choledochus, in five cases in the gall-bladder. Hence 
cholera 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 has produced cholera-like conditions. It almost seems 
as if the bacilli, in their growth, produce toxic substances. At least 
Nicati and Pietsch state that cholera 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 two-thirds as long as tubercle bacilli, but thicker 
and slightly curved. As a rule, the curve is not greater than that of a comma, more 
rarely it is almost semi-circular. The bacilli are sometimes in juxtaposition, and 222 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
may then form S-shaped figures. They often grow into long threads, which are 
delicately convoluted like spirilli, so that Koch believes that they are not true 
bacilli, but constitute a transitional stage between spirilli and bacilli. 
In dry preparations, they stain easily in a watery solution of fuchsin or methyl- 
blue. 
In the moist condition, they proliferate very rapidly (vide Fig. 39), but soon 
die on drying. Cultures are readily made in meat infusion, peptone-gelatin, or on 
agar-agar, also in meat broth and milk. But the nutrient fluid should not be acid, 
since the bacilli are very sensitive to the majority of acids. Their proliferation 
ceases almost entirely below 16° C., but they remain alive even at 10° C. Accord- 
ing to Raber, they die at 80° C. They also perish in media which contain numer- 
ous bacteria of putrefaction. Klebs suspects that the level of the barometer ex- 
ercises an influence on their proliferation. Spores have not been discovered. 
Curved bacilli are also found in diarrhoeal stools, cholera morbus, tartar of the 
teeth, and cheese. Certain biological properties must also be present to permit 
the recognition of Koch’s comma bacilli. Especially characteristic is their be- 
havior in cultures in meat infusion and peptone-gelatin. At the start, the culture 
Fig. 39. 
Fig. 40. 
Comma bacilli upon damp linen, from the 
dejections of cholera. Enlarged 600 times. After 
Koch. 
Funnel-shaped retraction at the point of in 
oculation of the gelatin in the test tube. After 
Koch. 
appears irregularly circumscribed, and has a granular appearance. Later the 
gelatin becomes fluid in the immediate vicinity of the colony, the latter sinks 
more and more in the gelatin, and finally forms a funnel-shaped depression, in 
the middle of which the colony is recognized as a small white spot (vide Fig. 40). 
Cases have been reported, especially during the first epidemics, 
in which animals are said to have been attacked by cholera, but 
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 subcutaneously. Some experimenters obtained negative, others 
positive results; but it must be remembered that most of the substances 
employed were putrid, and that all the symptoms, accordingly, were 
probably the result of putrid infection. Koch found that the acid gas- 
tric juice of animals will destroy the comma bacilli. 223 
Even human beings have made the disgusting experiments of swal- 
lowing the vomit and stool of cholera, and some suffered for their fool- 
hardiness. That some escaped evil effects is not astonishing, if we bear 
in mind that the susceptibility to infection varies greatly in different in- 
dividuals. 
The virus of cholera is undoubtedly contained in the stools. In two 
cases Koch also found the bacilli in the vomited matters. The faeces 
are infectious in the fresh condition, and their virulent properties are 
intensified when they stagnate in a moist place. If they enter a water- 
closet, the germs are sometimes destroyed by excessive proliferation of 
putrefaction germs, but sometimes they meet with conditions favorable 
to their further development. 
The risk of infection is run by every one who comes 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 follows 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 
slight diarrhoea. Such patients may spread the disease, and in this way 
an epidemic may apparently develop spontaneously. 
Simple contact with a patient is not contagious, but the disease often 
attacks those engaged in cleaning the clothing or bodies of cholera 
patients. A house which contains the undisinfected stool of a cholera 
patient may become a source of infection for all its inhabitants. Hence, 
the rapid transfer of the patient to a hospital is not so important as the 
immediate removal of the healthy inmates of the house. 
If the 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. 
Nicati and Pietsch kept the 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- 
fectious fluids with the air, inasmuch as the bacilli rapidly perish when 
in a dried condition. 
Inanimate objects which are soiled with cholera stools or vomit are 
also capable of infection. Koch found unusually active proliferation of 
the bacilli upon wet articles of clothing. 
Vegetables and fruit which are not thoroughly cleaned may also con- 
vey the germs. Koch stated that insects may act as carriers of comma 
bacilli, and Grossi found them upon the wings and belly of flies which 
alight upon cholera dejections. 
In all probability, the infection is at first purely local from the gastro- 
intestinal tract. The general symptoms of cholera are probably the re- 
sult in part of the enormous losses of water in the stools, and perhaps of 
the production of toxic substances by the bacilli. 
It is assumed that the virus is generally inhaled into the naso-pharyn- 
geal space, and then is swallowed with the food. It may also enter the 
stomach directly in infected drinking water or food. 
Some individuals possess permanent or temporary immunity from the 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 224 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
disease. Sex exerts very little influence, although women are attacked 
somewhat more frequently. The majority of cases occur between the 
ages of 20 and 40 years, but the disease may also attack the new-born, 
children, and old people. In children, the disease is less frequent dur- 
the first five 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 especially apt to be 
attacked. 
A predisposition may be created by excesses of all kinds, the adminis- 
tration of laxatives, 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. Cases 
have been reported in which the patients were attacked three times, and 
Stoufftet reports a case in which 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. 
The 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. 
Cholera 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, Symptoms.—-The duration of the period of incubation is generally 225 
estimated 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 distinguish three different forms, according to the severity of the 
disease, viz.: cholera diarrhoea, 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 
gradually (stage of reaction). If, after the specific cholera symptoms 
have ceased, the patient is apathetic, and a condition develops resembling 
typhoid fever, we call the condition cholera typhoid. 
It is not impossible that the cholera virus may produce milder 
symptoms than those of cholera diarrhoea. The psychical depression, 
palpitation, feeling of oppression, borborygmus, and cramps in the 
calves, which are observed in many individuals during cholera epidem- 
ics, have been attributed to cholera infection. 
In many cases, cholera diarrhoea cannot be distinguished from 
diarrhoea due to ordinary causes. Its occurrence during an epidemic, 
and its infectious properties, especially the possibility that the faeces 
may give rise to severe cholera, are its chief characteristics. Its real 
nature is often doubtful, so that it is well to treat every case of diarrhoea, 
during the prevalence of an epidemic of cholera, as cholera diarrhoea. 
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, they 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 microscope, are also found to contain crystals of the triple phos- 
phates, desquamated epithelium of the intestinal mucous membrane, 
debris of food, and innumerable round and rod-shaped schizomycetes. 
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 straining and severe burning in the posterior part 
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 thickly coated, there is often foetor ex ore. Thirst is increased, while 
the appetite is lost. The patients not infrequently experience a sensa- 
tion of 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 be cramp-like pains in the muscles, es- 
pecially the calves. 
If aid is rapidly brought, the disease may terminate in a few hours. 
In other cases, it lasts several days to a week and then terminates spon- 
taneously, or it passes into the severe forms of cholera. Children, old 
INFECTIOUS DISEASES INYO LYING THE DIGESTIVE APPARATUS. 226 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
and exhausted individuals 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 business and even travel long distances, 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 they lose their biliary character and finally form a 
colorless or gray fluid, mixed with yellow or gray flakes (rice-water 
stools). At the same time the faecal 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, but more 
.severe than, those of cholera diarrhoea. 
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 stage of reaction of asphyctic cholera. So long as the 
stools contain bile, the prognosis is not very grave. But if rice-water 
stools appear and persist for some time, asphyctic cholera often devel- 
ops, and a fatal termination is then the rule, rather than the exception. 
In asphyctic cholera, the chief symptoms are the rice-water stools and 
vomit. The other symptoms are in great part the result of the great 
losses of water. Hence the blood is thickened, and thus gives rise to a 
series of circulatory 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 intestines are found filled, 
in such cases, with large amounts of fluid. 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 usually alkaline or neutral; 
their specific gravity varies from 1.006 to 1.013. They have a gray color 
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 detritus of 
food, a few triple phosphates, a few round cells, still fewer red blood- 
globules, round and rod-shaped schizomycetes, punctate masses and 
drops of fat. Intestinal epithelium cells are often almost entirely 
absent, in other cases we find a few shreds, often coherent cells. 
The latter form part of the flocculi. The latter contain nothing else 
beyond a punctate mass, and are then composed of mucin and a trace of 
albumin. 
The comma bacilli are obtained by spreading one of the flocculi upoD INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPAEATCS. 
227 
a cover glass, drying it by drawing it several times through the flame of a 
spirit lamp, and then covering it with an aqueous solution of fuchsin 
or methyl blue. The cover glass is then rapidly washed in water, again 
dried, and imbedded in Canada balsam (vide Fig. 41). 
Despite every precaution, no bacilli may be found, 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 a 
small amount of solid constituents, especially of organic matters. Al- 
bumin is present, if at all, in mere traces. Urea and carbonate of 
ammonia are also present. Sodium chloride is the chief inorganic con- 
stituent, the phosphates and potassium 
salts are present in very small amounts. 
Kuehne found a sugar-producing ferment 
in all cases, and this led Cohnheim to as- 
sume that the stools are not a simple 
transudation from the vessels, but 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 secre- 
tion stimulates peristalsis and thus causes 
frequent evacuations ; this probably gives 
rise, by reflex action, to increased excit- 
ability of the muscular coat of the stomach 
and thus causes the frequent vomiting. 
The older writers applied the term cholera 
sicca to cases in which, while the patients had 
other choleriform symptoms, they rarely or 
never had an evacuation from the bowels, but 
the autopsy showed that the intestines con- 
tained a large amount of fluid. In an epidemic 
in Koenigsberg, in which I treated nearly one 
hundred cases of cholera, I observed one case 
of this kind. In the Genoa epidemic of 1883, 
a comparatively large number of such cases 
appear to have been observed. 
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 patients yield to the feeling of thirst. When the patients are 
prostrated, the vomiting may be replaced by singultus which often pro- 
duces violent epigastric pains. Singultus and vomiting sometimes alter- 
nate with one another. 
The vomited masses consist at first of debris of food, later they are 
stained with bile, and then present the characteristics of the rice-water 
stools. They may amount to 35,000 ccm. in twenty-four hours. 
Goldbaum calculated that one of his patients drank 10,200 ccm. of 
fluid and vomited 21,250 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 intestinal canal. Its reaction is 
Fig. 41. 
Comma bacilli from a flake. After 
Koch. 228 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
usually alkaline or neutral, its specific gravity varies from 1.002-1.005, 
and contains oniy a small amount of solid matter. 
The microscope generally shows drops of fat, even if fat has not been ingested, 
epithelium cells from the oesophagus and buccal cavity, a few round cells, and 
various schizomycetes, rarely comma bacilli. 
The abdomen, as a rule, is slightly sunken; the lower part is more 
prominent than the upper. There is generally no tenderness on pres- 
sure. Below the umbilicus we often feel a peculiar shaky feeling of 
resistance and gurgling, and find dulness on percussion. 
The appetite is lost, but the patients are tortured by thirst. If too 
much is drunk, vomiting is produced. The majority of patients com- 
plain of burning in the mouth and internal heat, especially in the 
gastric region. The tongue may be clean and unusually red, or it is cov- 
ered with a gray coating; it is usually dry and sticky. 
The loss of water, as a matter of course, gives rise to gradual drying 
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 the 
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 muscles, 
interefres with closure of the 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 Graefe, the 
rolling upwards of the eye is only apparent, and produced by the im- 
perfect closure of the lids. The patient acquires such a peculiar ex- 
pression as to justify the use of the term facies cholerica. 
The exposed portions of the conjunctiva are often dry and devoid of gloss. 
Along the lower edge of the cornea we not infrequently find intense congestion 
of the subconjunctival vessels. Joseph observed subconjunctival hemorrhages 
in some cases. The absorption of substances which are dropped into the con- 
junctival sac takes place very slowly. Joseph states that the patients are un- 
able to weep. 
The sclera sometimes contains irregular bluish and blackish patches, arranged 
concentrically around the lower edge of the cornea (partial desiccation and thin- 
ning of the sclera). They are said to occur only in fatal cases. 
The lowermost portions of the cornea sometimes contain dry brownish 
patches, which leave opacities if recovery takes place. In unfavorable cases, 
softening and destruction may occur. 
The pupils are usually contracted, perhaps from paralysis of the sympathetic. 
Choroidal hemorrhages have been observed in some cases. 
The ophthalmoscope shows that the retinal arteries are unusually narrow, but 
intensely red. Slight pressure on the globe suffices to produce pulsation in the 
retinal arteries, and if the pressure is increased, complete anaemia develops. The 
retinal veins are very wide and bluish-red in color ; in places they are sometimes 
empty. The optic disk often has a pale lilac color, its centre is somewhat paler. 
Vision is generally unaffected. The obscuration of the field of vision, which 229 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
is observed particularly at the beginning of the disease, is probably the result of 
purely nervous disturbances. 
The skin, particularly on the forearms and backs of the hands, is 
wrinkled and flabby. If it is cut, the edges of the wound do not gape; 
if they are separated, they do not exhibit any tendency to approach one 
another. Vesicles can no longer be produced by the application of blis- 
ters or the actual cautery. Not infrequently the skin feels clammy, 
moist, and ice-cold (cholera algida). 
The panniculus adiposus is flabby and diminished in size. The 
absorptive properties of the subcutaneous tissue are impaired, but not 
abolished. 
For example, Goldbaum pi-oduced dilatation of the pupils by subcutaneous 
injection of atropine. Sodium salts, which were injected subcutaneously, were 
found in the evacuations, potassium salts were found in the saliva, but not in 
the stools. 
Painful muscular spasms are an extremely annoying symptom of 
cholera. They are most frequent in the calves, next in the thighs, 
forearms, and fingers, rare in the muscles of the abdomen and chest, 
most rare in the face. When they occur in the calves, the thighs and 
legs are involuntarily flexed 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 substance, but, in our opinion, nervous causes cannot be 
excluded. 
Some authors mention increased mechanical and electrical excitability of the 
muscles. Jo6ias has found that, in severe cases, the tendon reflexes were increased 
at the height of the disease, and became normal during convalescence. 
Consciousness is generally retained to the last moment; in rare cases, 
delirium occurs towards the 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 the evacuations from the bowels. If the disease 
runs a very rapid course, there may be a loss of one-half to one per cent 
of the weight of the body within an hour. 
The bodily temperature always appears subnormal to the hand, and 
the thermometer in the axilla also, a3 a rule, shows subnormal tempera- 
ture. The thermometer rises so slowly that it should be left at least 
half an hour in the axilla. The mouth and tongue generally feel cool. 
The vaginal and rectal temperature, however, is rarely subnormal, some- 
what more frequently normal, and, as a rule, increased to 40° C. (there 
may be a difference of 3.7° C. between the rectal and axillary tempera- 
tures). Shortly before death, the temperature sometimes increases rapidly 
to 42.4° C. 
The pulse is accelerated and not infrequently irregular. The more 
profuse the vomiting and evacuations the more it diminishes in ful- 230 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
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 grows 
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 together, and exhibit but little tendency to 
form rouleaux. In a few cases, free drops of fat have been found in the blood. 
The specific gravity varies from 1.036-1.058 (normally 1.026-1.029). The amount 
of albuminoids and potassium salts in the blood is unchanged, that of sodium 
chloride is diminished. 
C. Schmidt furnishes the following analyses : 
Healthy woman, 
Woman, set. 36 years, 36- 
hours after the beginning 
set. 30 years. 
of an attack of cholera. 
Water 
760.85 
Solid matters 
175.45 
239.15 
Haemoglobin 
154.30 
Fibrin 
1.91 
3.50 
Other organic substances 
48.49 
74.35 
Inorganic salts 
8.62 
7.00 
Sodium chloride 
2.845 
1.953 
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 drops 
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 for 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). This 
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, they generally contain albumin. 
The complications of asphyctic cholera generally appear during the 
stage of reaction. We may mention bloody stools (usually an unfavora- INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
231 
ble sign) and haematemesis. The latter is commonly small in amount 
and produced by violent vomiting. 
Cutaneous emphysema is a rare complication which is secondary to interstitial 
pulmonary emphysema, produced by the violent respiratory movements. 
The majority of cases 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 seventy-two hours. Life gradually becomes 
extinct from excessive weakness of the heart and general prostration. 
The danger is not always ended when the symptoms improve, inasmuch 
as relapses are apt to occur, and severe sequelae develop in not a few cases. 
The 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 by slight fever 
and congestive symptoms. The conjunctivae are injected, the face 
flushed, 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 
typhoid fever (cholera typhoid). The temperature rises considerably, 
the pulse is accelerated, full and tense, the tongue is dry and covered 
with sordes, the abdomen 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 uraemic symptoms appear. This will occur if the 
renal circulation has been interrupted, or almost interrupted, for 
such a long time that the endothelium of the Malpighian bodies and 
the tubular epithelium are rendered incapable of function. In some 
cases, no more urine is secreted; in other cases, the urine is abnormal. 
Hence, urea accumulates in the blood and tissues. Crystals of urea have 
even been observed upon the skin (urhidrosis). The uraemic form of the 
stage of reaction not infrequently presents a typhoid character, although 
not all cases of cholera typhoid are uraemic in character. 
The anuria occurring in cholera is the result of the low blood pres- 
sure and the slowness of the circulation. It may continue after 
the attack of cholera, and sometimes lasts six days. The longer its 
duration the more certain is the fatal termination. According to Gold- 
baum, recovery never takes place if anuria persists for more than seven- 
ty-two hours. 
The quantity of urine passed on the first day after an attack of 
cholera varies from 30 to 500 ccm. (about 200 ccm. 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 
reddish or reddish-brown color, and is ordinarily cloudy. Its reaction 
is almost always acid; sometimes so intensely that Stokvis suspects the 
presence of an unknown free acid. In one case, this observer found a 
neutral reaction. The specific gravity varies from 1009 to 1025.5 (1015 232 
on the average). 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 much 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, hiedwetzky 
found spermatozoa. 
The urine which is first voided almost always contains albumin. In 
the subsequent portions the albumin diminishes, and disappears before 
the amount of urine has returned to the normal. Stokvis noticed that 
the higher the specific gravity 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 the 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. Glycosuria 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 lasted a week. 
The amount of urea is very slight (2.5% on the average) in the first 
cholera urine. If recovery occurs, it gradually 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 cholera ■ 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 the attack 
of cholera. Miliaria and erysipelas have also been described. 
Gangrene 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 anaesthetic or hyperaesthetic. 
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 
been reported in other cases of cholera. Among other nervous compli- 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
233 
cations may be mentioned: general convulsions, trismus, tonic and clonic 
spasms, monoplegia, paraplegia, and hemiplegia, rarely meningitis, 
and chorea (in children). 
Catarrhal or diphtheritic changes are observed on the buccal mucous 
membrane, and salivation has been reported in a few cases. Purulent 
parotitis (more rarely inflammation of the submaxillary gland) has also 
been mentioned, and, according to Gueterbock, is always secondary to 
catarrh of the excretory ducts of the glands. The lesion is sometimes 
bilateral, and may terminate fatally on account of burrowing of pus, 
erosion of vessels, or oedema of the glottis. Paralysis of the tongue and 
palate has been observed in one case. 
Diphtheritic changes may also develop upon the mucous membrane 
of the pharynx, oesophagus and stomach, duodenum and large intestine 
(tenesmus and bloody stools). 
Bronchitis is not uncommon; less frequently there is necrosis or 
oedema of the laryngeal tissues. Pneumonia, abscess, hemorrhagic in- 
farctions, gangrene of the lungs, and pleurisy are observed occasionally. 
Icterus and peritonitis are rare complications. AVomen often suffer 
from pseudo-menstrual bloody discharges. Gangrene of the genitals 
may develop in both sexes. 
Pregnancy does not protect against cholera. When pregnant women are 
attacked, premature delivery is often produced. The foetus sometimes dies in 
utero; in other cases, it is born alive, but is attacked by cholera immediately after 
birth, or a short time afterwards. 
In nursing women, the lacteal secretion is not affected by an attack of cholera, 
and the milk does not appear to be infectious. 
The sequelae include chronic Bright’s disease and diabetes mellitus. 
In some instances, it is said that diabetics recovered temporarily or even 
permanently after an attack of cholera, 
III. Anatomical Changes.—AYhen death occurs during the cholera 
attack proper, the corpse often presents a peculiar appearance^ 
The body is pale, but deep cyanosis is exhibited in the lips, tip of 
the nose, and finger nails. The features are sunken and peaked. Rigor 
mortis is unusually pronounced. The arms, legs, and fingers are flexed, 
and the contours of the muscles are distinctly visible under the skin. 
The corpse cools very slowly, and there is sometimes a post-mortem rise 
of temperature. Decomposition sets in very slowly. 
Post-mortem twitchings of the muscles constitute a noticeable fea- 
ture. They generally begin immediately after death, sometimes not 
until fifteen minutes later. They appear first in the lower limbs, and 
then extend to the arms, trunk, 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 
muscles is reddened uniformly or in patches, and that its temperature 
may rise 0.7° C. Contractions could be brought about by pouring chloro- 
form on the skin and allowing it to evaporate. The cause of this phe- 
nomenon is unknown. 
Similar phenomena appear to occur in the involuntary muscles. Drasche ob- 
served cutis anserina above the contracting muscles, and states that in one case 
a discharge of semen took place one and a half hours after death. 234 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
The subcutaneous cellular tissue and muscles are generally very dry/ 
and the muscles are unusually dark and red. The medulla of the bones 
is also extremely red. 
The serous membranes have a sticky, soapy feel, and their cavities 
do not contain the ordinary post-mortem transudation. 
More or less extensive hemorrhages are found not infrequently 
beneath the epicardium and also in the heart muscle. The right heart 
and main venous trunks are filled with blood, the left heart is empty. 
Fatty and waxy degeneration is observed in the muscular fibres of the 
heart. 
The blood has a tarry color and consistence, and is very slightly or 
not at all coagulated. 
The lungs are strongly retracted and pale; on section, a few thick 
drops of blood can be squeezed out of the larger vessels. The consist- 
ence of the lungs is leathery and tough. 
The loops of the small intestine are filled with rice-water masses, and 
agonal invaginations are often present. The serous layer is injected and 
often cyanotic. The mucous membrane is swollen. The top of the 
folds and villi is often congested, and sometimes infiltrated with blood. 
The solitary follicles and Peyer’s patches are swollen and may be sur- 
rounded by a halo of distended vessels. In the beginning of the disease, 
the swollen follicles, if punctured, discharge a clear fluid and 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 fluid, 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 have been 
traced to the pylorus. 
Kelsch and Renault found marked infiltration of round cells in the subepithe- 
lial and subserous connective tissue, considerable dilatation of the submucous 
vessels, ar»d occlusion of the lymphatic vessels, partly with round cells, partly 
with desquamated and swollen epithelium. Lieberkuehn’s glands were dilated 
in part with mucus, and the epithelium of the upper portions often absent (prob- 
ably a post-mortem change). Koch found comma bacilli in these glands, partly 
in their lumen, partly between the epithelium and basement membrane. Other 
bacteria are also found, but appear to have entered after the death of the tissues. 
In some instances, especially in very rapid cases, the intestinal contents form 
almost a pure culture of comma bacilli. 
Small losses of substance are sometimes produced in the central portions of 
the swollen lymph follicles by hemorrhagic infiltration and softening. 
The large intestine may appear intact. In other cases, there is con- 
gestion of the serous and mucous membranes, with swelling of the latter. 
The microscopical changes are similar to those found in the small intes- 
tines. This is also true of the stomach. 
Goldbaum describes swelling of the circumvallate papillae 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 anaemic, the gall-bladder occasionally distended 
with watery bile or with a serous fluid. According to Nicati and Rietsch, 
the mouth of the ductus choledochus is often occluded by epithelial and 
mucous masses; the functions of the liver are soon abolished, and its 
weight diminishes considerably. They believe that acholia plays a part INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
235 
in producing the fatal termination. In one case, Goldbaum described 
diphtheria of the gall-bladder. 
The kidneys are pale, but hypersemic in places. The interstitial 
tissue is cedematous. The tubules contain numerous red blood-globules. 
The epithelium cells of the tubules are partly granular, partly desqua- 
mated, and in places in a condition of coagulation necrosis. These 
changes are degenerative in character, and result from the imperfect 
circulation of the blood. 
Hemorrhages 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 urine mixed with mucus 
and shreds of epithelium. Diphtheria of the vesical mucous membrane 
is sometimes observed. 
The mucous membrane of the uterus is not infrequently swollen and 
suffused with blood, and may also contain blood on its free surface. 
Hemorrhages are sometimes found in the ovaries. 
The sinuses of the dura mater are usually filled with blackish blood. 
The pia mater is often moist and sticky. Meningeal and cerebral hem- 
orrhages have been described. 
IV. Diagnosis.—During an epidemic of cholera, 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 may occur in our latitudes at any time, and that 
it rarely terminates 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 comma 
bacilli, they have more of a spindle shape with rounded ends; they develop 
fewer threads which are not so long or so twisted as those of the comma bacilli. 
Cultures of Finkler’s bacilli on plates of nutrient gelatin first form regular disks 
with smooth borders, which liquefy the gelatin much more vigorously than do 
the comma bacilli. The two varieties of bacilli also present other biological 
differences. 
The diarrhoea of cholera presents no specific characteristics, so that 
it is well to regard as choleraic every diarrhoea which occurs during an 
epidemic. Poisoning with arsenic, tartar emetic, and corrosive sub- 
limate, and incarceration of the intestines may be mistaken for cholera 
during the prevalence of an epidemic. Even the gross anatomical 
lesions of arsenic poisoning may be similar to those 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. Prognosis.—As a matter of course, the prognosis is so much more 
favorable the milder the form of the disease. In asphyctic cholera re- 
covery is exceptional. The average mortality is about sixty per cent of 
all cases, although it varies greatly in different epidemics. The sudden 
cessation of vomiting and diarrhoea is regarded by many as an unfavora- 
ble sign, and the formation of blackish specks on the sclera is consid- 
ered a forerunner of impending death. After the symptoms of cholera 
have subsided, the prospects of recovery are so much more favorable the 236 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
earlier the urinary secretion is re-established. If this does not take 
place within three days, death is almost inevitable. 
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 eating 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 
of 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 and 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 : 
R. Tinct. valerian, aether., 
Tinct. opii simp aa 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). 
Cholerine 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, brandy, and champagne are 
given as stimulants, ice to relieve thirst; internally, we may order laud- 
anum or 
R. 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 mustard 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, calabar, curare, belladonna, 
ergotin, chloroform, chloral hydrate, amyl nitrite, etc. ; b, styptics: tannin, bis- 
muth, alum, etc.; c, drastics ; d, emetics ; e, nervines: arsenic, nitrate of silver, 237 
etc.; /, antiparasitics: carbolic acid, calomel, quinine ; g, venesection ; h, trans- 
fusion of blood, sodium chloride solution, or milk ; i, subcutaneous infusion of 
sodium chloride solution in large amounts ; fc, enemata of starch, narcotics, and 
styptics ; l, inhalations of oxygen. 
6. Yellow Fever. 
I. ETIOLOGY,—The home of yellow fever is the West Indies, particularly the 
greater Antilles. It is also endemic on the gulf coast of Mexico and on the west 
coast of Africa. 
From these regions the disease has often been conveyed to other parts of 
America, and also to European countries, especially to sea-ports. 
The spread of the disease is associated with communication by water, and 
hence it appears chiefly in sea-ports or cities situated on large rivers. It often ap- 
pears on shipboard; or vessels coming from yellow-fever localities, despite the 
fact that the disease does not appear upon the vessels themselves, infect other 
ports when they discharge their cargo, bilge water, or other refuse. 
It was formerly supposed that the disease may develop autochthonously upon 
vessels as the result of bad ventilation, overcrowding, and stagnant bilge water, 
but these conditions simply offer a favorable soil for the virus. 
The nature of the virus is unknown, but it probably consists of bacteria. The 
virus directs its attack mainly against the liver, and gives rise to changes similar 
to those of acute yellow atrophy of the liver. 
The outbreak of epidemics depends 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 
favored by protracted rains or great moisture of the atmosphere. 
Those parts of the city are in greatest danger which are nearest to the har- 
bor or banks 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 epidemics, 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 then return, the susceptibility to the 
disease also returns. According to recent reports, the importance of acclimatiza- 
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 
foetus 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-makers) are not attacked. Excesses of all kinds favor the out- 
break of the disease. 
More than one attack is very rarely experienced by the same individuals, but 
relapses 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. 
II. Symptoms.—The average duration of the period of incubation is said to be 
two or three days. Some 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 (nausea, anorexia, malaise, etc.). 
The disease begins not infrequently with a single vigorous chill or several 
slighter chills. The bodily temperature rises 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 occi. 
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 repeated vomiting. The patients feel unusually weak and despondent. 
They often emit a cadaverous odor, which Stoone claims to have detected 
before the outbreak of other symptoms. It is said that the patients, after recov- 
ery, are no longer bitten by mosquitoes. On the other hand, it is claimed that the 
disease may be conveyed by these insects. The majority of patients complain of 
severe pains in the loins, and pains in the joints and muscles are also common. 
The heart and lungs remain unaffected. 
The gums are often loose, and covered with desquamated epithelium ; 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 238 
INFECTIOUS DISEASES INVOLVING THE DIGESTIVE APPARATUS. 
this may be followed by ulcers and hemorrhages. The epigastrium is often 
sensitive. There is usually constipation, rarely diarrhoea. The urine grows 
scanty and soon contains albumin. Complete anuria occasionally develops. 
This stage of the disease lasts one to four days. It is followed by the second 
stage (stage of remission), which generally lasts one or two days. Profuse 
diaphoresis suddenly appears and the temperature and pulse become normal in a 
few hours. The patients feel better, and sometimes recovery ensues forthwith. 
Next follows the stage of blood dissolution and jaundice, which lasts, on the 
average, one to three days. An icteric color of the conjunctive has not infre- 
quently been noticed on the preceding days. This now increases and extends to 
the general integument, and may attain the most intense grade possible. 
Diuresis, which had increased during the period of remission, again becomes 
scanty, and the urine contains a large amount of bile pigment, while the biliary 
acids are sometimes absent. Anuria and death from uraemia are not infrequent. 
UlJersperger 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, intestines, kidneys, urinary passages, and genitals. 
Gastric hemorrhage is especially dangerous, and is regarded by some as an 
infallible sign of impending death. The vomited masses often look like soot, and 
contain, according to Gibbs, 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 suspicion of their condition, attempt to leave the bed, and perhaps 
fall over dead. 
The abdomen is often tympanitic, the gastric and vesical region tender. 
The majority of patients die in collapse; in some, death is the result of uraemia ; 
in a small percentage of cases, gradual recovery ensues. 
Purulent parotitis, multiple cutaneous abscesses, and suppuration of the glands 
may occur during convalescence. 
III. Anatomic al Changes.—The skin is jaundiced sometimes to a more marked 
degree than during life. Jaundice is also noticeable in the internal organs and 
other tissues of the body. Rigor mortis generally appears quickly and is very pro- 
nounced. 
Hemorrhages are found in the subcutaneous tissue, muscles, epicardium, 
heart, pleura, lungs, 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 size 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 gall-bladder. As a 
rule, there is no catarrh of the biliary passages, so that the jaundice is probably 
hematogenous, 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 gasti'o-intestinal mucous 
membrane presents hemorrhages, from which superficial losses of substance 
often 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 hemorrhages. At a later period, the tubular epithelium undergoes marked 
fatty degeneration. Hemorrhages may also be found in the mucous membrane 
of the urinary passages and uterus, and in the ovaries. 
IV. Diagnosis.—The diagnosis is easy in tropical regions if the disease is epi- 
demic. It may possibly be mistaken for the following affections: a. Bilious in- 
termittent: the spleen is enlarged and prompt effects are produced by quinine. 
b. Bilious typhoid: the spleen and liver are enlarged, and spirilli are found in the 
blood, c. Phosphorus poisoning: recognized by the history, the garlic odor of INFECTIOUS DISEASES AFFECTING THE GENITAL ORGANS. 
239 
the expired air and contents of the stomach, and the chemical demonstration of 
phosphorus in the latter, d. Acute yellow atrophy of the liver: the liver rapidly 
diminishes in size. e. Grave jaundice: these cases not infrequently remain ob- 
scure. 
V. PROGNOSIS is grave; the mortality in some epidemics was seventy-five per- 
cent. Black vomit, stinking exhalations from the skin, pronounced albuminuria, 
and anuria are unfavorable signs. 
YI. Treatment.—Ships, passengers, and merchandise from yellow-fever ports 
must be strictly quarantined and disinfected. 
In the first stage of the disease, we may order mild laxatives, fluid food, and 
wine. Later, lukewarm baths and stimulants. 
Some recommend quinine, others carbolic acid, salicylic acid, and kairin. 
PART VI. 
INFECTIOUS DISEASES CHIEFLY AFFECTING THE GENITAL ORGANS 
(VENEREAL DISEASES). 
1. Gonorrhoea. Urethritis Blennorrlioica. Urethral Pyorrhoea. Clap. 
I. Etiology.—Gonorrhoea is an inflammation of the urethra, caused 
by a definite form of bacterium, the gonococcus, first demonstrated in 
the inflammatory products by Neisser, afterwards cultivated and suc- 
cessfully reimplanted in the human urethra by Bockhard, Welander, 
Chameron, and Bumm. 
The mucous membrane of the vagina and neck of the uterus is a 
very favorable site for the development of the gonococcus. It may de- 
velop in the rectum, and cause clap, if the discharge overflows from the 
vagina, or is introduced unnaturally. The conjunctiva is a favorable 
spot, 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 experienced recent authorities 
as rather theoretical. • 
Mucous or purulent discharges from the urethra do not always constitute clap, 
i. e., they are not always due to the gonococcus. Many persons have a discharge 
from the urethra after being catheterized; others, when a stone has been caught 
by the urethra and irritated it. 
Chemical irritants, as diluted sal ammoniac, may cause inflammation and dis- 
charge. So can coitus with women suffering from simple fluor albus, the lochial 
discharge, the irritating discharge of uterine cancer, or the menstrual discharge. 
These inflammations are not specific urethritis in our sense of the word. Neither 
are those discharges of fluid which are described in a few cases of sarcoma of the 
penis; nor that sticky secretion which comes from the penis in very small amount 
during violent erection in great sexual excitement. The latter fluid comes from 
the glands of Littre 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. Gouty persons sometimes have a non.gonor- 
rhceal discharge. 
Gonorrhoea is almost always acquired by impure coitus. It rarely oc- 
curs in children, usually through violation; in the case of boys, in the 
rectum. Most of the cases occur in bachelors, especially between 20 
and 40 years of age. 
The attempts often made by patients to deceive the physician are ludicrous 
enough. Some will say it is the sequel of a mere pollution in sleep; others, of 
taking cold, or bad liquor, or making water against the wind or against the cur- 
rent in bathing, and still more incredible things. 240 
INFECTIOUS DISEASES AFFECTING THE GENITAL ORGANS. 
A first attack increases the predisposition to a second. Many have 
an attack after almost every coitus. One is almost tempted to imagine 
the existence of a sort of gonorrhoeal constitution. Experience shows 
that when several men copulate in succession with one Avhore, they do 
not all get clap. There is least risk when the discharge of semen occurs 
quickly, and most when it is intentionally retarded, for, the longer the 
back and forth movements continue, the more abundantly and deeply does 
the infecting fluid penetrate into the urethra. 
The typical locality of the disease in man is the urethra; in woman, 
the vagina. Gonorrhoea of the female urethra, however, is more common 
than is supposed. 
The affection is at first local, and then spreads to the neighboring 
parts. Infection of the conjunctiva at birth, when the mother hasgonor- 
Fig. 42. 
Pus from gonorrhoea, with gonococci. Dry preparation colored with methylene-blue. 450 dia- 
meters. (Authors observation.) 
rhoea, is not uncommon. A man sometimes has several venereal diseases 
at once, caught either from one person or from several. 
II. Symptoms.—Gonorrhoea, like all other infective diseases, has a 
period of incubation. The first symptoms usually appear from twenty- 
four to seventy-two hours after coitus, though many authors mention 
shorter periods: for example, Kuhn declares he has seen it begin in six 
hours; while others still allow a much longer period, as two, three, four, 
and even eight weeks. Statements going beyond the second week must 
be looked upon with suspicion. 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 
such belong to the inexperienced sinners, and learn afterwards to take 
things more coolly. INFECTIOUS DISEASES AFFECTING THE GENITAL OKGANS. 
241 
Eustache reckoned that the period of incubation exceeded fifteen days only in 
35 out of 2,070 patients; he never observed a period of six weeks. 
The course of gonorrhoea may be acute or chronic; there is also an 
intermediate or subacute form. We shall, for practical reasons, describe 
the disease separately in the two 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 permanent, and changes to a painful, burning sensation, while 
the inclination 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 urethra, corresponding to the fossa navicularis, is 
very sensitive to pressure. Drops of greenish-yellow pus soon flow out, 
either spontaneously or on pressure; these foul the clothes, and leave 
stiffened 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 towards 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 most acutely 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 slight provocation, so that 
the disease hangs on for much longer than a year, are not specially 
rare. 
Examining the discharge microscopically (with precautions), we find 
cast-off pavement epithelium and pus-corpuscles, but especially specific 
gonococci (Fig. 42). 
These bodies may be demonstrated thus: Place a little drop of gonorrheal pus 
between two covering glasses, press the glasses together so that the pus is dis- 
tributed between them in a very fine layer, and wipe the edges with blotting paper. 
Then separate the glasses, hold each with forceps, and pass it slowly ten or fifteen 
times through an alcohol flame till the purulent coat is quite dry. Then lay the 
glasses with care on the surface of a concentrated watery solution of methylene- 
blue or gentian violet, in a watch-glass, letting them float if they will, and allow 
them to remain half a minute. Then take out the glasses with a pincette, and 
pour distilled water over them; dry them as at first in a spirit flame, and lay 
them on a glass slide on which a drop of Canada balsam, dissolved in chloro- 
form, is laid. The preparation is now ready for microscopic examination. 
The inexperienced observer should take notice that the pus-corpuscles seem 
enlarged and transparent, so that only their nuclei are distinctly recognizable. The 
gonococci at once attract attention by their deep color. They are roundish, 
with sharply marked outlines, large, with diameter about 0.83 (1 yu=0.01 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 a gelatinous 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. 
Neisser states that they multiply by the prolongation of the individual, a par- 
tition forming in the middle and making two. The same process then takes place 
in each of the halves, the new partition taking a direction vertical to the first 
one. 242 
INFECTIOUS DISEASES AFFECTING THE GENITAL ORGANS. 
Gonorrhoea has a groat many complications, and patients are rarely 
free from them. 
The discharge may become bloody. This is especially the case when 
venereal excesses occur during the disease; it may also accompany obsti- 
nate erections, and excessively frequent pollutions. This form is said to 
have been common among the Russian soldiers at the time of 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 coloring-matter of the blood may give a brownisli or blackish hue; 
hence the expression black clap. 
Erections are commonly troublesome, and chiefly by night, and in 
the recumbent posture. They give pain by mechanically stretching the 
inflamed urethra. Sexual desire is much increased in many, and this 
favors the occurrence of erections. 
Pollutions frequently occur by night, sometimes by day if the fancy 
is allowed to dwell on sexual thoughts oris excited by bad pictures, read- 
ing, and company. The pollutions are painful, because they are at- 
tended by erection. They weaken the patient, and keep up the inflam- 
mation. I have repeatedly observed a gonorrhoeal discharge cease for 
two or three days and then return after a nocturnal pollution. 
Chordee is 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 stretched through 
the penis. The cause is probably the pressure of thrombi in some of the 
cavities of the corpus cavernosum which prevent the distal parts from 
becoming filled with blood. Circumscribed periurethral inflammations 
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 due 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 fistula. In many 
cases, the abscesses are limited to the follicles of the mucous coat (follic- 
ular ulcers). 
If gonorrhoeal pus accumulates in the sac of the prepuce, inflammation 
of the glans often occurs, balanitis; or of the inner layer of the prepuce, 
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 is usually increased. A long, 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 oedema, becomes red INFECTIOUS DISEASES AFFECTING- THE GENITAL ORGANS. 
243 
externally, and cannot be pushed back over the glans. This condition 
is called phimosis. The orifice may be so narrow that the opening of 
the urethra can hardly be uncovered. Phimosis occurs much more 
readily and severely in persons whose prepuce is congenitally narrow. If 
the swelling and compression of the prepuce go on, they may turn to 
gangrene unless arrested; black necrotic spots appear, the necrosed mass 
falls out, and the freed pus escapes through the hole. 
Attempts to draw back an inflamed prepuce in phimosis may lead to 
paraphimosis, popularly known as the Spanish collar; the prepuce 
springs back behind the edge of the glans and clasps ic so tightly that re- 
duction is almost or quite impossible. The prepuce is turned inside out 
and thrown back. If the glans is not released, it may become gangre- 
nous through compression and anaemia; and the like may occur 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 penis is 
painful; a red streak is seen under the skin, marking the course of the 
lympathic vessel, and a rather hard cord is felt, in places knotty, sensi- 
tive to pressure. Abscesses very seldom form. The lymphangitis may 
sometimes be traced up to the symphysis pubis, and the inguinal glands 
sympathize, with acute painful swelling. Inguinal lymphadenitis, on one 
or both sides, also occurs, very rarely with suppuration. 
One of the commonest complications of clap is acute inflammation of 
the epididymis, due to the passage of material which excites inflamma- 
tion from the prostatic part through the vas deferens to the epididymis. 
As gonorrhoea generally begins at the front part of the urethra and extends 
backwards, the epididymis is not usually affected till the second week. 
Both sides are affected with equal frequency, but seldom both at once. 
A distinct cause is commonly to be traced: long walks, dancing, gym- 
nastic exercise, riding, or long standing without a suspensory bandage, 
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 gonorrhoea. 
Varicocele and scrotal hernia predispose to inflammation of the epididy- 
mis of the corresponding side. But there are also cases in which a 
cause is not easily found. 
The first symptoms are sometimes general, as a chill or chilliness, 
headache, dulness of the head, rise of temperature. Some vomit repeat- 
edly. The organ at first feels heavy, and very soon becomes intensely 
painful, the pain becoming intolerable with every movement, and on 
standing. The patient stoops and straddles and walks slowly. The 
epididymis is very sensitive to touch; feels doughy and lumpy, and is 
enlarged. A free exudation soon occurs in the cavity of the tunica 
vaginalis propria —acute hydrocele. The inflamed organ swells to the size 
of a man’s fist and more. The half of the scrotal sac is distended, loses 
its folds, its skin shines and is often reddened, hot, and cedematous—in- 
flammatory oedema. The testes and skin of the scrotum seem grown 
together. The testis often turns upon its long and transverse axis; if 
the oedema and hydrocele are great, it may be hard to gain certain evi- 
dence by palpation. If the patients take care of themselves, the swell- 
ing disappears after about four weeks, the inflammatory fluids are re- 
absorbed, and retrogressive change occurs. But if injuries are inflicted 
at the time of the acute inflammation, an abscess may form, though 244 
INFECTIOUS DISEASES AFFECTING- THE GENITAL ORGANS. 
that is very rare; even gangrene of the testis may be caused by the hy- 
drocele pressing very severely on the testis. 
In the favorable case of absorption, a complete return to the former state 
is rare. Lumpy hardness usually persists, which takes a long time to go 
away, or may last a lifetime; tuberculosis of the urino-genital apparatus 
is a quite common result, through bacillary infection and caseous degen- 
eration of the inflammatory deposit. Impotence has been much dreaded 
in bilateral inflammation, through obliteration of the vasa deferentia. 
This occurs, but not so often as many think. Atrophy of the testis, 
mentioned by many authors, can hardly occur except as a consequence of 
too tight bandaging. Absorption of the fluid may not occur, and the 
consequence is chronic hydrocele. Neuralgia of the testis after gonor- 
rhoeal epididymitis has been seen to occur. 
Terillon examined the seminal fluid during acute double epididymitis, and 
found it purulent, with a large number of granular globules; the spermatozoa 
diminish progressively in number. He suspects purulent catarrh of the smaller 
seminal ducts. The spermatozoa may quite disappear, and may remain absent a 
long time after recovery. In unilateral inflammation, the changes are harder to 
recognize, as they are partly concealed by the normal semen of the other side. 
General symptoms may continue during the height of the developed 
disease; meteorism, vomiting, even vomiting of faeces, 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 paraes- 
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. 
Sturgis reports a case in which epididymitis preceded the clap; I have seen a 
similar one in which I could not detect an error of observation. 
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 skin above it is reddened and often cedematous. De- 
ferenitis without epididymitis is rare. Abscesses may form, and burrow 
outwardly. 
Gonorrhoeal prostatitis is a rather rare complication. It often begins 
with general symptoms. Patients soon complain of a sense of burning 
and painful pulsation in the region of the perineum. It is difficult or 
impossible to urinate, and the catheter meets an obstacle. The gonor- 
rhoeal discharge usually ceases. Pain is intolerable at defecation, and 
makes many faint; the stool is intentionally held back, but the suffering 
is only the greater. The perineum is reddened and swollen, usu- 
ally warm to the touch, and very sensitive. The finger in the rectum 
feels the gland swollen, hot, and very sensitive to pressure. Chills 
sometimes occur, abscesses form in the inflamed gland, bursting into 
the rectum, or urethra, or though the perineum. There is danger of 
pyaemia and death. 
After an attack of gonorrhoea, the prostate sometimes remains per- 
manently swollen, and prostatorrhoea develops; compare Vol. II., page 
350. 
Acute inflammation is sometimes propagated to the glands of Cowper INFECTIOUS DISEASES AFFECTING THE GENITAL OKGANS. 
245 
or the seminal vesicles, which may cause abscess. In the former case we 
find, about half-way between scrotum and anus, laterally from the 
middle line, a prominent spot covered with red and (edematous skin, 
hot to the feel, and painful when touched. Pus usually breaks into 
the urethra. Infiltration of the surrounding connective tissue with pus 
and urine may cause pyaemia, as in the case of suppurative prostatitis. 
In inflammation of the seminal vesicles, the finger in the rectum feels 
swollen and tender bodies at the sides of the prostate. Inflammation not 
seldom passes from the urethra to the neck of the bladder and the 
bladder. There is dysury and ischury ; the urine is very rich in mucus, 
pus-corpuscles, and epithelium from the vesical mucous membrane. 
Hemorrhage from the bladder may occur. I lately treated a laborer whose 
gonorrhoea had been cured for several weeks, but who was suffering from 
very violent hemorrhagic cystitis. The diagnosis is established by find- 
ing gonococci 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 and ureters and urinary canals, and 
casts. Abscesses are sometimes found in the kidney, and uraemia and 
pyaemia may then cause serious danger. 
All the complications here described are mentioned as caused by ex- 
tension of the disease by continuity. But this does not exclude the oc- 
currence of general disturbances during the course of acute gonorrhoea. 
Some patients have a slight fever, especially if found to labor hard. 
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 the metastases of gonorrhoea, which, without doubt, 
are due to the transference of gonococci, contrary to rule, to distant 
organs, where they set up a fresh inflammation. The only case where 
gonococci have been demonstrated is that of articular disease. 
Shifting, so-called rheumatoid muscular pains are often complained 
of, and my experience agrees with that of authors who have observed 
symptoms of acute muscular rheumatism in 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 emphasis on gonorrhoeal periostitis, which causes pain- 
ful swelling of the periosteum, most frequently on the spine of the sca- 
pula, os calcis, phalanges and trochanter major, lasts one or two weeks, 
and sometimes suppurates. 
The long-debated question as to whether the occurrence of gonor- 
rhoeal arthritis is due to mere coincidence is at last settled by Petrone's 
and Kammerer’s demonstration of gonococci in the inflammatory fluids 
of the affected joints. Petrone states that he has even seen them in the 
blood. The attack usually occurs later than the fourth or sixth week of 
the gonorrhoea, often sometime after the purulent discharge has ceased. 
Acute clap in men is the most frequently combined with rheumatism. 
The attack may come very gradually, and may be limited to one or a 
few joints, the knee being one of the favorite points attacked; in other 
cases it is acute and multiple, and is entirely like acute non-gonor- 
rhceal rheumatism of the joints. 
French authors have properly divided the affection into distinct 
classes. Some cases are gradual and painless, developing without inflam- 246 
INFECTIOUS DISEASES AFFECTING THE GENITAL ORGANS. 
mation or larger exudation like hydrarthrosis. In other cases, there are 
painful inflammatory swellings as in acute rheumatism. In a third class, 
there is excessive sensitiveness to pressure or movement without local 
alterations. Cases of acute inflammation with suppuration, pyaemia, and 
death have been seen; or suppuration, ankylosis, and permanent stiffness 
of joints. I have repeatedly and recently seen cases of inflamed joints 
accompanied by purpura or nodes like those of erythema nodosum. 
Endocarditis, pericarditis, pleurisy, and meningitis occur. Schedler 
reports a case of death from ulcerative endocarditis after clap. Erythema 
of the skin and disease of the larynx are reported by Liebermann and 
Bernier. Phlebitis has been observed. The sheaths of tendons and 
bursae mucosae are sometimes attacked like the joints. 
Inflammation of the eye has been observed in patients with gonorrhoea 
who formerly had the joint disease. The commonest forms are iritis 
and irido-choroiditis, sometimes associated with opacity of the vitreous, 
but changes also occur in the cornea. Pauss describes descemetitis; 
Clemens the same, and also with radiating keratitis. 
The following sequelae of gonorrhoea may be again named : Azoo- 
spermia, tuberculosis of the epididymis and uro- 
genital apparatus, chronic hydrocele, stiff and de- 
formed joints, synechiae of the eye, etc. Pointed 
condylomata sometimes develop after clap; some- 
times at the meatus, usually in the sulcus of the 
corona, but also at the opening of the preputial 
sac; they are warty excrescences with many pro- 
tuberances, sometimes surrounding the entire 
penis (Fig. 43), caused bythe irritating secretion. 
Chronic gonorrhoea in men is extremely com- 
mon, almost always due to badly treated or neg- 
lected acute gonorrhoea. There are various ana- 
tomical changes: chronic granular inflammation, 
or chronic ulcers of the mucous membrane with 
granulations that bleed easily, or contraction of 
the urethra with protracted inflammation behind 
the stricture. In all cases the membranous por- 
tion is chiefly or exclusively affected. 
There is not a continuous discharge, but a mixture of purulent frag- 
ments, threads, or shreds with the urine, especially in the morning, when 
the secretion has been accumulating for some time. The meatus is often 
stuck together in the morning before water is passed, and a drop of 
sero-mucous rather than purulent fluid will flow out or may easily be 
pressed out, the pressure beginning as far back as possible and going 
forward. “ G-outte militaire” is a slang term for this affection; another 
is “ hussars’ clap.” 
The microscope shows that these discharges contain pus-corpuscles, 
angular and shrunken, forming a sort of clot; and pavement-epithelium, 
often in a state of hyaline degeneration (Furbringer) (Fig. 44). There 
are no gonococci. 
Many cases of chronic gonorrhoea take the form of fibrinous or croupous 
urethritis, and fibrinous clots are found in the urine. 
If stricture of the urethra is the cause of chronic clap, there will be 
difficulty in passing water; the stream is weak, twisted, forked, or drib- 
bling; long pressure and much straining are necessary to start it and 
Fig. 43. 
Pointed condylomata of the 
inner layer of the prepuce, 
following gonorrhoea. Au- 
thor’s observation. Zurich 
clinic. INFECTIOUS DISEASES AFFECTING- THE GENITAL ORGANS. 
247 
keep it going. If there are ulcerations with bleeding granulations on 
the mucous membrane of the urethra, little streaks or clots of blood may 
be seen in the discharge. 
Chronic urethritis involves many dangers. Patients are liable to be- 
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 subsequent attacks are less violent than the first. There is dan- 
ger from a stricture—or the contraction caused by gradual cicatrization 
of chronic ulcers in the urethra. 
Fig. 44. 
Thready discharge in old gonorrhoea. Author’s observation. Zurich clinic. 250 diam. 
Acute gonorrhoea in women most frequently affects the vagina, 
vulva, ancl vaginal part of the uterus, less commonly the urethra; though 
the latter is oftener affected than is generally supposed. Especially 
when urine has not been recently passed, pus may often be made to 
flow out by pressure on the urethra. In acute gonorrhoea of the vulva, 
the labia are often swollen, reddened, hot, and oedematous, the inner 
surface thickened, secreting purulent fluid, which is partly dried in thin 
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 discharge of urine, there is pain if the urine touches the inflamed 
parts. 
Swelling, redness, pus, and erosions are also seen in the vaginal and 
cervical affection. Gonococci in the pus prove the virulent (or rather, 248 
infectious diseases affecting the genital organs. 
contagious) nature of the discharge. If the urethra is affected, there 
are frequent desire to pass water, and burning sensations while passing it. 
If a woman goes about a good deal while the secretion is free, it runs 
down and causes eczema intertrigo 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 secondary inflammation. There is pain behind one 
labium, and a tumor is visible, which forms an abscess and may break 
into the vagina or through the skin. Para- and peri-metritis have been 
known to occur after acute gonorrhoea; 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 gonorrhoea 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 at stool; 
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-purulent 
secretion is left on the finger. 
III. Anatomical Changes.—As gonorrhoea seldom causes death, 
there are few autopsies. In place of such examinations, much 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. Desormeux in 1855 made the first thorough 
studies, and G-riinfeld some of the best in Germany. The whole anterior 
half of the urethra can be seen with an ear-speculum and mirror. 
In acute urethral gonorrhoea, the mucous membrane is much swollen 
and reddened. In some places, vascular trunks full of blood can be 
recognized; in others, the epithelium is gone; there are small accumula- 
tions of pus here and there. The membrane may bleed very easily. 
In the chronic affection, the mucous membrane is most commonly 
swollen, diffusely reddened, and granular—chronic granular ure- 
thritis. In other cases, there are ulcers in the membranous part of the 
urethra, some of which are granulating. Stricture may be added. 
IV. Diagnosis.—The microscope renders this easy, for every in- 
flammation containing gonococci in its products is gonorrhoea. Neisser 
has demonstrated them in 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 its 
presence. If we cannot prove it, our diagnosis first lies between 
granular inflammation of the mucous membrane and chronic ulcera- 
tion; the latter will be inferred if the sound, or pressure from out- 
side, gives sharp pain at any special point of the pars membranacea, 
or if streaks of blood are seen in 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. Prognosis.—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 carelessness is rarely death, but often INFECTIOUS DISEASES AFFECTING THE GENITAL ORGANS. 
249 
enough the health is impaired for a long time or permanently. The 
chronic disease often resists radical treatment for a very long time. 
VI. Treatment.—The best safeguard is to avoid diseased women. 
The frequency of disease could be much restricted by having women in 
brothels strictly examined several times a week by physicians, who 
should be instructed how to make the certain diagnosis by the micro- 
scope. The more completely the profession of prostitutes is brought 
under police control, and private prostitution checked, the less the 
danger of contagion. 
An English physician named Condom is the author of the india-rub- 
ber bag 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 penis 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 
Ereventives are not absolutely sure. Another thing to avoid is, visiting 
ouses of prostitution after indulgence in conviviality. 
Many plans for cutting short or aborting the disease when it appears 
have been invented. As a rule, it is said that such treatment must not 
be applied later than two days from the beginning of the purulent dis- 
charge. The remedies advised are nitrate of silver (one part to thirty 
for injection), or solution of caustic potash, or aqua calcis. This 
method is theoretically justifiable, but in practice almost always does great 
harm, for the discharge is not generally suppressed, while severe diseases 
of the bladder, epididymis, and so on, are readily excited. 
Much experience in our own practice has led us to the following 
plan. The patient lies abed, drinks no strong coffee or tea, eats no 
highly seasoned food, avoids all sexual excitement through conversation, 
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 a 
two-per-cent solution of carbolic acid into the urethra every hour in 
order to get rid of the secretion as soon as possible. 
If the disease lasts longer than six days, use an injection of 
5 Zinc. Sulph gr. vi. 
Aquae fl. § vi. 
Iodoformi 3 iiss. 
Solve; misce. Shake well before using. 
This is to be injected every second hour, directly after using the 
former 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- 
other mucous membranes, or sore places. 
The syringes that we prefer are the glass ones, with the tip rounded to avoid 
injuring the urethra. The piston must fit well and draw well. It is filled with 
the fluid, and held point upward, and the piston pushed forward to expel the air; 
then the point is slowly and carefully introduced into the urethra, till the nozzle 
is all within the canal. The thumb and forefinger then press the meatus gently 
against the nozzle so as to keep the fluid from escaping, and the piston is pressed 250 
INFECTIOUS DISEASES AFFECTING THE GENITAL ORGANS. 
very 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 the 
nozzle is drawn out. Great 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 acute clap a number of astringents or disinfectants 
have been recommended, none of which seem to be equal to the above 
treatment. We should in general begin with weaker solutions and 
increase to stronger ones by degrees. It is advisable to change the 
remedy once in five days, as the mucous membrane grows accustomed to 
one. We mention the following solutions: Tannic acid, gr. xv.-lxxv.: 
1 vi.; Crude alum, gr. xv.-lxxv. : vi. ; Acetate of lead, gr. xv.- 
xxx. : 3 vi. ; Nitrate of silver, or acetate of zinc, or sulpho-carbolate of 
zinc, or sulphate of copper, gr. iij.-viij. : | vi.; Sulphate of cadmium, 
gr. -2V4-: 0 vi.; Subnitrate of bismuth, gr. xv.-xxx. : 3 vi.; Kaolinum 
purum pulveratum, gr. lxxv. : § vi.; Corrosive chloride of mercury, gr. 
t4s~¥V '• 1 vi. > Permanganate of potash, gr. : 1 vi.; Muriate of 
quinine, gr. xv.-xxx. : 3 vi,; Chloral hydrate, gr. xv.-xxx. : 3 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 testes 
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, Tolu 
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 
ffl 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 Yenere for a long time; too early return to beer 
often produces relapses. 
The treatment of complications can only be sketched. For large 
hemorrhage, raise the penis against the belly and wrap it in cold com- 
presses; if bleeding continues, inject the following: 
B Liq. ferri perchlorid gr. xv. 
Aquae fl. 3 vi. 
For erections and pollutions, direct the supper to be taken several 
hours before bed, and to consist chiefly of fluids. Also give 
B Potass, bromidi gr. xxx. 
Lupulini gr. yiij. 
Pulv. camphorae gr. iss. 
Morph, hydrochlor gr. I 
Pulv. Gflycyrrhizae gr. viij. 
M. f. pulv. no. ij. S. One before bed-time. INFECTIOUS DISEASES AFFECTING THE GENITAL ORGANS. 
251 
Cold compresses by day for the same trouble. Digitalis is recommended 
by Berenger-Feraud. 
For chordee, the treatment just described; if induration is felt in 
the region of the urethra, inunction with iodide of potassium ointment. 
For frequent micturition, suppositories of opium or morphine, and 
not belladona, which often increases the trouble. 
B Morphini hydrochlor gr. viiss. 
01. Theobromae q. s. 
F. supposit. No. iij. 
Avoid also the too free use of fluid and carbonic-acid drinks. 
Periurethritis requires poultices, and sometimes opening of abscesses. 
Balano-posthitis: bathe the penis every three hours in a lukewarm 
two-percent solution of carbolic acid, and insert with an olive-tipped 
sound, between glans and foreskin, some thread-charpie covered with 
B Ac. tannici gr. xv. 
Yaselini. 3 ss. 
M. 
AVe have also found it very useful to touch the glans and foreskin 
with lead-water just after washing. 
If there is phimosis in addition, inject solution of carbolic acid every 
three hours with a syringe between prepuce and glans, besides the oint- 
ment on charpie. If the phimosis is excessive and inflammatory, use 
lead-water compresses, and if this does not relieve inflammation, the 
prepiice must be divided to avoid gangrene. 
For paraphimosis, first use cold lead-water compresses, as the trouble 
often subsides after the inflammation is relieved. If it is thought neces- 
sary 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 mercurial 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. Jalapae, 
Sacch. alb aa gr. viij. 
M. ft. pulv. No. ij. S. Take one powder. 
Place three to six leeches around the anus if pain is excessive. If the 
inflammatory symptoms diminish, wind the testis every day in a wet 
gauze bandage beginning at the upper part. This is much better than 
shaving the parts and applying sticking plaster in strips, as it is easy to 
remove the bandage if it presses. It is also superior to the rubber 
bandage of Neumann. Scarifications have been successful in case of 
great accumulations of inflammatory fluid. 
For persistent induration of the epididymis, give iodide of potassium 
( 3 iiss. in § vi. of water, a tablespoonful three times a day), or for 
anaemic patients iodide of iron, and frictions with ointment of iodine 
or mercury. 252 
INFECTIOUS DISEASES AFFECTING THE GENITAL ORGANS. 
If there are symptoms of vesical catarrh or inflammation of the kid- 
neys, suspend the injections, and give tea of uva ursi leaves, tannic acid, 
or arbutin; for severe pain in the bladder, warm cataplasms to that 
region. 
In inflammation of the prostate, seminal vesicles, or Cowper’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. 
viij. hourly till the ears ring), but neither gives prompt relief. Of late, 
I have often found benefit from pencilling the joints with iodoform- 
collodium 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 successful. 
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. Injections 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. 
B Aluminis 3 iiss. 
Iodoformi 3iv. 
Yaselini § iss. 
M. S. To be introduced into the vagina morning and evening, spread 
on a pledget of cotton. 
For inflammation of Bartholini’s glands, warm cataplasms and inci- 
sion when suppuration begins. 
2. Soft Chancre. Ulcus Molle. 
(Pseudosyphilitic Ulcer. Chancroid (Clerc). Ulcus Contagiosum 
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. INFECTIOUS DISEASES AFFECTING THE GENITAL ORGANS. 
253 
When at its height, the ulcer is very contagious. A single drop of pus has 
been mixed with half a glass of water without losing its activity. In closed 
glass tubes, the inoculability remains longer than a fortnight. The dried secre- 
tion may be found active if softened in water a long time after. Placed in boil- 
ing water, alcohol, concentrated mineral acid, caustic alkali, or astringent fluids, 
it entirely lost its communicability. 
Physicians or midwives may easily get soft 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 pus running down from the genitals. Kissing, the use of water- 
closets after chancrous persons, the use of drinking cups, eating-vessels, 
and pipes, foul linen and bandages, and infected wash-tubs 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 diseased women without becoming affected, 
but have transmitted disease to Other women whom they have visited directly 
after, the explanation being that they have carried infecting pus under the pre- 
puce from one to the other (Ricord, 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, 
though 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 have repeatedly heard 
patients trace all the cases to one woman. The soft chancre is seldom 
found in children; if seated on the genitals or anus, it may be caiised by 
violation; if elsewhere, it maybe due to accident. 
Soft chancre, like clap, while uncomplicated, is a purely local lesion 
of the genitals; at farthest, the neighboring lymphatic glands are impli- 
cated. The disease is not hereditary, nor does one attack insure against 
another, in case of new exposure. A coincidence of soft chancre, gonor- 
rhoea, and syphilis is not rare, as one form does not exclude the 
other. If a man with soft chancre cohabits with a syphilitic person, his 
sore may be changed into a syphilitic or hard chancre. While his soft 
chancre, perhaps, heals by degrees, the hard chancre develops very 
slowly, becomes more and more indurated, and in the place of the former 
soft sore, a lump of cartilaginous hardness rises, which is afterwards fol- 
lowed by syphilitic changes of the skin and mucous membrane. We 
must, therefore, be a little careful about prognosis. Such a case is called 
a mixed chancre (Clerc). 
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; in 
forty-eight hours, there is a red papule, quickly turning to a pustule, with pus 
under the epidermis; this bursts, and dries to a crust. If this is removed on the 254 
INFECTIOUS DISEASES AFFECTING TEE GENITAL ORGANS. 
fifth or sixth day, there remains a deep ulcer with the characteristics of a soft 
chancre. The virus is inoculable on animals. 
The characteristics of the soft chancre are usually very marked. It 
is usually deep, with steep edges, forming a crater ; often perfectly round 
as if punched out, while at other times its edge has bays, as if eaten into. 
The edge is always sharply defined, often a little raised in waves and 
undermined (Fig. 45). The immediate vicinity is inflamed and red. 
The surface of ulceration has a yellowish or greenish-gray, tallowy, ne- 
crotic, diphtheritic coat, at the period of full development, and the secre- 
tion is infectious only as long as this coat continues. The surface is also 
full of holes, as if worm-eaten. The purulent coat contains pus-cells, 
and sometimes crystals of ammonio-magnesian phosphate and carbonate 
of lime. The ulcer cleans itself afterwards, the secretion becomes puru- 
lent, the base shows good granulations, and cicatrization occurs; at this 
period no infectious secretion is produced. If the ulcer is pressed with 
the finger from one side, pain is felt; prickling, itching, and pain may 
Fig. 45. 
Multiple soft chancre of the inner layer of the prepuce and the sulcus coronarius. Author’s 
observation. (Zurich clinic.) 
be felt spontaneously. The ulcer bleeds easily when compressed or 
touched with a sponge. The base and vicinity are often slightly hard- 
ened, from inflammation, but this hardness passes gradually into the 
neighboring parts. 
In the majority of cases, soft chancres are multiple; the edge of the 
prepuce, the labia, etc., being fringed with them. Opposite surfacesof 
skm in close contact often have ulcers of exactly corresponding size and 
shape; we can-sometimes see the auto-inoculation of superjacent skin by 
an ulcer. 
The size varies from that of a pin’s head to that of a finger-nail or 
larger. 
The commonest seat of ulcers in man is the external prepuce. They 
often occur on the edge of the prepuce, its inner surface, and the sulcus 
coronarius; in the latter case, they may destroy the franum, or perforate 
it, or may open the artery of the fraenum and cause very troublesome 
bleeding. Chancrous ulcers may be found at the meatus or in the 
urethra, but not deeper than the fossa navicularis. In the latter case, a 
purulent flow occurs from the urethra, and the disease may easily be INFECTIOUS DISEASES AFFECTING THE GENITAL ORGANS. 
255 
mistaken for gonorrhoea. They occur also on the skin of the scrotum, 
in the genito-crural fold, on the symphysis pubis, and the navel. 
In women, soft chancres are most commonly seen on the inner surface 
of the labia and the posterior commissure of the vagina. The labia are 
often swollen and red, and the ulcers covered 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 
of the vagina or the vaginal portion of the uterus. The rectum has been 
mentioned. 
Chancroids usually cicatrize by degrees. The cicatrix is soft, and 
leaves on the 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 chaucroid and the superficial chancroid form a kind of 
transition to the complications. 
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 are 
common on the glans. Jullien has lately described bullous chancre, 
which leads to vesicular elevations of the skin. Ulcus molle elevatum 
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 gangrenous chancre is nearly related to this; gangrene, of 
the ulcer and its vicinity, often spreads very fast, so that in a short time 
extensive destruction of the penis and skin of the scrotum, the perineum, 
inguinal region, and abdominal wall occurs. Such cases have been ob- 
served with special frequency in hot summer weather, and in anaemic 
persons, those far gone in consumption, and persons addicted to drink. 
The use of mercury causes a predisposition to gangrene. Phagedaenic 
chancre also causes rapid destruction without decided gangrene. In these 
cases, the parts below the skin (as the muscles of the abdomen) may be 
exposed, as if dissected with a knife. Serpiginous chancre is a term for 
cases in which a chancre heals and cicatrizes at one point, while extend- 
ing in another; it is often protracted, and causes extensive ulceration 
and cicatrization. 
Complications may originate from local circumstances, as when the 
fraenum is perforated, or its artery. On the 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- 
mella of the foreskin and the fossa of the glans may also cause phimosis 
through inflammation and oedema 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. 
Inflammation in neighboring organs often causes complications. Es- 
pecial attention is due to inflammation of the inguinal glands, which is 
usually acute, and is designated as acute bubo. This complication is 
favored by irritating local treatment of the ulcer, or by irritation 
through bodily exertion, tight trousers, long marches, gymnastics, danc- 
ing, riding, etc. Continued excesses with wine and women favor it. The 
locality has some influence, for buboes often accompany ulcers of the 256 
INFECTIOUS DISEASES AFFECTING THE GENITAL ORGANS. 
frgenum or fossa, since numerous lymphatics originate in those parts, 
and their nearest meeting-place is the glands in the groin. 
The lymphatics of the dorsum penis are also often inflamed, and then appear 
as a tender cord, round, somewhat hard, often knotted, the skin over which may 
be reddened; pus is rarely formed. 
Ulcers on one side of the penis cause bubo in the corresponding 
groin. This is evidently due to the anatomical connections of the 
lymphatics. Both groins are affected when the ulcers are in the me- 
dian line, on the fraenum, or dorsum of the glans or prepuce. 
Buboes may be sympathetic, in which case they resemble those which 
arise from the presence of any inflammation in the vicinity of the glands. 
The swelling is usually multiple; the glands tender to pressure, painful 
in walking, and gradually disappearing when care is taken. Such swellings 
are always more common in people who are predisposed to glandular en- 
largment—that is, the scrofulous. They often remain for months or 
years, and this form has been called strumous bubo. 
Chancrous buboes affect only one or few adjacent glands, and 
have a tendency to acute suppuration. The gland swells, and is often so sen- 
sitive that the patient can only walk slowly and haltingly in the stoop- 
ing position; the skin over it is cedematons, then reddens, and adheres 
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 orifices. In many cases, the pus burrows deeply and may erode blood- 
vessels in the leg, endangering life by bleeding; or circumscribed or dif- 
fuse peritonitis occurs. 
The chief point that distinguishes a chancrous bubo from the puru- 
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, phagedsena, or a serpiginous 
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- 
blee. The point is disputed, and more than doubtful. 
Among the sequelae of soft chancre is destruction of large parts of the 
sexual organs; in some cases only the stump of the glans or penis re- 
mains. Perforation of the fraenum is usually of no consequence. Ulcers 
of the meatus may contract the opening when they cicatrize, which will 
require an operation for relief. Pointed eondylomata may spring up 
where the external genitals are irrigated with irritating secretions. Fis- 
tulous passages may remain for a long time after suppurating buboes. 
III. Diagnosis.—Soft chancre is not usually hard to distinguish. 
We must consider especially acne, herpes, hard chancre, and cancer. 
Acne is connected with sebaceous follicles, and makes abscesses and 
ulcers which heal spontaneously in a few days. 
Herpes produces a group of vesicles crowded together on a reddened 
base; the contents are at first serum, which afterwards dries to thin 
crusts. After the crust falls off, no deep, crater-like ulcer remains. The 257 
INFECTIOUS DISEASES AFFECTING THE GENITAL ORGANS. 
trouble heals spontaneously in a few days. Patients often state that 
they have repeatedly had similar attacks without having had coitus. 
Hard chancre, the first distinct symptom of syphilis, differs from soft 
chancre by its sharply defined cartilaginous 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. 
Caspary gives the following histological points of difference: In hard chan- 
cre, greater deficiency of blood-vessels, greater development of the trabeculae in 
which round cells are distributed, numerous open lymph-spaces. Lustgarten’s 
studies assign a greater importance to the demonstration of syphilis bacilli in hard 
chancre. 
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 be sure to 
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 tissues of the skin, in which it was doubtful whether phage- 
daenic or gangrenous chancre was the cause, or not. 
IV. Prognosis.—Though manifold complications maybe associated 
with soft chancre, and may develop into serious diseases, yet the prog- 
nosis is usually good. The more care a patient takes of himself in mind 
and body the better chance of a good sound recovery. Anaemic, poorly 
nourished, or tuberculous persons are in more danger from the develop- 
ment of complications than robust patients. It is well to keep a patient 
under one’s eye for a time, lest symptoms of syphilis may break out after 
an unrecognixed mixed chancre. 
V. Treatment.—As regards prophylaxis, we refer to the remarks 
already made in connection with gonorrhoea. Washing the penis and 
scrotum with five-per-cent solution 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 appearance of the sore. It consists in cauterizing the 
ulcer 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 by a chancrous state 
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 must 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 {%%). 
The following dressings are old favorites : solutions of sulphate of 
copper, £ per cent; of sulphate of zinc, nitrate of silver, carbolic acid, 
permanganate of potash, creasote, etc. 
17 258 
INFECTIOUS DISEASES AFFECTING THE NEEVOUS SYSTEM. 
In the case of gangrene, phagedasna, or serpiginous ulceration, try to 
remove the cause (e. g., forbid 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 phagedsenic 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 
advantage. 
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 rubbing in 
ointment of iodide of potash or iodoform, giving also cod-liver oil, iodide 
of potash or iron, and arsenic. 
PART VII. 
INFECTIOUS DISEASES AFFECTING THE NERVOUS SYSTEM CHIEFLY. 
1. Epidemic Cerebro-Spinal Meningitis. 
I. Etiology. —Epidemics of cerebro-spinal meningitis 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 usually 
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 male 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 (Praentzel). 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, insignificant 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. INFECTIOUS DISEASES AFFECTING THE NERVOUS SYSTEM. 
259 
A disposition to purulent inflammation of other parts— e. g., boils— 
is often noticed during epidemics of cerebro-spinal meningitis. 
Sporadic cases of the disease maybe called spontaneous cases; though 
the patients often assign such causes as taking cold, over-heating in the 
sun, mental over-work, or excess of drink, which are unimportant, or 
at the most only aggravate the complaint. 
Nothing is certainly known in regard to the nature of the infectious material. 
Gaucher, Leyden, and Leichtenstern observed oval micrococci in the inflamma- 
tory products, joined in pairs (diplococci), and according to Leyden in chains 
of from three to six. 
II. Anatomical Changes.—The local changes affect principally 
the pia mater and arachnoid of the brain and cord. There is inflamma- 
tion (piitis and arachnitis, or collectively leptomeningitis), causing a 
deposit of exudation, which is commonly fibrino-purulent, more 
rarely sero-purulent. Death may occur so quickly that at the autopsy 
nothing beyond severe hyperaemia is found. Secondary alterations of 
the nervous system also occur; and indications of general infection are 
very prominent. 
The corpse usually decomposes quickly. 
On removal of the cranium, unusual tension of the dura mater is 
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 dura is cut 
and turned back, its inner surface is usually dry, lustreless, and dotted 
with hemorrhages. In the tissue of the pia and the subarachnoid tissue 
purulent and fibrino-purulent masses are seen. The veins of the pia, 
full of blood, are often bordered on both sides by streaks of this mate- 
rial. Purulent secretion is especially common in the sulci of the brain,, 
such as the fossa Sylvii, the optic chiasm, the anterior surface of the 
pons, and surface of the cerebellum. The tissue of the pia is also swol- 
len, and the sulci of the brain obliterated. 
The cortex and adjoining cerebral substance are watery and swollen, 
and the highly hyperaemic septa of pia mater may often be seen at some 
depth. Small hemorrhages, lying close together in a group, are often 
seen. Striimpell described cases of abscess in an epidemic at Leipzig. 
The fluid of the 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 comparatively 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—hyperaemia and 
purulent-fibrinous exudation in the tissue of the pia and arachnoidal 
trabeculae, hyperaemia 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 brain and cord are greatly 
affect :d. The inner coat and the adventitia are full of numberless round cells, 
which collect on the outside of the blood-vessel and form purulent streaks, as 
seen by the naked eye; the same, to a less extent, is seen in the blood-vessels 
which enter the substance of the brain and cord. The cortex experiences many 
alterations, especially that of proliferation of nuclei in the neuroglia, and swell- 
ing of the ganglion cells and ganulo-fatty degeneration of the finer nerve fibres. 
In the cells of the ependyma of the ventricles, there is cloudiness, fatty degenera- 260 
INFECTIOUS DISEASES AFFECTING THE NEKVOU8 SYSTEM. 
tion, desquamation. Inflammatory softening may take place in the adjacent brain 
substance. 
Interstitial inflammation and granulo-fatty degeneration of the nerve fibres 
may also be observed in the substance of the brain. 
De Giovanni has observed hyperaemia of the sympathetic and peripheral 
nerves, with interstitial nuclear proliferation and fatty degeneration of nerve 
fibres 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 the brain remain permanently. 
The muscles are usually dry, brown-red, pale-yellow in some places. 
The microscope shows cloudy swelling (Klebs), fatty and waxy degene- 
ration (Rudnew). 
The blood is generally of a remarkably dark, berry-juice color, and 
thick. 
The heart usually relaxed; microscopic 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-follicles of the 
intestine, and mesenteric glands sometimes enlarged and hypersemic. 
III. Symptoms.—The disease often appears in the midst of health 
without premonition. Prodromata may consist of depression and loss of 
appetite for one, two, or three days, with nothing specially characteristic. 
The outbreak generally consists of a single severe chill; more rarely 
a repetition of slighter chills. The temperature rises quickly, soon at- 
taining 39° or somewhat higher, though 40° is rare. The pulse in- 
creases in frequency, often more than the fever seems to call for, and the 
same is true of respiration. Violent headache is complained of from 
the beginning, referred to the front, the vertex, or the back part, or 
without distinct localization. The pain is overpowering ; even when the 
consciousness is wholly gone, patients sometimes contract the face and 
press their hands to the head. Giddiness often accompanies the pain, 
so that the patient totters like a drunken man, grasps objects, and soon 
cannot stand upright. There is hypersesthesia of the nerves of sense; 
patients are greatly annoyed by bright light, and are startled by slight 
noises. 
Drowsiness and coma gradually come on, and with them delirium. 
During the second period comes the ominous symptom of stiff neck 
(which gives the German popular name of Genickstarre or Genick- 
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 cases, strong back- 
ward bending of the head, and twisting movements, are easy and 
painless. The head sometimes goes as far back as possible; Hart 
states that in one case the occiput pressed between the shoulder blades 
so as to cause gangrene of the skin. The rigidity may vary; I have 
repeatedly seen it disappear 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 arising in the cervical region. As the inflam- 
mation extends, opisthotonus attacks an increasingly large part of the INFECTIOUS DISEASES AFFECTING THE NERVOUS SYSTEM. 
261 
spine ; patients often lie on the occiput and sacrum. There is great 
tenderness on pressing the spinous processes—rhachialgia. 
In early stages, there is great restlessness, but this soon yields to 
stupor, in which a person may remain a long time in most uncomfort- 
able positions. Sometimes a short, loud, clear cry is uttered (cri 
hydrocephalique). The pupils are usually contracted, often unequal, 
and sometimes dilated in an oval form. The tongue is often dry, 
cracked, red, even dark with sordes; in other cases, the coating is white, 
gray, brownish, and not characteristic. The sensibility of the skin is 
usually excessive, so that slight pinching of the skin causes a loud cry. 
Vomiting is very common and may be very obstinate. The abdomen is 
usually sunken, sometimes to the form of a boat or basin, and the ab- 
dominal aorta may even be seen beating. The iliac fossae present deep 
depressions, marked by the prominence of the crests and spines of the 
ilium. Traube associates the sinking of the abdomen, not with contrac- 
tion of its muscles, but with spasmodic contraction of the intestines, due 
to irritation of the vagus (?). The belly is often sensitive to pressure. 
Spleen often enlarged, but not uniformly. Stupefied patients often pass 
no water ; the bladder may be full nearly to the navel, and the catheter 
must be used regularly. Others wet the bed. The urine is scanty and 
dark, owing to fever, and the small amount of drink taken in the stupor; 
it almost always contains albumin. Sometimes a large amount is passed, 
and is light and watery in spite of the fever (urina spastica, vaso-motor 
and secretory disturbances). Constipation is usual, diarrhoea rare. 
The chemical analyses of the urine x-equire confirmation; increase of urea and 
sulphates and phosphates, and peptonuria, are mentioned (Grocco). 
Duration.—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 
just before death (to -43° and over); the rise may continue a short time 
after 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 dulness, giddiness, and 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 
easily be misunderstood except during an epidemic. Sometimes, however, 
the disease develops more or less suddenly into the severe form. 
The foudroyant attack (m. siderans sive acutissima) comes on with 
incredible swiftness. Cases are known in which the patient went 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 equal 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 constant changes, and quinia has no effect. 
Complications. The nervous system is often involved'. Paralysis may 
be fully developed, or merely paresis. The facial nerve is often affected. 262 
INFECTIOUS DISEASES AFFECTING THE NERVOUS SYSTEM. 
In the limbs there may be monoplegia, hemiplegia, or paraplegia. Para- 
lysis of the tongue, and dysarthria, or palsy of swallowing, have 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. Fraser 
mentions a child that had spasms with left hemiplegia as the first symp- 
toms. General convulsions, or twitching and contracture in certain limbs, 
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. Chemosis 
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 oedema). Lagophthalmus sometimes develops, 
stated by Wilson to be due to rapid shrinking of the orbital fatty 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 synechia. 
Purulent inflammation of the uveal tract is not rare—iritis and irido- 
choroiditis—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 
neuro-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. 
Rudnew found purulent inflammation of the uveal tract to be the rule in 
njerebro-spinal meningitis, at least when microscopic examination is made after 
death. The disease usually begins in the choriocapillaris, and afterwards extends 
to the entire choroid. Rudnew 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 Lucae and Moos 
found the trunk of the auditory nerve bathed in pus; its neurilemma 
swollen and hyperaemic; purulent inflammation in the tympanic cavity; 
hyperaemia, bleeding, and purulent inflammation in the 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 tympanic 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 of ten 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, and bullous and pustular eruptions are not rare. 
They appear at the beginning or the end of the disease, sometimes dur- infectious diseases affecting the nervous system. 
263 
iag convalescence. The distribution is sometimes remarkably symmetri- 
cal, reminding one of the influence of trophic or vaso-motor nerves. 
Bed-sores or gangrene of the skin may develop so suddenly that they 
appear to be due to direct tropho-neurotic disturbances. Multiple joint- 
swellings have been repeatedly observed, shown by autopsy to be due to 
purulent discharge or great swelling of the synovial membrane. Kosto- 
nopolus, in an epidemic at Nauplia, 18G2 to 1864, found joint-affections 
preceding meningitis. 
Catarrh of the throat is much commoner than is usually stated. 
Diphtheritic changes may occur. Bronchial catarrh is one of the com- 
monest complications; more serious ones are broncho-pneumonia, fibrin- 
ous or hypostatic pneumonia, 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 
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 apncea. 
The pulse often shows irregularity in the succession and force of the 
individual pulsations. Irritation of the centre or the trunk of the vagus, 
from meningeal inflammation, causes retardation of the pulse, while 
paralysis of the vagus (a much more ominous symptom) causes enormous 
acceleration. 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 
after recovery. Leyden described aphasia and anaesthesia. 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 
seen chronic hydrocephalus in a child just one year old, which caused 
enormous dilatation of the skull. Multiple boils of the skin or muscu- 
lar abscesses occur. 
IV. Diagnosis.—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 abdomen, constipation. For 
tubercular meningitis, see a subsequent section. In children, febrile 
conditions, especially if connected with intestinal disorder, often cause 
stiff 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, diarrhoea, an early 
eruption of roseola, enlargement of the spleen; in fibrinous pneumonia, 
the sputa are rusty, if any are ejected. 
Y. Prognosis.—This is always very bad; in some epidemics the 
mortality has exceeded eighty per cent. 
VI. Treatment.—A quiet room, not too light, easily ventilated. 
Diet liquid; chiefly milk, meat-soup, eggs, diluted wine. If there is 
stupor, have the biadder emptied regularly three times a day with the 
catheter. Secure one stool a day, giving, if necessary, two tablespoonfuls 
of castor-oil in beer foam; or calomel and jalap, gr. viij. each; or com- 
pound infusion of senna, nine parts, Epsom salt, one part, tablespoonful 
three times a day; or clysters. On the head place ice-bladders reaching 264 
INFECTIOUS DISEASES AFFECTING THE NERVOUS SY8TEM. 
from ear to ear; also under the back of the neck. It is very desirable 
to lay the spine on ice, by means of Chapman’s bags. If pain is violent, 
use repeated injections in the cervical region (hydrochlorate of morphine, 
15 grains; glycerin, water, aa % oz. M.; $ of a syringeful). 
The following methods are mentioned among many. a. Derivatives to the 
head; rubbing pustulating salve on the shaven head, moxa, painting with iodine, 
blisters or sinapisms on the back of the neck, cups at the same place and along the 
spine, the actual cautery, salt or mustard baths for hands and feet, etc. b. Antiphlo- 
gistics: ice-bladder, leeches to the forehead or mastoid processes, bleeding, inunc- 
tion with mercurial ointment, ether spray on the back of the neck, calomel 
internally, nitre, etc. c. All kinds of drastics, d. Diuretics, e. Absorbents, as 
iodide of potassium. /. Narcotics: opium, bromide of potassium, chloral 
hydrate, ergotin, conium, etc. g. Nervines, as preparations of zinc. h. Febri- 
fuges: baths, quinine, antipyrin, etc. i. Electricity. 
2. Simple Cerebrospinal Meningitis. 
Meningitis Cerebro-Spinalis Simplex. 
I. Etiology and Anatomical Changes.—Purulent inflammation 
of the pia mater and arachnoid may occur under other conditions than 
as 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; but the base may be the part chiefly affected. “ 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 always 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 may occur during purulent catarrh of the 
frontal sinuses. A few cases have occurred after operations on the eye, 
especially enucleation. It has originated repeatedly from disease of the 
ear: foreign bodies in the ear, 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- 
scesses or tumors of the brain sometimes cause it. 
Purulent meningitis may originate by metastasis from many infec- 
tious diseases if the bearers of infection find their way from the original 
disease to the meninges. This may occur in fibrinous pneumonia, pleurisy, 
pericarditis, ulcerative endocarditis, pulmonary phthisis, gangrene or 
abscess of the lungs, peritonitis, erysipelas, diphtheria, dysentery, 
cholera morbus, parotitis, typhoid, typhus, relapsing fever, cholera, 
pyaemia, puerperal fever, septicaemia, rheumatism of the joints or 
muscles, scarlatina, 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 that every purulent meningitis is 
an infectious disease in the modern sense. Eberth and Klebs described 
micrococci in the fluid of the ventricles and the pus of meningitis com- 
plicating fibrinous pneumonia. If it is associated with inflammation of TUBERCULOSIS. 
265 
neighboring organs, it may be that the excitants of inflammation find 
their way through the blood-vessels and lymphatics to the meninges. 
II. Symptoms.—The symptoms agree with those of the epidemic form, 
depending in both cases upon altered circulation of blood, and increased 
pressure in the cavity of the skull; but in the simple form they are 
usually slower in their approach, and may be overlooked, owing to the 
severity of the original diseases. 
III. Prognosis and Treatment as in the epidemic form. 
B. INFECTIOUS DISEASES WITH VARIABLE LOCAL- 
IZATION. 
PART I. 
TUBERCULOSIS. 
Tuberculosis includes all the changes ascribable to the presence of 
the tubercle bacillus discovered by Koch. Almost any tissue may fur- 
nish the soil to develop this fungus, and it is not strange that the 
domain of tuberculosis is so broad. 
The symptoms of tuberculosis in different organs vary so very greatly 
that they often leave us 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 Koch’s discovery: 
lupus, fungous inflammation of joints, scrofulosis, etc. 
Almost any organ may be the 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 
apparatus. In case more than one organ is affected, the original disease 
was probably situated in one and was transferred to the other. 
Solitary tuberculosis, 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 clinically 
marked by being often accessible to local treatment, so that by destruction 
or operative removal of the diseased centre the disease may be cured. It 
may be that secondary infection will follow in other organs, as 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 one infected spot or organ, indicates 
a general affection of the body, and takes an acute or subacute course. 
The following pages describe the various forms of non-surgical tuber- 
culosis. 
1. Consumption of the Lungs. Phthisis Pulmonum. 
(Chronic Ulcerous Tuberculosis of the Lungs.) 
I. Etiology.—A chronic destructive process of the lung tissue, with 
cheesy degeneration of the morbid products, followed by softening and 
purulent wasting; excited by the proliferation of tubercle bacilli in the 
lung tissue. It seems doubtful whether there exists, in addition, a non- 
bacillary form, as has been asserted. 
The disease is very common. Hirsch states that one-seventh of all 
deaths arise from it; "two-thirds of all chronic diseases. It is certainly 266 
TUBERCULOSIS. 
favored by modern social modes of life. In factory towns and cities, 
where the proletariat supports on scanty food its overtasked life, in 
damp, dark, crowded cellars, it is commonest. But it was known to an- 
tiquity, and the writings of Hippocrates contain excellent observations. 
Scarcely any disease is so much affected by the influence of constitu- 
tion. Weakened, feebly resistant, anaemic 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 propagate themselves. Not that they are found every- 
where; for they seem to find the conditions favorable to their growth 
only in human and animal organisms, and at a permanent temperature 
of 30° (Koch). 
A morbid constitution may be inherited, congenital, or acquired. 
There can be no serious doubt that pulmonary consumption is inherited in cer- 
tain families; but it is uncertain what the mode of inheritance is. The fact that 
it does not always pass directly from parent to child, but often is derived from 
grandparents or, collateral relations, seems to show that a weakness of constitu- 
tion is transferred rather than germs of disease. In rare cases, the contagious 
material seems to pass directly from mother to foetus, causing severe injury to 
the lungs in utero. Demme saw a case of extended phthisical changes with cavi- 
ties in the lungs of a girl aged 12 days. Berti has found extensive phthisical 
changes in the lungs of two new-born infants. Johne describes a similar case in 
a foetal calf, with tubercle-bacilli in the diseased spots. Landouzy and Martin 
obtained equally positive results in experiments. In addition to predisposing 
causes, there must be special occasions for the development of consumption; such 
occasions, however, occur very often, and only those will escape disease whose 
constitution resists 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 family are attacked purely by accident. 
To hereditary weakness of constitution we must add that which affects chil- 
dren whose parents were debilitated by chronic disease at the time of begetting. 
Persons having tertiary syphilis or cancer beget children that are weakly from 
birth, and often fall victims to pulmonary consumption. So with children 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 chiefly to break-down of the constitution, as consump- 
tion usually belongs to the late stages of the disease. Onanism, excesses in wine 
and women, protracted lactations without sufficient rest between assist the 
development of consumption. 
We have stated the frequency of direct exciting causes. Affections 
of the lungs are naturally the most frequent excitants of consump- 
tion; bronchial catarrh or fibrinous or catarrhal inflammation of the 
lungs may lead directly to consumption in a person predisposed; while 
in others they run their course quickly and favorably. Symptoms 
of consumption very often appear some time after recovery from serous 
pleurisy. Inhalation of dust is often fatal in its effect, hence the bad 
reputation for producing consumption attached to certain trades. Con- 
tinuous residence in close rooms may be harmful; consumption is ex- 
ceedingly common in prisons and pensioners’ establishments. 
Defects of constitution conjoined with these exciting causes do not 
form the only way in which consumption is developed. The disease is 
contagious, and close intimacy and frequent contact with a consumptive 
person may easily cause the disease in a person not originally predisposed. 
A long observation of phthisical patients and their families often shows 
us instances in which a consumptive wife infects her husband, and vice TUBEKCULOSIS. 
267 
versa. Years often intervene; the one is long since dead, the other may 
have married again in perfect health, but the signs of the disease come 
gradually to view. Consumption was thought contagious in the last 
century, especially by physicians south of the Pyrenees and Alps (Bris- 
seau); a Neapolitan decree of the year 1783 ordered the destruction 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 
dust. The material seems not to pass directly through the air from the 
sick to the well, at least. Celli and Guarnieri could not find the bacilli 
in the air of hospitals for consumptives. 
Villemin, Lippi, Schweninger, and others have shown that animals 
may be made consumptive by inhalation of pulverized phthisical sputa. 
A similar experiment has been made accidentally in the human subject. 
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 tuberculosis of the sheaths of the tendons and lymphatic 
glands, which made an operation necessary. An observation by Reich 
deserves notice here; the case of 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 faeces loaded 
with the bacillus is possible, but not demonstrated. Villemin has shown 
by experiments in inoculation that the sweat is not infectious. 
Tuberculosis of the lungs may be due to secondary bacillus infection 
from other organs. It has long been known that scrofulosis, 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 during life, for tubercle, located primarily in the 
lung, may often develop to so small an extent as 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 victims 
from the fifteenth to the thirty-fifth year of life, but Wiirzberg has lately 
published extensive statistics (relating to Prussia) which show that the 
highest rate is 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 is hardly of great importance, though there are certain regions 
where consumption is hardly known, as the high plateau of Mexico, 
Peru, Costa Rica, the interior of South Africa, Egypt, Iceland, etc. 
Absolute temperature seems to be less important than dryness of the air 
and absence of violent changes of temperature. Altitude is unquestion- 
ably important. Consumption occurs only by exception in places more 
than 500 metres high. A change of residence may be fatal; persons in 268 
TUBERCULOSIS. 
places free from consumption moving to unhealthy places often are at* 
tacked with surprising rapidity Race seems to have less influence, and 
must be considered with caution. 
Dropsy reports that the native peasantry of Galicia are almost perfectly healthy, 
while the numerous Jewish population die in large numbers about the twentieth 
year. Early marriages and excessive toil are justly considered as causes. 
Much has been said of mutual exclusion between consumption and 
other diseases—as malaria. This is surely incorrect. Consumption 
occurs in malarial places; Sangalli reports 144 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 cases 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 (22 times in 277 cases of valvular 
lesions). One form of valvular disease (congenital stenosis of the pul- 
monary artery) almost always has consumption associated with it. (See 
Yol. I., p. 101.) Alveolar emphysema of the lungs is a rare associate, 
Sangalli’s thirty-five patients with round gastric ulcer, without a case of con- 
sumption, are too few to permit an inference to be drawn. 
II. Symptoms.—They usually develop very slowly, often leaving one 
in doubt for 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. Menstruation 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 scrofulous 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 the 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 diarrhoea 
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 anaemia of the larynx has correctly been remarked as suspicious. 
Semon speaks of a rapid change from anaemia to hyperaemia. TUBERCULOSIS. 
269 
Repeated haemoptysis, when the first in the train of symptoms, is 
commonly thought decisive, though years may pass before unquestion- 
able alterations of the parenchyma of the lung are physically demon- 
strated. 
Frequent nosebleed has often been seen in persons who afterwards became 
consumptive. 
Fibrinous or catarrhal pneumonia must be expected to give rise to 
consumption in debilitated persons; in such case, the upper lobe is 
known to be mostly affected. 
Pleurisy often causes consumption. It is suspicious, when dry 
pleurisy occurs repeatedly in the region of the upper lobe, because latent 
phthisis often causes it. Moist pleurisy, without demonstrable cause, 
running a slow insidious course, sometimes affecting both sides at once 
or alternately, is usually referable to phthisical changes in the lungs. 
Fig. 46. 
Cyrtometer curve from a phthisical thorax, at the level of the fifth costal cartilage; one-fourth 
natural size. (Author’s observation.) 
We see, therefore, how manifold and insidious the beginnings are, 
and can understand how great the need of care to avoid errors. We 
would add that tuberculous disease 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 constitu- 
tion is seen in the face. 
Many patients are persons that have grown tall quickly, and have 
long necks. The skin is delicate, poor in fat, and strikingly pale; the 
muscles small; the bones slender. The face is often so lean and 
sunken that the cheek-bones project sharply. The eyes are sunken, 
and often have a dark circle around them; they often have a peculiar 
lustre, and the sclerotica is strikingly blue. The teeth are often long, 270 
TUBERCULOSIS. 
bluish-white, transparent, and inclined to caries. The gums have a red 
border next to the teeth. 
The chest is quite peculiar; usually very long and flat, as may be 
best seen by the cyrtometer curve (Fig. 46). In young persons, it is 
often very resistant, owing to premature ossification of the cartilages. 
The intercostal spaces are broad and unusually deep; the angle at which 
the ribs are attached to the sternum is more acute than normal. The 
junction of the manubrium and body of the sternum (angulus Ludovici) 
is unusually prominent, owing to depression of the upper part of the 
manubrium. 
The depressions of the upper part of the chest are extremely deep 
(Fig. 47). The pectoral and dorsal muscles are usually very small. The 
shoulders come sharply forward, often giving a marked stoop to the 
trunk, so that the body threatens to fall forward in rapid walking. 
Fig. 47. 
Phthisical thorax in a girl aged eighteen years; front view. Author’s observation. Zurich clinic. 
Seen from behind, the posterior edges of the shoulder blades are raised so 
that the hand can be partly thrust in under them (wing-shaped, scapulae 
alatae, Fig. 48). This form of thorax has 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 drum-sticks), 
and the nails curved like claws. This peculiarity has been explained by 
deficiency of fatty tissue. The hair of the head "is scanty and inclined 
to fall out. 
These constitutional anomalies are not (of course) sufficient to establish a diag- 
nosis, but may be of value in doubtful cases. 
The complexion is usually pale. If the disease in the lungs is ex- 
tensive, cyanosis occurs, producing a livid tint when slight, but well 
marked in advanced cases. 
The vaso-motor system is very often very excitable. The face, or TUBEKCTTLOSIS. 
271 
the prominence of the cheeks, turns 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, hasmoptysis '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 
Fig. 48. 
The same, rear view. 
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 shining, 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 375.) 
Pityriasis versicolor is most common on the skin of the breast and lower part 
of the throat. It begins in spots, spreads over large 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 the 
tendency of the skin to scale, which assists their attachment. 272 
TUBERCULOSIS. 
Pityriasis tabescentium is a distinct affection with branny scaling of 
the epidermis, occurring in many debilitating diseases besides phthisis 
which produce loss of fat and abnormal secretion of sweat and sebum. 
Miliaria or sudamina are not rare—vesicles, clear as water (m. crys- 
tallina), or with a little milky turbidity (m. alba), or surrounded by a 
red areola (m. rubra), usually liberally sprinkled and easily recognized. 
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 corneum 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 vertebra 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 patient’s 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. Traube suspected that the skin excreted 
water vicariously, as the lung performed that function imperfectly. Lauder 
Brunton says that the respiratory centre being depressed in activity, carbonic 
acid may accumulate in the blood 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. 348. 
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 if 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 TUBERCULOSIS. 
273 
side and back is a matter of individual preference, though inflammation 
of the pleura of one side may lead the patient to lie on the other side. 
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 is characteris- 
tic to see the mind cheerful and courageous, often busy with plans, 
while the body is slowly perishing. Delirium is very rare; it is almost 
always 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 is often very slight; but 
very high temperatures may occur at noon or evening, often preceded by 
a slight chill with great pallor of skin. If the morning temperature is 
normal or beneath normal, while the evening heat is excessive, we have 
hectic fever (Fig. 49), due, as it often is, to absorption of purulent 
masses. Continuous high fever is especially common in very rapid cases 
(phthisis florida). 
Fig. 49. 
Temperature curve in the Anal period of consumption. Hectic fever. (Author’s observation.) 
Inverted types of fever with the greatest heat in the morning are not rare, 
as Traube showed. Briinniche says he finds it chiefly when there is associated 
miliary tuberculosis. 
Peter and Vidal state that the skin temperature is raised over caverns and in- 
filtrated spots, and that the thermometer can be used to define the diseased dis- 
trict. I have not found it so. McAldowic found in cases of unilateral disease 
that the temperature in the axilla of the sound side was higher than in the other 
as often as the contrary; but if infiltration existed on one side, and- caverns on 
the other, the former side usually had the higher temperature in the axilla. 
The pulse gives no characteristic signs; it is usually accelerated: as 
emaciation and weakness increase, it becomes small and soft, and in fe- 
brile states dicrotism is usually quite striking. 
Dyspnoea may give no trouble during the whole disease, probably be- 
cause the wasting body requires less air and gets used to less. In bron- 
chial catarrh, or if the disease becomes acute, it is generally felt; febrile 
states may excite it. 
(Edema is one of the late symptoms. It may be simply due to ma- 
rasmus, or may form a symptom of nephritis. It usually begins in the 
lower extremities. If patients are obliged to lie chiefly on one side, 
oedema of the subcutaneous cellular tissue affects one side chiefly or 
solely. In one extremity it may be caused by marantic thrombosis. 274 
TUBERCULOSIS. 
Local changes in the lungs almost always begin at the apex, and 
often are wholly confined to the upper segment of the lung. 
The cause of this may be that the apices are the parts least used in breathing, 
whence come opportunities for deposit and long retention of inflammatory pro- 
ducts, especially in the alveoli. In addition, this region has a poor supply of blood. 
In persons of consumptive habit, the poor development of the upper chest-mus- 
cles, and the early ossification and deformity (Freund) of the upper costal carti- 
lages, still further impair the movements of the chest and the expansion of the 
lungs. The arms, attached to the thorax, have also a normal power of restrict- 
ing the excursions of its upper part. 
The local changes in the lungs may long consist solely of catarrh of 
the apex. Rough vesicular breathing, interrupted vesicular breathing, 
decided prolongation of expiration localized at the apex, or unequal in- 
tensity of respiratory murmur at the two sides are often the first and 
only signs. These symptoms are especially important when confined to 
one side and varying in intensity; if on both sides, they may not denote 
phthisis. Sibilant rhonchus or single moist crepitant rales may occur. 
Fig. 60. 
Boundaries of percussion in retraction of the right apex; front view. Author’s observation. 
In forced breathing, single, clear, and clicking crepitant sounds may occur, 
due to contraction of the chest-muscles. 
Eccentricities in the respiratory movements are often connected with 
the above symptoms. Parts of the thorax where respiration is abnormal 
may be seen—or more readily felt with the flat of the hand—to move 
less actively than other parts. 
Haenisch has made a special instrument to measure the excursions of the re- 
gions of the chest. 
Abnormal percussion sounds are often the first signs; slight dulness 
in the upper fossa on light percussion, and increased resistance to pal- 
patory percussion. 
Slight differences often occur in health; a fuller development of the muscles 
on the right side often gives a greater dulness on percussion. 
A very important sign is the difference in the height of the apices, 275 
TUBERCULOSIS. 
shown by percussion, as was first stated by E. Seitz. This symptom in- 
dicates simply contraction of the apices, but it is a specially frequent ac- 
companiment of chronic tuberculosis of the lungs (Eigs. 50, 51). 
When consumption is allied with extensive contraction of the lungs, 
the thorax is retracted, sometimes in the upper fossae, sometimes over 
one whole side. 
The diagnosis is usually certain when there are signs of extensive infil- 
tration or caverns in the lungs; the symptoms agree in all points with 
those of similar conditions due to other causes. 
Infiltration of the alveoli with firm, usually cheesy masses is indi- 
cated by increased vocal fremitus, dulness, bronchial respiration, in- 
creased bronchophony, and consonance of crepitant rales which may be 
present. Williams’tracheal tone may also be formed. 
Cavern-symptoms are distinct in proportion as the cavern is near the 
surface, and is large and smooth-walled. If situated deeply, they re- 
quire stronger percussion. Over those of the size of a walnut we hear a 
Fig. 51. 
The same, from behind. 
tympanitic percussion-sound, bronchial breathing, and tinkling crepitus. 
If the cavity is about six centimetres in size, with smooth walls, metallic 
symptoms occur, both on percussion and auscultation (cracked-pot sound, 
increased vocal fremitus, bronchophony), but only when the cavity contains 
air. If quite full of secretion, there is dulness; and the alterations from 
dulness to tympanitic sounds may be a very important 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; Gerhardt’s variation in pitch, and the respiratory variation 
in pitch. 
It is not always easy, though desirable, to make a certain diagnosis of 
caverns. E. Seitz gave as a sign the metamorphosing respiratory mur- 
mur, though Botuwschikoff states that he has observed it in fibrinous 
pneumonia. Baas gives post-expiratory crepitus as a sure sign. 
Metallic symptoms have repeatedly been heard over smaller cavities (Kolisko, 
Wintrich), but it seems necessary that the cavern should be superficial, regularly 
formed, and especially smooth-walled, should lie near a large bronchus, and be 
connected with a bronchus with wide opening. Symptoms which are connected 
with the movement of the heart, especially systolic crepitus, may exist over 
caverns. Peculiar roaring or hissing sounds are sometimes heard (von Brunn, 276 
TUBERCULOSIS. 
Schrotter), apparently originating in the blood-vessels, which project partially 
into the cavity, and have their resonance increased. 
The sputa are of great and special importance. The demonstration 
of tubercle bacilli is decisive, for they occur in the sputa of no other 
disease. In a few cases of undoubted consumption, they are not found 
in the sputa after repeating the attempt several times a day; this hap- 
pens very rarely. I have repeatedly suceeeded by letting the sputa stand 
twenty-four hours, and trying again. 
The bacillus may be demonstrated in the following manner: Take from 
sputa which certainly come from the lungs and not the upper air passages, a 
piece of the size of a pin-head, and distribute it on a perfectly clean covering- 
Fig. 52. 
Tubercle bacilli from the sputa of a consumptive patient. Fuchsine preparation. Immersion, 750 
diameters. (Author’s observation.) 
glass with a carefully cleaned platinum wire or needle. Lay on it another per- 
fectly clean cover-glass, and press the two carefully together so as to distribute 
the sputa uniformly in a thin layer. Wipe the edges, if necessary, with blotting- 
paper. Draw the glasses apart sideways, let the material dry half a minute; 
then take each glass in a pincette, and pass it through the flame of an alcohol 
lamp or Bunsen burner from four to ten times, about as fast as one cuts bread, 
holding the sputa upward. 
The coloring fluid is best prepared fresh every time. A concentrated alco- 
holic fuchsine solution, pure colorless aniline oil, pure nitric acid, and solution of 
malachite-green are kept on hand. The oil, originally almost as clear as water, 
turns when exposed to light, and had best be kept in a box. 
Pour into a clean test-tube enough aniline oil to fill the bottom, then add 
water till four-fifths full. Close the mouth with the thumb, and shake vigor- 
ously until a partial emulsion of the oil is produced. Filter, and collect the clear 
filtrate in a large watch-glass. Add to the clear contents of the watch-glass five 
to ten drops of alcoholic solution of fuchsine, and place the two covering-glasses, 
sputum downward, so that they float on the fluid. Cover the watch-glass with 
another, to keep out dust, and let it stand twenty-four hours. If necessary to TUBERCULOSIS. 
277 
finish quickly, heat the solution (as Rindfleisch proposed) over a flame until bub- 
bles begin to form; let the cover-glass lie in it ten minutes, and prepare it for 
microscopical examination. We prefer the former way. 
The next step consists in filling 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 mixing 
carefully. The two cover-glasses are laid in this with the sputum side up, when 
the diffused fuchsine tint will quickly depart, and by degrees the glasses grow 
pale. When the color is gone (or, if there are many bacilli, nearly gone), rinse 
them quickly in distilled water. The bacilli now show the staining, while the 
other parts are colorless. A pretty contrast, useful for a beginner, is made by 
coloring the other parts with another tint; we prefer malachite-green as giving 
a fine contrast. For this purpose, lay the glass one minute in the malachite- 
Fig. 53. 
Tubercle bacilli with spores from the sputa of a consumptive patient. Author’s observation. 
(Zurich clinic.) 750 diameters, immersion. 
green solution, face downward, raise it with the pincette, and wash off again 
quickly in distilled water. Then press both surfaces gently on clean blotting-paper 
to remove the water, draw it several times through a spirit or gas flame, with 
sputum side up, and finally treat with chloroform-Canada-balsam. Place a 
drop of the balsam on a clean slide, and lay the cover-glass, sputum down, on 
the drop; the later spreads equally under the glass. In most cases, ordinary 
lenses of three hundred to five hundred diameters suffice, but in doubtful cases 
we require Abbe’s apparatus for illumination and oil immersion lenses. 
The tubercle-bacillus is a rod, sometimes straight, sometimes bent at 
an angle, from to n long (1 = 0.001 millimetre), equal to about 
one-third or one half of the diameter of a red blood-corpuscle. They 278 
TUBERCULOSIS. 
are often very numerous, and distributed with much uniformity in the 
preparation (Fig. 52), while at other times they are grouped, and so 
crowded that the groups can hardly be analyzed into their elements (Fig. 
53), or they are single, and careful inspection is required to bring to 
view one example. Sometimes one glass shows some, while the other 
does not. On successive days, the number may vary greatly. They 
are usually numerous in proportion to the acuteness of the process in the 
lungs. Fine globules are often found inside of the bacilli which do not 
take the aniline stain; they are spores (Fig. 53). 
The chemical examination of sputa is not of great importance. Renk estimated 
the daily sputa of three patients at the average of one hundred and twenty-four 
grams. The average composition by percentage was as follows: 
Water 
Case 1. 
Case 2. 
94.97 
Case 3. 
93.84 
Solids 
5.03 
6.16 
Organic components 
4.66 
4.12 
5.36 
Inorganic components 
0.76 
0.90 
0.80 
Mucin 
1.80 
2.56 
2.84 
Albumin 
0.49 
0.11 
0.29 
Fat 
0.36 
0.30 
0.52 
Extractive 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 very 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 fibres are easily recognized by their curled, sharply outlined, often 
divided form (Fig. 54). The addition of potash solution causes the cell-compo- 
nents to disappear, while the elastic fibres become more distinct. They are 
distinguished from crystals of fatty acid by not dissolving in ether or boiling 
alcohol, not melting when warmed, and showing no varicose swellings when 
pressed. The fatty acid crystals are dissolved by long treatment with caustic 
alkalies. 
In consumption, the loss of tissue is almost always very gradual, and the par- 
ticles in the sputa are generally microscopically small. Visible fragments (as 
seen in abscess or gangrene of the lung) are very rare. Hence it requires both 
patience and skill to find elastic fibres. 
In microscopic work, select very small bits, and work them out finely; pay 
special attention to peculiarly opaque and slightly grayish spots, which often 
contain elastic fibres. 
Fenwick gives a convenient and certain way of finding elastic fibres, which 
we repeat with a slight practical change. Put the sputum into a beaker glass 
with an equal quantity of distilled water and as much of a solution of caustic 
potash (1:3). The thickish gelatinous mass is heated to boiling, being constantly 
stirred meanwhile, which makes it perfectly fluid. The glass is allowed to 
cool, the clear fluid is poured off from the sediment, the latter is poured into a 
pointed glass, and the sediment having settled again, is taken by a pipette for 
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 remaining 
the same. 
Remak’s statement that elastic fibres from the bronchial mucous membrane 
are distinguishable from those of the lung-parenchyma by being finer, is not of 
practical use. 279 
TUBERCULOSIS. 
The presence of alveolar epithelium in the sputa is of much less im- 
portance. It has diagnostic value only when very abundant, and when 
there are also signs of apex-catarrh. The cells are usually roundish or 
roundish-angular, and in the condition of fatty or myelin degeneration; 
partly broken down, so that little granules of fat and drops of myelin 
have been set free (Fig. 55). They often compose almost the whole of 
the sputa. They are blackened by osmic acid, like all fatty substances. 
They may be taken as showing that active throwing off of epithelium is 
taking place in the alveoli, with degeneration of the cells. 
Cholesterin-crystals, sarcina. and mould-fungi are of less consequence. For 
the latter, see Vol. I., p. 326. Phthisical changes due to inhalation of dust may 
exhibit the dust free or inclosed in cells. We give a view from Traube, showing 
pneumoconiosis anthracotica (Fig. 56). 
Fig. 54. 
Elastic fibres from the sputa of a consumptive patient. (Author’s .observation.) diameters. 
“ 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). Kloman also found in them 
elastic fibres, lung-pigment, granular detritus, and tablets of cholesterin. Many 
consumptives cough up such lumps so frequently as to give rise to the term 
“phthisis calculosa.” 
Lime concretions sometimes originate, not in lung-tissue, but in cretaceous 
changes of bronchial glands which afterwards break through into the air-pas- 
sages. They may be so large that they cannot pass the vocal cords, and suffocate 
the patient (Riihle). 
Bone-formations occur in the sputa; originating in thejlung, or passing from a 
vertebra into the lung (Charon). 
The gross appearances vary greatly. At the beginning of the disease, 
we often have a tough, glassy, slimy, transparent sputum, which differs 
little from that of bronchial catarrh. It is sometimes gelatinous, or 280 
TUBERCULOSIS. 
like frog's spawn, which indicates a similar alteration in the lung. If 
consumption follows fibrinous pneumonia, the expectoration is often 
green (Traube and Nothnagel). 
The more extensive the disease in the lungs the more abundantly is 
pus found in the sputa, which may often be chiefly purulent. If cavities 
form, the sputa often take a distinct characteristic form, either that of 
coin (sputum rotundum, nummulare, sive nummulosum), or that of 
balls (s. globosum). Nummular sputa consist chiefly of opaque green 
purulent matters, found at the bottom of the spit-cup in the form of 
regular round lumps, usually sharp-edged. The globular sputum is a 
roundish, gray-green, separate ball of pus, with a torn and ragged sur- 
face, sometimes kept floating by air-bubbles, sometimes sinking to the 
bottom of the glass. 
Fig. 55. 
Fatty alveolar epithelium cells; some full of lung-pigment, some broken down. Also, myelin forms. 
375 diameters. 
The peculiar form of these sputa is due to the cohesion between the particles 
of pus. If sputa are collected in water, a crumbly sediment is often deposited ; 
if the sputa are very thin, the same occurs without water. Exactly similar 
masses are found after death on the walls of cavities, and Virchow long ago 
showed that they proceed from the purulent decay of lung-tissue. They form no 
unimportant sign of cavities ; they often contain large numbers of the bacilli. 
Bloody sputa form a very important sign, often giving the first indi- 
cation of consumption; though not every one that has had haemoptysis 
becomes consumptive. The demonstration of the bacilli in the bloody 
spit is decisive. The sputa may be pure blood, or tinged with blood. 
In the later course of the disease, severe haemoptysis may occur repeat- 
edly. It is either provoked by bodily and mental exertion and excite- TUBERCULOSIS. 
281 
ment, or occurs spontaneously. Yery profuse bleeding may proceed 
from the rupture of aneurisms of arteries in the walls of caverns. Ras- 
mussen has studied this form of bleeding closely, and Fraentzel has 
added observations. 
Gerhard and Brehmer have lately noted intermittent haemoptysis, occurring at 
certain hours of the day, and relieved by quinine. In Gerhard’s cases, it occurred 
at night at the apyrexia, while Brehmer saw it also at the height of the fever. 
The frequency of haemoptysis is usually exaggerated. Among 369 
Fig. 56. 
Sputa in pneumoconiosis anthracotica; after Traube. Magnified 290 diameters, a, Tupfelzellen. 
cases, Condie 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- 
siderably larger; 70 per cent, or 569 in 1,000 cases. 
Expectoration is difficult, especially at the beginning of the disease; 
the irritation and the effort involved in coughing are a torture, the sleep 
is disturbed, and there are pains due to the violent contraction of the 
muscles of the chest and abdomen. At a later stage, expectoration is apt 
to be easier, and usually more copious. 
In a few cases, there is very little cough and expectoration, and the physical 
signs over the lungs are very slight, in spite of extensive alterations of the 282 
TUBERCULOSIS. 
lung-parenchyma; but the wasting of the body should arouse suspicion and pre- 
vent error. 
The heart is very often involved. The second (diastolic) pulmonary 
sound is often intensified, a sign of increased blood-pressure in the dis- 
tribution of the pulmonary artery. If there are signs of retraction of the 
lungs, the heart may be dislocated. If smooth-walled cavities lie near 
the heart, the sounds of the heart sometimes receive a metallic character, 
through resonance. 
The subclavian murmur, described by Stokes, is thought very important by 
some authors. Ruble considers the subclavial expiratory murmur a valuable 
diagnostic sign. 
It is heard during expiration as a hissing or roaring sound with the systole. It 
has been explained by pleuritic adhesions excited by lung-changes, which have 
involved the subclavian artery, and thus cause bending and narrowing of the arte- 
rial tube during the movements of respiration. It is found in healthy persons. 
There are no characteristic peculiarities in the urine; its amount is 
commonly lessened, and the urea and chlorides are usually diminished. 
Some authors affirm an increase in the phosphates (Teissier), but Stokvis 
rightly denies this, and found them usually diminished. Stokvis, op- 
posed to Beneke, found no characteristic change in the earthy phosphates. 
Senator mentions increased excretion of lime. Traces of albumin may 
be found in very exhausted patients. Vibert found sugar three times in 
fifty cases. 
All the other functions may be unaltered, though such is not the rule; 
consumption very often has complications, and almost every organ can 
be involved. 
The bones are often carious—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 abscess of the 
brain. The presence of tubercle bacilli in the discharges 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. 
In very weak patients, the muscular excitability is often increased. If 
we give the pectoral muscle a light blow with a percussion-hammer, the 
spot struck rises, and remains 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 calls it myoidema. Without assenting to 
all that he says, I have often seen (as he states) that it sometimes occurs 
on one side only, and is apt to be stronger on the side most diseased. 
The peristaltic contraction (best described by Auerbach) is essentially 
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 wave to 
the two attachments of the muscle. This form is not frequent; is some- 
times limited to single muscles; is not characteristic of consumption, but 
exists in the marasmus of gastric and intestinal disease, and probably in 
many other weakened states. The symptom is often unilateral in these 
cases also. In a case lately seen by me in Kotiig’s clinic, the muscles 
were found microscopically unaltered. TUBERCULOSIS. 
283 
Tuberculous inflammation sometimes occurs in peripheral lymphatic 
glands; they swell and are hard, but may afterwards soften and become 
purulent, burst, and lead to protracted sinuous fistulae. 
The larynx is very often attacked. The trouble may be purely func- 
tional—obstinate hoarseness, either without anatomical change, or 
caused by paralysis of the vocal cords. The latter is probably due to the 
atonic state of the muscles of the larynx, dependent on general maras- 
mus. Permanent hoarseness is, 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, difficulty in 
swallowing, and other troubles are often so prominent as to throw those 
referred to the lungs into the shade. 
In rarer cases, there is paralysis of the recurrens, which may be due 
to compression by enlarged tracheo-bronchial lymphatic glands (cheesy 
metamorphosis), or to the retraction of pleuritic adhesions. Brieger 
published a case of double paralysis of the recurrens, due to enlarged 
bronchia] glands. 
Inflammation and ulceration of the trachea are common, and may 
often be detected during life by tracheoscopy. 
Betz states that goitre is found in youthful phthisical subjects. 
Consumption rarely develops into gangrene of the lungs; Traube ex- 
plains this by the infrequency of stagnation of the excretion in the air 
passages. If expectoration is checked, the sputum is liable presently 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 sign. 
Pleurisy is sometimes associated with consumption; it may be dry or 
moist, and in the latter case may cause a serous, or purulent, or hemor- 
rhagic exudation. The exudation is susceptible of absorption, even in 
tuberculous pleurisy; though usually this improvement is only 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 lately saw a case in which adhesion to the costal pleura preceded rupture of 
a cavity, so that subcutaneous emphysema covering a spot as large as a dollar 
occurred at the point 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 sometimes enables us 
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. 
Pericarditis is not frequent in phthisis; it may be tuberculous. In 
many cases, it seems to be excited by previous pleurisy; it rarely occurs 284 
TUBERCULOSIS. 
in consequence of rupture of a cavity into the pericardium. Cardiac 
thrombi are sometimes important as causing embolism of the pulmonary 
artery. Thrombosis of the pulmonary arteries and veins occurs, and 
the latter may cause embolism of the peripheral arteries, e. </., the cere- 
bral. 
Digestive troubles are very common. Sometimes they are purely 
functional and unaccompanied by anatomical changes ; for example, 
great want of appetite, or unconquerable dislike to certain articles of 
food. If this dislike is felt towards eggs, milk, meat, or other desirable 
things, the medical treatment is greatly interfered with. 
Many patients sutler from troublesome eructations or obstinate vom- 
iting ; or profuse diarrhoea occurs, and continues for awhile, without any 
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 papillae of the tongue are swollen and prom- 
inent, the secretion of saliva lessened, 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, 
oidium albicans develops (Yol. 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 fungus-spores and 
jointed mycelium. 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 in swallow- 
ing. 
Tuberculous ulcers are sometimes found on the tongue, said by Re- 
verdin to have been first described by Ricord. There may be also a deep 
diffuse tuberculous-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 usually recognized until there are slightly prominent yellow 
spots, irregular, often disseminated, and usually sharp-edged, and with 
indentations and angles. These cause very great trouble and pain in 
swallowing, though the subjective symptoms are often remarkably slight 
in even advanced cases. (See the following section on tuberculosis of the 
throat, for details.) 
Do not confound the common prominent mucous follicles with gray transpar- 
ent miliary tubercle, which is not very frequent. 
The intestinal functions are often disturbed. At the beginning of 
the disease, constipation and diarrhoea alternate frequently. Catarrhal, 
tuberculous, or amyloid changes in the intestine, with extensive destruc- 
tion of mucous membrane, often produce uncontrollable diarrhoea; pain 
may be absent, or may only be produced by pressure on the walls of the 
abdomen. In other cases, there are extraordinarily 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. Shreds 
of intestine are sometimes plainly visible in the stool, and may be con- 
founded with portions of undigested food. Obstinate constipation may 
occur, in spite of extensive changes in the mucous membrane. The best TUBERCULOSIS. 
285 
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- 
sequent section upon intestinal tuberculosis. 
Ulceration of the intestine may also cause hemorrhage which is apt to be 
abundant 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 have 
been known to cause a fatal result. 
Granger-Stewart says that hemorrhage is very common in amyloid degenera- 
tion, even if there are no ulcerations. 
Peritonitis maybe caused by intestinal ulcers; it is especially danger- 
ous when caused by perforation. 
Rectal 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 derivant, 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 metamor- 
phoses, or a combination of these. A fatty liver is doughy in consistency, 
blunt-edged, and often hard to reach by palpation (see Yol. II., p. 212). 
An amyloid liver is usually larger, harder, and more elastic and sharp- 
edged; it is considerably less common than fatty liver, and is usually 
associated with hard splenic tumor (amyloid spleen) and albuminuria 
(amyloid kidney). 
Splenic tumor in consumptives may depend on congestion or amyloid 
change. Large disseminated tuberculous-caseous spots are sometimes 
found in enlarged spleen. 
Caseo-tuberculous 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 
tuberculosis of the testis and prostate. The sexual appetite is often 
quite 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 clinical im- 
portance. 
Pregnancy is an unfavorable complication; the destruction of the lungs very 
often becomes rapid towards the close of the period, and still more so after deliv- 
ery; or a chronic case becomes acute; or general miliary tuberculosis begins. 
Uterine diseases are not rare in consumption, and very great caution is needed in 
treating them; some distinguished gynecologists have seen such increase in the 
phthisical symptoms after such treatment that they strongly 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; diarrhoea is often attended with 
transitory slight albuminuria. 
If the quantity increases, and fibrinous casts are also present in the 
urine, we may suspect parenchymatous nephritis if the urine is also 
scanty, dark-colored, and of very high specific gravity. 
Albuminuria, in the presence of symptoms of amyloid changes of the 286 
TUBESCULOSIS. 
liver and spleen, may be referred to amyloid change of the kidney, but 
parenchymatous and amyloid changes are almost always combined in the 
kidney. 
Albuminuria is often due to congested kidney, but very extensive 
changes in the lungs are required in order to produce it. 
Purulent urine is sometimes found, originating in tuberculous dis- 
ease of the urinary apparatus. 
Nervous symptoms are almost always of serious import. Violent 
headache is often the first; referred either to the frontal or occipital 
region. Eepeated 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; consciousness is obscured, 
delirium occurs, and death follows, often immediately preceded by very 
great increase in temperature (hyperpyrexia). 
These symptoms are not confined to tuberculous meningitis; the purulent form 
may occur, especially when caries of the temporal bones extends inwardly. The 
organ of hearing should be most carefully examined 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 muscular pains, due to the exertion of violent coughing, or to 
parenchymatous changes in the muscles. They are either spontaneous 
or dependent upon pressure. Sometimes they are almost periodical, 
and occur (as I have repeatedly seen) at fixed hours in the afternoon. 
Very severe muscular pains may simulate other diseases. I lately saw a man 
of thirty-five years who had been suffering violent pains in the muscles of the 
back and belly, whose physicians disputed whether to call it rheumatism or 
trichinosis. They had forgotten to examine the lungs, which contained cavities 
on both sides; profuse haemoptysis 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 
very 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, and last but a few 
weeks; such cases occur chiefly in young persons. The terms “ phthisis 
florida” and “galloping consumption” have been applied to such cases. 
They usually involve extensive changes in the lungs, or it 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 be pneumonia, 
pleurisy, pericarditis, or peritonitis. General miliary tuberculosis often 
originates in chronic consumption of the lungs. The impulse to the 
acute form may be given by various injurious circumstances. 
Von Bulil mentions purulent peribronchitis as the cause of a very rapid death. 287 
Though death is the usual termination, yet cure, or decided improve- 
ment now and then occurs. If the tubercular parts of the lung heal 
completely, a contracting cicatrix of connective tissue remains. Imper- 
fect cure is more frequent than perfect cure; there is a diminution of 
local diseased action, but we are not sure that it will not again become 
progessive. 
If there is a slow and steady progress of the disease, the final symp- 
toms may be those of debility. Profuse hemorrhage may cause death 
unexpectedly. CEdema 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 
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). 
III. Anatomical Changes.—Either lung, or both, may be 
affected. The disease is often limited to the apices, while in other cases 
an entire upper lobe or a great part of it is involved, and in yet 
others the lower lobe is involved; but the process is apt to be most 
advanced in the upper ones. Cases in which the lower lobes are 
chiefly or exclusively affected are exceptional. The region around the 
hilus and the lower lobe are mentioned by Michael and Weigert as a 
favorite spot for the disease (the apices remaining untouched) in children 
only. 
Among the characteristic macroscopic changes, caseous degeneration 
is prominent; a more certain sign is the microscopic evidence of the pres- 
ence of the tubercle bacillus. The more recent the diseased portion is 
the more abundant 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 the parenchyma; hence, consumption has 
by many been considered identical with caseous pneumonia. 
The cheesy portions are easily recognized by their yellow color and 
crumbly, friable, 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 in size. In other 
places, several lobular spots unite to form large caseous surfaces, the lobu- 
lar 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 thickened like 
cheese, 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- 
chial mucous membrane are often seen; or knotty thickening of the 
bronchial wall with connective tissue, partly caseous, especially on the 
outside (peribronchitis). 
The cheesy product is not developed as such; it consists of degen- 
TUBERCULOSIS. 288 
TUBERCULOSIS. 
erated inflammatory products which have suffered the fatty change and 
great loss of water at the same time. In the stage preceding, we find 
masses like frog’s spawn, translucent-gelatinous, gray-transparent or 
gelatinous, formerly termed gelatinous inflammation of the lung. 
The cheesy deposit may become chalky or fluid. In the former case, 
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 innocent 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 
pneumonia) 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 large caseous mass generally leads to the formation 
of cavities (vomicae). The puriform 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 into folds 
and 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-purulent, crumbly mass, 
which can be easily scraped off with a knife. The cavity may be much 
larger than a fist, and sometimes may include almost a whole 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, which fre- 
quently cause profuse and obstinate hemorrhage. 
Cavities may also originate in dilatation of bronchi, which may be 
very large, and are usually 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 seen 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 num- 
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 inter-alveolar process, or whether it first attacks the minute bron- TUBERCULOSIS 
289 
chi. All these processes are usually found combined; but it may be 
right to assume that one only was the original one. 
It is a common error to consider that all cases have one point of 
origin. Of two such excellent observers as Oolberg and Rindfleisch, the 
former affirms chiefly the intra-alveolar origin, the latter the inter-alve- 
olar; is it not possible that both are right, but with too one-sided a bias ? 
The determination of the point of origin of inflammation may often 
depend on accidental causes—catarrh of the small bronchi, an intra- 
alveolar process, or (perhaps the rarest) inter-alveolar changes. The 
essential point in consumption is bacillar infection of inflammation pro- 
ducts followed by the caseous 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 fibrous thickening of the 
adventitious tissue. The caseous form is more characteristic, shown 
by cheesy, often lumpy and knotty thickenings, on the outer wall of 
fine bronchi, and not to be confounded with tuberculous formations. In 
the cavity of the bronchi, we often see thickened caseous masses, the cross 
section of which in small bronchi may be 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 alveolar epithelium, so that at the beginning we 
have to do with so-called desquamative pneumonia. True tubercle 
formation also occurs here. 
As 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. Yon 
Buhl stated that parenchymatous changes are not rare. E. Fraenkel 
has further described 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 
muscles. When affecting the larynx, eye, or diaphragm, they may 
account for many functional disturbances. 
The heart is usually small and flabby; its muscle is pale, sometimes 
deep-brown, occasionally 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. 
The bronchial lymphatic glands are often enlarged, or caseous, with 
tubercle or lime concretions. Large cheesy masses of lymphatic glands 
are especially frequent in children (Michael and Weigert). 
The liver and kidneys may show marks of venous congestion. 
IV. Diagnosis.—It is extremely hard to recognize consumption in 
its earliest stages. We may consider every case of apex catarrh as seri- 
ous, and treat it with great care, but it is going too far to infer consump- 
tion and an inevitable doom as necessary consequences. It is here that it 
is of great importance to demonstrate bacilli. And the same is true of 
haemoptysis, which may often be 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 
bacillus. In such cases, we must make especial use of the accounts 
given us of consumption in the family, scrofulous disease in youth, and 
great tendency to disease of the respiratory organs. Increased tempera- 290 
tare at evening and loss of bodily weight are symptoms not to be under- 
valued. Night sweats are important. 
The above points must be considered when we have to decide whether 
an existing affection of the larynx is caused by concealed phthisis, or 
whether chlorosis, or disease of the stomach or intestine, is connected 
with phthisis. 
In doubtful cases, the sputa might be inoculated into rabbits as a test, but it 
would require several weeks at least before we could expect to see tuberculosis 
develop in the animal. 
If consumption follows acute pneumonia, the signs 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 
ihe fact that the apex is chiefly affected may 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- 
grene, or the characteristic three layers, or the mycotic bronchial plugs 
in the sputa. The same is true in the case of bronchiectasia with putrid 
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 haeniatoidin crystals, 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 quick 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 bad 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. 
VI. Treatment.—Rational preventive measures are worth more than 
TUBERCULOSIS. TUBEKCULOSIS. 
291 
all that physic can do for an established case. There is little enough, 
however, that a physician can do by way of prevention, nor will his 
warnings be of much avail until 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 
classes, 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 spring 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 be ascertained by examination. 
If artificial food is given, let only thoroughly boiled milk, taken from 
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 lungs and strengthen the chest 
and muscles, and let the choice be made of an occupation which requires 
wholesome movement in the open air. All diseases of the respiratory 
organs in such persons require special care. We hardly need say how 
often these measures must remain theoretical, simply for want of means 
to carry them out. 
Scrofulous disease must receive energetic and persevering treatment. 
All diseases of the respiratory tract must be treated with uncommon 
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 them in danger of a more speedy development of 
the disease, or of hastening its progress; and inflicts a blight on the 
posterity. 
An important rule of prophylaxis relates to intercourse with consump- 
tives. There can hardly be a doubt that the disease is contagious, and 
we know that the contagious element is contained in the sputa. As 
protective measures, we should forbid the patient’s sleeping with 
another person. The sputa must be kept in a covered glass and disin- 
fected with a five-per-cent solution of carbolic acid, of which an amount is 
added about equal to the daily discharge. Fischer and Schill have proved 
that this destroys the tubercle-bacilli within twenty-four 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 on that person, or 
to many persons, who have received no harm from such contact. We 
must also be careful in using the clothing or linen of such patients; and 
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 treating 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 be admitted by every physician 
who has treated many consumptives of means. 292 
TUBERCULOSIS. 
If climate-cures are to be of use, they must be employed as soon as 
possible, for we can expect no benefit from them in those who present 
large cavities or extensive infiltration. Patients with one foot already in 
the grave are often sent off at the risk of life, only to return speedily, 
with their false hope gone, seeking their home to die in it. In the early 
stages, it will be well for those who have no restriction upon their actions, 
to visit climate-cures, even if there is only a suspicion of disease, for it is 
better to do this too early, or needlessly, many times, than to do it too 
late once. 
There is a very large number of climate-cures, and of late the num- 
ber has much increased, often to the injury of the cause. We do not 
attempt to give a long list. It is necessary first to decide between the 
limited or “closed” establishments, like Gorbersdorf in Silesia, Ko- 
nigstein in the Taunus, Inselbad near Paderborn, and Reiboldsgriin in 
Saxony, and the “ open ” health resorts. The former have been rather 
objected to since the discovery of KoclPs bacillus; they certainly should 
only be visited by decidedly tuberculous patients, not by those merely 
suspected, owing to the danger of contagion; and they must be well 
aired and carefully disinfected. Among the latter we can highly recom- 
mend from our own experience for summer residence Kreuth in the 
Bavarian mountains, while we place the localities in the Hartz, as 
Andreasberg, in the second list. For autumn and spring, select places 
in Tyrol (Meran, Gries, Gorz), in Upper Italy (Arco, Cadenabia, Lugano, 
Palanza), or on the lake of Geneva (Montreux, Clarens). For winter 
residence it is doubtful whether to prefer a high region with cold equable 
climate, or a southern place with mild climate. For patients from the 
northern parts of Europe we prefer high localities; Davos, with its ex- 
cellent arrangements, gives extremely good results. Not a few patients 
of mine, who have spent several whole winters in southern places, have 
complained that after returning borne, with all due precautions, they 
have found the change of temperature so disagreeable that the benefit 
they had derived soon disappeared. The residence at Davos, however, 
has agreed with them wonderfully, and the benefit has been permanent. 
Persons disposed to haemoptysis and affected with laryngeal disease 
should not generally go to Davos, but to southern climates. In all 
cases, patients must stay as long as possible in the place selected, must 
visit it repeatedly, and not return home until settled warm weather is 
established. 
Among the climate cures of the south we mention San Remo, Men- 
tone, Monaco, Nervi, La Spezia, Cannes, Hyeres, Pau; also Pisa, 
Florence, Venice, Rome, Palermo, Catania, Ajaccio, Malaga, Cairo, 
Algiers, Madeira, and Malta. We have known several very serious cases 
in which Madeira, especially, produced surprising results, but the 
symptoms very quickly returned as soon as the patient came home, and 
it was necessary to take up a permanent residence in Madeira. 
In summer, much good may be done by residence in sheltered coun- 
try places with good food and much exercise in the open air. 
Thiiringen, Bavaria, Baden, and especially Switzerland, are very rich in 
summer resorts. 
Residence on the sea coast has been again recommended of late; 
Wiedasch, among others, says that in Norderney consumption is very 
rare. Long sea voyages have been found useful; Maclaren, for example, 
advises them strongly, but Jones opposes them. The use of the grape 
cure and the whey cure is diminishing. TUBERCULOSIS. 
293 
But a very small part of our patients will be able to make use of 
these remedies; as for the rest, treatment offers little for them. 
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 
really needs. It has even been recommended by mauy to introduce food 
by the stomach-tube in cases of unwillingness to eat. 
Let the patient have in the morning several cups of milk, or cocoa, or coffee 
with egg. At the second breakfast, a soft-boiled egg, shaved ham, tender meat- 
sausage, white bread and butter, and a glass of port. At dinner, meat soup, good 
meat, well stewed fruit, and half a bottle of good red wine. In the afternoon, 
milk or cocoa. At supper, porridge of wheat-grits or rye, soft egg, ham, cold 
meat, white bread and butter, a glass of good Bavarian beer. A record should 
be kept of the person’s weight. He should go to bed from 9 to 10 p.m., and 
rise at 7 or 8 p.m. 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. 
Cod-liver oil is an important remedy, especially indicated for thin 
persons. Give from one to three tablespoonfuls in the morning; but 
leave it off when loss of appetite or diarrhoea occurs. Malt extract has 
also a reputation. 
Inhalation of iodine, iodide of potassium taken internally, arsenic, 
and salts of phosphorus have been recommended as specifics in con- 
sumption, but we must say that there are no specifics known, and that 
our treatment is purely symptomatic. 
Buchner’s recent recommendation of arsenic has aroused attention, 
and both favorable and unfavorable reports have been given. We have 
repeatedly seen very good results at the beginning of the disease, but no 
specific results as against the lung changes themselves. Appetite was 
improved, weight increased, febrile movement ceased in several cases ; 
after a time, even night sweats were lessened. In extreme cases with 
great cavities and extreme weakness, we have neither seen nor expected 
success from arsenic. We have found the combination of arsenic 
and creasote often useful, if the secretion was very abundant in the 
air passages, and expectoration difficult. ($ Creasoti, gr. vi.; acidi 
arseniosi, gr. ss.; adde vehic. q. s. ut ft. pil. no. 20. Consperge cortice 
cinnamomi. S. One pill three times a day after eating.) 
The transfusion of lamb’s blood, and the use of benzoate of soda, may have 
some historic interest; Brachet recommended inoculation with small-pox, saying 
that he had seen phthisis of the lungs cured after that disease. 
Steinbriick and Krull successfully employ inhalation of oxygen. 
Surgical operations have been employed, but without brilliant success. Among 
the elder physicians, Von Herff and Hoken have advised the opening of cavities 
and surgical treatment of them; more lately, Mosler, Pepper, Mutchinson, and 
Williams have repeated the experiment, by puncture or incision. Koch advised 
the injection of irritating fluids (carbolic acid or tincture of iodine) into the lung- 
tissue, to excite cicatrization. 
In every case, a record of weight and temperature must be kept, and 
must be continued a long time after cure seems to be attained. The 
spirometer shows the vital capacity of the lungs, the pneumatometer 
the pressure exercised in expiration and inspiration; both are much used 
as tests. 
For violent cough, use small doses of narcotics, but be cautious with 
such remedies, as it is easy for a patient to acquire a habit of using them 
in the course of a chronic disease. 294 
TUBERCULOSIS. 
For abundant secretion in the bronchi use expectorants. In such 
cases, the use of the waters in Lippsprunge, Weissenburg, Selters, Eins, 
Soden, Obersalzbrunn, G-leichenberg, etc., has been recommended. 
If anaemia is very prominent, use mild preparations of iron. A mix- 
ture of iron and chalk is often advisable; e. g., R Ferri lactat., calcii 
phosph., aa 3 iiss.; magnesia carb., sacchari albi, aa Siv. M. S. A knife- 
point three times a day after eating. 
The iron waters of Pvrmont, Driburg, Cudowa, Reinerz, Salzbrunn, 
Konigsdorf-Jastrzemb, Steben, or Spaa may be useful. 
For loss of appetite bitters are suitable, as quinine in small doses, £ 
gr. three times a day [? gr. Transl.]; compound tinct. cinchona bark 
(decoct. cinchona3,1 :18, f vi.; ac. hydrochlor, gr. xxx.; syr. simp]., 3 v.; 
M. S. Tablespoonful every two hours); or folia trifolii fibrini (R Fol. 
trifol. fib., gr. xxiv., boil with equal parts water and claret wine and 
strain to make 3 vi.; simple syrup, 3 v. M. S. Tablespoonful every two 
hours). 
A careful use of Carlsbad or Kissingen water is sometimes indicated. 
For febrile symptoms, antipyrin is the surest remedy (3 i. in 3 iss. 
of water by enema). 
Heavy sweating is quite amenable to atropine (Wilson, Fraentzel, 
Williamson) (R Atrop. sulph., gr. TV; pulv. althaeas, q. s. ut. f. pil. no. x. 
S. One or two at night). In many, it causes diarrhoea, which obliges the 
patients to suspend its use. Seifert recommended agaricin (gr. to £) and 
Fraentzel, hyoscine (gr. y Cauldwell has lately used with success 
picrotoxine (gr. £ for a dose). Kohnhorn recommends powdering the 
patient with salicylic acid (R Ac. salieyl., 2> i j.; starch, 3 iiss.; talc., 3 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., p. 256. That of 
diarrhoea, in a following section on intestinal tuberculosis. 
2. Laryngeal 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 
patient’s 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 
first symptoms appear in the lungs. 295 
TUBERCULOSIS. 
Heinze found among 1,226 autopsies of consumption made at the 
Pathological Institute of Leipzig from 1867 to 1876, 376 cases of laryngeal 
phthisis, or 30.6 per cent. Mackenzie gives a similar result (33 per cent) 
from his own experience. 
It is stated by good authorities that sometimes all disease of the 
lungs has been absent, making the ulceration of the larynx independent 
or primary. It is even said that the lungs have been the part secondarily 
affected. The existence of the primary form can only be proved by 
autopsies, which at present are wanting, for we cannot certainly affirm 
that the lungs are unaffected merely because physical signs are want- 
ing. We personally believe in the existence 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 Changes.—By KoclTs revolutionary discovery, the 
domain of laryngeal phthisis has been sharply defined, its sign and stamp 
being the presence of the bacilli in the diseased parts. 
As regards the histogenesis of the disease, later researches, especially 
those of Heinze, show that the mucous and submucous coats of the 
larynx are thickened in most cases, owing to the accumulation of 
round cells, and more especially to the development of numerous tuber- 
cle nodules. The mucous coat is pale, gelatinous, and its surface often 
irregularly nodular. The nodules become caseous, and afterwards break 
down, producing tuberculous ulcers of the mucous 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 the mucous membrane 
of the larynx to that of the fauces or trachea. Tuberculous ulcers in 
the trachea alone are rare. 
There is much variation in the size and appearance of the ulcers. 
The size may be that of a pin's head, or a pea, or large parts of the sur- 
face may be covered. The shape is often circular; sometimes they are 
irregular. The loss of tissue may be superficial 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 
growths of the edge of the ulcer are sometimes found. The base of the 
ulcer often has a yellowlish 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 called follicular ulcers of the larynx; 
Rindfleisch has particularly studied their origin. They originate in 
ulceration of the outlets of the glands of the mucous membrane. A 
roundish and flat-funnel-shaped ulcer first appears, and afterwards 
spreads both downwards and laterally. The glandular body at the same 
time perishes under the same process, and the ulceration finally involves 
the perichondrium. If neighboring ulcers run together, they produce 
indented or (as Rindfleisch well says) bunch-of-grapes ulcerations. 
Marked tuberculous tumors form in rare cases in the larynx or trachea (Chiara, 
Mackenzie). 
A very favorite seat of these ulcers is the posterior wall of the larynx 
in the inter-arytenoid region. They are often formed on the mucous 296 
TUBERCULOSIS. 
membrane of the vocal processes and the posterior end of the true vocal 
cords, on the false vocal cords, the mucous membrane of the arytenoid 
cartilages, and the epiglottis. 
If the ulcers extend, 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 
part of the epiglottis especially being often quite destroyed. Perichon- 
dritis or oedema of the glottis with fatal 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 found ossified, even when the perichondrium is not 
implicated in the ulcerations. 
Fauvel remarked the almost invariable freedom of the laryngeal (i. e., 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. Symptoms.—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 hoarseness to complete aphonia. We often perceive a striking 
disproportion between the slight ulcerative changes and the severe affec- 
tion of 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 marked phthisical disease, but laryngeal 
phthisis sometimes seems to stand alone. TUBERCULOSIS, 
297 
Death may be due to exhaustion with increasing hectic symptoms ; 
or it is caused suddenly by oedema of the glottis, or is associated with 
the above-described symptoms of laryngeal perichondritis (see Yol. I., 
p. 189). 
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 formation of con- 
tracting cicatrices is equally rare. 
IV. Diagnosis.—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 bacillus. 
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 combination 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 taking 
sputum that has stuck there. 
V. Prognosis.—The nature of the disease renders the prognosis 
usually unfavorable. Recovery 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. Treatment.—We should avoid all energetic local measures. If 
there is severe pain, or trouble in swallowing, muriate of cocaine may 
be pencilled on the parts (solution of one part in twenty) several times a 
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. 
If inclination to cough is strong, give narcotics and inhalations, for 
which we especially recommend solution of bromide of potash (gr. xxx.: 
5 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 acetici. 
Do not relax attention to the main disease; and treat complications 
according to known rules. 
With many other physicians, I have seen no good results from touching the 
ulcers, or insufflation; sometimes there has been distinct harm. Nitrate of silver, 
iodoform (Lincoln), and bromide of ammonium (Gerhardt) have been recom- 
mended. 
The two cases of recovery which we mentioned (demonstrated after death) 
resisted for many months all treatment by inhalation and touching, and did not 
begin to heal until every kind of treatment of the larynx had been given up for a 
considerable time. 
Appendix.—Chronic tuberculous changes—usually tuberculous ulcers—may 
affect the mucous membrane of the nose as well as that of the larynx. They are 
commonly secondary, but are said to have been seen as primary. 
3. Phthisis of the Pharynx. Phthisis Pharyngea. 
(Chronic Ulcerous Tuberculosis of the Pharynx.) 
I. Etiology.—Tuberculosis of the soft palate and throat may be 
primary or secondary. In the latter case, tubercle is developed second- 298 
TUBERCULOSIS. 
arily on the mucous membrane of the soft palate and throat of consump- 
tive persons; in the former, the disease appears in otherwise healthy 
persons. It is not always easy to he sure that a case is primary, as con- 
sumption may lurk 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 German authors, 
and the patients have been all adults, with hardly an exception—Isam- 
bert’s 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 in 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. Kiistner, 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. 
IY. Treatment.—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-glycerin (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 TUBERCULOSIS. 
299 
early and actively, using nitrate of silver, chromic acid, or the galvano- 
cautery. 
Appendix.—Chronic tuberculous change of the tongue has more 
surgical than medical interest; it comprises ulcerations or large tumors, 
easily confounded with cancer or gummata. The diagnosis is rendered 
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 mucous membrane of 
the digestive tube, either spreading directly from the pharynx to the 
oesophagus, or occurring in the latter after a rupture of tuberculous 
tracheo-bronchial glands. They often cause no symptoms during life, 
and seldom lead to cicatricial stenosis (Beck and Chiari). 
Tuberculous ulcers of the mucous membrane of the stomach are 
sometimes found at autopsies, but not usually unless there is extensive 
destruction in the intestine also. Litten has described a case in whicli 
there was one tuberculous ulcer in the stomach alone, which had caused 
no trouble during life. 
Tuberculous ulcers of the stomach often do cause trouble; Paulicki observed 
perforation of the stomach; Oppolzer, fistula of the stomach, and Hattulo saw 
stenosis of the pylorus, which had been preceded by cicatrization and retrac- 
tion. 
4. Intestinal Phthisis. Phthisis Enterica. 
('Chronic Ulcerative Tuberculosis of the Intestine.') 
I. Etiology.—Tuberculous ulcers of the mucous membrane of the 
intestine are almost always secondary to consumption of the lungs. 
Cases of primary intestinal tuberculosis are so scarce that their existence 
is often denied, though, we think, incorrectly. 
The association with lung disease is even more in the 
case of laryngeal phthisis. Heinze, for instance, found 630, in 1,226 
cases of phthisis of the lungs (about fifty-one pei cent), while only 376 
(30.6 per cent) had signs of laryngeal tuberculosis. The ingestion of in- 
fectious sputa, or self-infection, is probably the usual method of produc- 
tion in cases of consumption, more especially as 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 using the unboiled milk 
of tuberculous cows, or raw or rare-done meats from tuberculous animals. 
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 is 
common among cattle. 
II. Anatomical Changes.—Tuberculous ulcers of the intestine 
agree with typhoid ulcers 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; sometimes there is a single one just below the 
ileo-caecal valve, or ulcers in the vermicular process only, while in other 
cases they are very numerous, and extend over large segments of the in- 
testine. 
The phthisical changes always originate in the lymphatic follicles of 
the mucous membrane, either the solitary or the agminated. In thelat- 300 
TUBERCULOSIS. 
ter, the change usually affects a part, and not the whole mass of follicles. 
There is first hyperplasia of the cell-elements, so that the follicle en- 
larges, and projects as a little knot into the intestinal cavity. The new- 
formed cells compress each other, causing disturbance of nutrition; 
whence proceed drying, caseation, and breaking down, and afterwards 
softening and bursting, the result of which is the formation of a sharply 
defined, deep, crater-like ulcer—the so-called primary intestinal ulcer. 
If neighboring ulcers join, they form great patches of destruction—sec- 
ondary ulcers of the intestine. 
The 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 belts or rings. 
Through the 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 for a long distance, beneath the serous coat. 
The ulcers can usually be felt without opening the intestine; their 
edges can be felt 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 an 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 of the 
abdomen as knobby lumps. 
Koch has shown that tubercle bacilli take a prominent part in the 
origin ot‘ intestinal phthisis. The 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. 
IIT. Symptoms and Diagnosis.—The symptoms are suprisingly 
varied. Extensive ulcers of the intestines often remain undiscovered 
during life, if the examination of the fasces has been neglected. The 
process of examination 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 fasces. 
In other cases, symptoms of sudden peritonitis, perityphlitis and para- 
typhlitis, intestinal perforation or hemorrhage, hsematemesis, 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 are of 
chief importance. Diarrhoea is frequent, and is explained by the irri- 
tant action of the faeces 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 
increase the tendency to diarrhoea. Several thin stools are often passed 301 
TUBERCULOSIS. 
ill the early hours (2 to 5 A.M.), which has given rise to the expression 
*( diarrhoea nocturna.” In many eases the stools are unaffected, or vari- 
ous degrees of constipation exist. Such is the case when the small 
intestine alone is affected, especially its upper part, as this gives op- 
portunity enough for condensation of faeces in the large intestine. De- 
struction of the nerves in the ulcers may annihilate reflex action, and so 
prevent diarrhoea. The muscular coat may be altered, and may be ex- 
tremely slow in its reactions and functions. Obstinate diarrhoea some- 
times alternates with periods of obstinate constipation. The stools in 
diarrhoea are thin, often smell like carrion, and sometimes contain un- 
digested pieces of food, as potatoes, vegetables, tendon, and flesh, a con- 
dition termed lientery. Blood, pus, 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 much 
oftener than the naked eye. But the presence of blood does not allow us 
to infer an ulcer of the intestine until we can exclude other sources of 
hemorrhage. 
Undue weight has been laid, especially by Nothnagel, on the occurrence 
of pus in the stool. It is easily understood that pus often is absent 
when there are ulcers, since pus-corpuscles can easily be dissolved and 
destroyed by the digestive juices. But in this respect we 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 less altered state, instead of the suspected pus- 
corpuscles. Pieces of parenchyma from the mucous membrane will be 
found less frequently than pus. 
Pain is a frequent, but not a constant symptom. It is sometimes ex- 
treme, and is described as cutting or boring. Sometimes there is no 
spontaneous pain, but it may be 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 valvula 
Bauhini. 
Vomiting is rare, unless peritonitis occurs. 
The 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 faecal masses 
must not be mistaken for them. The result is always fatal, due to in- 
creasing marasmus or the above complications (perforation, bleeding, 
peritonitis). 
IV. Prognosis and Treatment.—The prognosis is bad; owing in 
secondary cases to the nature of the primary affection, and in primary 
cases to the want of tendeucy to healing. 
Prophylaxis is important. The patient is to be warned against swal- 
lowing his sputa, and may try to disinfect such as he may swallow by 
stiff doses of alcohol, which is also useful for keeping up the strength. 
If tuberculous ulcers are formed, give easily digested food, such as 
makes a small amount of faeces: milk, eggs, meat soup, solution of meat, 
and meat, but no vegetables, and little bread. If diarrhoea is present, 
give the astringents mentioned on p. 110, vol. II. 
Opium, Dover's powder, columbo, cascarilla bark, and subnitrate of 
bismuth, are especially recommended. Injections of nitrate of silver 
(gr. iss. to viiss.), or injections of starch with opium, are useful. Sub- 302 
cutaneous injections of morphine have lately been recommended 
(hydrochlorate of morphia, gr. xv.; glycerin, distilled water, aa fl. 3 
ss. M. S. syringeful). 
We often have to combat constipation; solid masses may easily irritate 
the ulcer to a dangerous extent. 
Use gentle laxatives; perhaps the best are those given in Yol. II., p. 
122. 
Pains must be relieved by warm cataplasms to the abdomen, subcu- 
taneous injections of morphia, and chloral hydrate. 
Complications to be treated as usual. 
Appendix.—With tuberculous ulcerous changes of the intestine we must as- 
sociate many cases of rectal fistulae, originating primarily or secondarily, in 
connection with phthisis; they belong to surgery. 
5. Chronic Ulcerative Tuberculosis of the Urinary Organs. 
(.Renal Phthisis. Phthisis renalis, sive Nephrophthisis.) 
I. Etiology.—Tuberculosis of the urinary organs may lead to de- 
struction of tissues and is always due to the introduction of the tubercle 
bacillus, which mixes with the remains of destroyed tissue in the urine, 
and is found in the sediment by the method described in Yol. IY., p. 276. 
Chronic tuberculosis, as elsewhere, affects the urinary organs either 
primarily (i. e. independently and alone) or secondarily. In the latter 
case, the primary disease may be found in adjacent organs, as the sexual 
parts, or in the lungs. In the former case, we speak of a tuberculosis of 
the urino-genital apparatus. The secondary disease of the urinary organs 
usually arises from cheesy tuberculous changes of the epididymis, semi- 
nal vesicles, 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- 
sible to detect a very slight affection of the lungs, which may have 
been the cause of the disease in question, but a primary affection of the 
urinary organs may also have been the cause of the lung affection. 
Chronic tuberculosis of the urinary organs is not rare; many cases 
have been hitherto regarded as chronic catarrh of the bladder or of the 
pelvis of the kidney. It appears most frequently between the fifteenth 
and the fortieth year of life, but has been seen after the seventieth year 
and before the completion of the third year. Men are affected ofteuer 
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 blood-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 genitals. 
Gonorrhoea with epididymitis is a frequent source of tuberculosis of the 
epididymis. The usual process is that the acute symptoms of inflam- 
mation of the epididymis disappear, but that a lumpy hardness remains, 
which subsequently receives bacillary infection, undergoes cheesy meta- 
morphosis, and becomes a point for the further spread of disease. Con- 
cubitus also brings danger, for every well person who lies with one suffer- 
ing from tuberculosis of the urino-genital apparatus is in danger of 
infection with tuberculous masses, either mingled with the secretions, 
or stagnating, in the form of tuberculous urinary sediment, in various 
places. 
TUBERCULOSIS. 303 
TUBERCULOSIS. 
The causes of primary tuberculosis of the urinary organs are little 
known. Simple catching cold cannot cause it, for catarrh produces 
no bacilli; the most that it can do is to make the tissues hyperaemic and 
less able to resist the settlement of tubercle bacilli. 
II. Anatomical Changes.—The anatomical changes in chronic 
tuberculosis of the urinary organs may affect nearly their whole extent, 
or may be distributed in spots, separated by intervals of sound tissue. 
A distinction may be drawn between ascending and descending disease, 
according as the peripheral organs or the kidneys form the starting- 
point. Many authors doubt the existence of the ascending form. 
The kidneys are oftener affected on one side than on both; Meckel 
thinks the right kidney is more frequently affected than the other. The 
non-tuberculous kidney may be perfectly sound, or may be in a state of 
chronic parenchymatous nephritis; Badt and Rosenstein have described 
an obervation in which there was medullary cancer. Chronic tubercu- 
losis of the urinary organs is rarely limited to the kidneys. 
The alterations are characterized by cheesy infiltrations, at first of the 
papillae, 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 infiltration. 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 therefore 
a true consumption of the kidney. The papillae 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 cheesy, friable substance. The cavities are separated 
from one another by the calyces, but their lateral walls 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 masses, which sometimes have the consistency of brain 
(encephaloid). 
The altered kidneys have generally increased a good deal in size and 
weight. In a case described by Klebs, the right kidney weighed 4 lbs. 
13 oz. (normal weight was in. long, and 12f in. in circum- 
ference. 
The pelvis is usually dilated, as detached caseous masses occasionally 
clog the ureters and dam up the urine. It is probable that tuberculous 
disease of the ureters often lessens the muscular power of expelling the 
urine. Tuberculous ulcers of the mucous membrane of the pelves, a 
cheesy friable sediment, and cheesy tuberculous infiltration of the sub- 
mucous tissue are almost always found. 
The ureters are often changed to rigid, knotty, irregularly dilated 
tubes, marked by the same changes as the pelves of the kidneys. 
In the bladder, the first changes are usually developed at the fundus, 
near the neck. The cheesy tubercle breaking down gives rise to sharp- 
edged, sinuous-outlined ulcers with raised borders, at first often no 
larger than a lentil, but afterwards running together and thus gaining 
in size. They do not usually go below the mucous coat. The base of 
the ulcers is sometimes incrusted with phosphates. 304 
Tuberculous ulceration of the urethra not infrequently causes peri- 
urethral changes. 
Eupture has often occurred from the kidneys, the pelves, or the bladder, 
into the neighboring parts, such as the paranephritic connective tissue, 
the intestine, etc. Chronic tuberculous cheesy inflammations are often 
observed in the neighborhood of the organs affected with tubercle. 
III. Symptoms —-These often hardly differ from those of a vesical ca- 
tarrh: frequent desire to urinate, cloudy purulent urine, sometimes de- 
composed urine with ammoniacal or putrid odor, or that of sulphuretted 
hydrogen. We cannot be sure that chronic tuberculosis exists until 
we demonstrate the presence of specific tuberculous properties in the 
TUBERCULOSIS. 
Fig. 57. 
Tubercle bacilli with spores from the urinary sediment, in chronic tuberculosis of the urinary 
organs, from a woman aged 30. Fuchsine and malachite green preparation. Immersion. 750 
diameters. (Author’s observation: Zurich clinic.) 
purulent sediment. I have often succeeded in doing this by placing the 
sediment on a glass slide, distributing the drop tinely by revolving 
the cover glass, shaking off the superfluous part, drawing the covering- 
glass several times through the flame, and then staining according to the 
rule given on page 276 of Vol. IV. Such a preparation is given in Fig. 
57, containing abundance of tubercle bacilli with spores. But I 
must add that I have seen not a few cases in which, in spite of all care, 
I could not make the bacilli appear in tbe sediment, though the experi- 
ment was tried repeatedly and the diagnosis seemed established. There 
would then remain the inoculation-tesfc, which is made by putting some 
of the urinary sediment, with antiseptic precautions, into the anterior TUBERCULOSIS. 
305 
chamber of the eye of a rabbit. If the sediment contains specific germs, 
miliary tuberculosis will develop in about three weeks, at first in the iris, 
then on the other coats of the eye (Damsch and Ebstein). 
The urine is usually light yellow, and very often increased in amount. 
Its specific gravity is usually unchanged. It often contains a very 
abundant purulent sediment, in which cheesy crumbs are often found, 
sometimes 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 these small bodies elastic fibres and components of connective tissue; 
and above all tubercle bacilli. We also find in the sediment round cells, 
Fig. 58. 
Urinary sediment in chronic tuberculosis of "the urinary organs. The same patient as in 
. Fig. 57. 250 diameters. 
much detritus, epithelium cells from the urinary passages, and triple 
phosphates (comp. Fig. 58); the latter are often found even when the 
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 is added to the tuberculosis. Hsematuria sometimes 
occurs. 
If the bladder is implicated, the urine sometimes 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 the bladder is yet intact. 
The matter must always seem suspicious when there are hard 306 
tuberculosis, 
(caseous) lumps in the epididymis, or in the prostate when examined per 
rectum, together with frequent micturition and purulent urine. 
The implication of the kidneys can only be inferred when there are 
local renal symptoms. These include pain in 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 m the latter. The pain may be continuous or paroxysmal. Pain, 
however, is not a constant symptom, and sometimes it can only be pro- 
voked by pressure upon the region of the kidney. 
A very important fact is the demonstration of enlargement of 
the kulney by palpation. The surface is usually smooth and sensitive 
to pressure. We sometimes succeed in observing alternate enlargement 
and diminution of the tumor. With enlargement, there are usually 
very severe pains and remarkably clear and scanty urine, while, when 
the urine becomes freer and cloudy, the pain diminishes. This is plainly 
-due to temporary stoppage of the ureters bv the detachment of large 
cheesy morsels, and hydronephrosis with retention of the purulent 
urine. I have repeatedly seen chills and high fever at the time of these 
occurrences. 
In the case of a girl aged fourteen, I was enabled to diagnosticate 
tubercle of the ureter by the fact that a thickened, knotty cord was 
felt along the posterior wall of the bladder on the right side, by palpa- 
tion per rectum. 
Similar changes may sometimes be seen in chronic tuberculosis of the 
bladder. 
In case of rupture outwardly, symptoms of paranephritic abscess, 
external renal fistula, vesical, rectal, or vesico-vaginal fistula, or peri- 
urethral abscess may occur. 
The lungs are often tuberculous; and the same disease in the larynx 
and intestine may cause profuse diarrhoea, hoarseness, and trouble in 
swallowing. Sweats, chills, fever—in short, hectic symptoms—occur, 
strength is lost continually, and the result is death. The usual average 
duration is said to be one year, but cases lasting from ten to seventeen 
years are known. 
IV. Diagnosis.—This is based on the demonstration of tubercle 
bacilli in the sediment of the urine, on the success of inoculation with the 
sediment, the occurrence of cheesy fragments in the sediment, the demon- 
stration of local changes in the kidneys or urinary passages, and the ex- 
istence of cheesy spots in the epididymis or prostate, or chronic tubercu- 
losis of the lungs. 
V. Prognosis—unfavorable, for treatment is powerless. But I 
have lately seen two cases in the Zurich clinic which recovered—both 
cases of primary tuberculosis. Persons with cheesy tubercle of the epidi- 
dymis or prostate should avoid coitus, in order not to infect others. 
VI. Treatment.—Treat the symptoms—give iron, quinia, and cod- 
liver oil to improve nutrition; if there is ammoniacal decomposition of 
the urine, wash out the bladder with disinfectants; send the patient to a 
good country place. Attentive care of gonorrhoea may be of prophylac- 
tic U3e. 
Appendix.—Chronic tuberculosis of the male or females exual organs is not 
here described, being chiefly of surgical interest. TUBEKCULOSIS. 
307 
6. Solitary Tuberculosis of Internal Viscera. 
Solitary tubercles are tuberculo-caseous foci which have run together and 
formed one cheesy tumor of varying size. An organ often contains only one 
large tubercle-focus, a solitary tubercle in the stricter sense; in other cases, sev- 
eral of them are found. They may grow to the size of a fist and larger. 
The disease is almost always secondary, excited by tuberculous disease in 
other organs, chiefly the lungs. The symptoms may be prominently those 
caused by a growing tumor. The tumor may soften and break; or miliary 
tuberculosis may occur. We we will merely give a few special examples. 
a. Solitary tubercle of the brain is most common in childhood. Its favorite 
seat is the gray substance, especially that of the cerebellum, where it fre- 
quently begins in the boundary between gray and white matter. It may grow to 
the size of a good-sized apple, but often forms only a knot of the size of a pea or a 
hazel-nut. In most cases, there is only one nodule; sometimes there are as many 
as twenty or more in different parts of the brain. Their form is roundish; more 
rarely irregularly knobby. The mass of the tubercle is dry, yellow, and cheesy, 
while its periphery often forms a gray translucent border. The mass is sometimes 
encysted, witli distinct layers in the outer parts of the tubercle. Small nodules, 
becoming cheesy, are sometimes seen in the peripheral parts, showing that the 
large Jumps were formed by a gradual coalescence of the smaller ones. If the 
tubercle extends close to the meninges, it may adhere to them. 
Other metamorphoses occur besides the caseous, especially puriform liquefac- 
tion and calcification. Sometimes one-half liquefies, while the other calcifies. 
The microscopic structure is like that of other tubercles. The chief mass is 
composed of round cells, giant cells also occur, and tubercle bacilli, especially in 
the latter. In the peripheral layers, fibrous tissue is more prominent, and many 
cases are distinguished by a striking development of fibrous substance—the so- 
called fibrous tubercle. 
All cheesy substances in the brain are not tubercle, for the same change occurs 
in abscess, sarcoma, cancer, and especially gumma; the differential diagnosis of 
the latter 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 said to occur. 
Symptoms may be absent; or there may be the symptoms of cerebral tumor 
(see Yol. III., p. 241). Cerebral tubercle may give rise to tuberculous meningitis 
or general miliary tuberculosis, after a previous latent course. 
b. Solitary tubercles in the cord are said by Hayem to be most common in the 
lumbar enlargment, and to occur in children 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. 98). They may exist simultaneously with solitary tubercle of the 
brain. In general, that which was said of the one applies to the other. 
c. 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 has almost disappeared. The organ 
may 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. 
e. Solitary tubercles in the muscle of the heart occur, but have only an ana- 
tomical interest. 
7. General Miliary Tuberculosis. Tuberculosis Miliaris Disseminata 
sive Universalis. 
I. Etiology.—In this form, the name tubercle, or little nodule (tu- 
berculum), has its full anatomical significance, for the disease is charac- 
terized by the appearance of little nodules in many organs—which are 
gray and translucent, and in the older stages opaque and cheesy-yel- 
lowish. 
Before Koch’s discovery of the bacillus, it was generally assumed 
that the process was an infectious one, but the knowledge of the poison- 
ous element was derived from his studies. The chronic ulcerous tuber- 308 
TUBERCULOSIS. 
culosis of the different organs, and general miliary tuberculosis, have 
one and the same virus, in spite of the variety of their symptoms and 
anatomical changes. 
General miliary tuberculosis is distinctly a metastatic disease. 
The virus—that is, the bacilli—pass from any centre where they 
exist into the venous, 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 afEection. Whether the bacilli enter the general circulation 
directly from outside and at once produce general infection—that is, 
whether primary miliary tuberculosis exists—is still doubtful. Yon 
Buhl was unable to find a primary source of infection in 10 out of 300 
observations, but Simmonds lately found such a source in every 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 observed next in frequency in tuberculous 
caseation of lymphatic glands, especially the tracheo-bronchial; but also 
after tuberculous psoas abscess, and tuberculous paranephritis and para- 
typhlitis. Tuberculous disease of the bones and joints sometimes causes 
miliary tuberculosis; Doutrelepont has described it as following lupus, 
which is nothing else than chronic tuberculosis of the skin. Tubercular 
pleuritis, pericarditis, and peritonitis are among the commoner sources 
of infection. In general, any sort of tuberculosis may become the start- 
ing-point of general tuberculosis. 
Yon Buhl has made the excellent observation 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- 
nective 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 Yon Buhl states in regard to Munich, and 
Lebert in 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 given 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 have followed the removal 
of tuberculous rectal fistula. Litton states that general tuberculosis not 
uncommonly occurs after very rapid absorption of pleuritic exudations. 
Reich has described a very curious 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 Lavaran and Burkart), cancer (case by TUBERCULOSIS. 
309 
Simmonds, cancer and miliary tubercle of the liver), and alveolar 
emphysema of the lung. 
II. Anatomical Changes.—General miliary tuberculosis often in- 
fects most of the organs in one patient. In other cases, it is limited to 
single 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 of 
frequency with which the different organs are attacked, based on one 
hundred cases : 
Lungs 76 per cent 
Pleura 25 “ 
Pericardium 4 “ 
Liver 82 “ 
Kidney 62 “ 
Spleen 56 “ 
Intestine 57 “ 
Stomach 1 “ 
Peritoneum 26 per cent 
Pia mater ... 28 “ 
Dura mater 23 “ 
Brain 10 “ 
Suprarenal bodies.... 2 “ 
Thyroid 3 
Female genitals 2 “ 
Striped muscles 2 “ 
Tubercle in the heart-muscle is also reported; in the endocardium (by Weigert); 
the inner coat of vessels (by Miigge and Weigert); in the thoracic duct, tongue, 
and fauces, marrow of bones (thirty-one per cent of Litten’s cases); the choroid, 
retina, and iris. 
In general miliary tuberculosis, as in many other infectious diseases, 
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 easily recognized by the eye. The 
lung is everywhere filled with little gray transparent nodules, some so 
small as to be hardly visible, others as large as a poppy-seed, pin-head, 
and larger. The smallest are perfectly transparent, but 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 a bag of shot. The lumpi- 
ness 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 cases, one lung, or even but one lobe, is affected; but usually 
both sides are involved. 
We usually note, in addition, symptoms of consumptive disease; re- 
traction; frequently emphysematous change; recent pneumonia; oedema 
of the lungs; bronchial catarrh. 
Miliary tubercle of the pleura is probably always associated with that 
of the lung; inflammation readily sets in, causing tuberculous pleurisy. 
In the heart, 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 as on 
the intima of the blood-vessels; most commonly on the veins. Miliary 
tubercle of the thoracic duct was first described by Ponfick. 
The spleen is usually enlarged, and often full of countless nodules, 
many of which are cheesy in the centre. If few in number and trans- 
parent gray, they may easily be confounded with the Malpighian bodies, 310 
TUBERCULOSIS. 
but 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 the Malpighian body 
a peculiar central blood-vessel, and in the tubercle, 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 omentum is often thickened, 
dense, rolled up, and wrinkled. 
Miliary tubercle in the mucous membrane of the stomach is rare. 
Strassmann and Chiari have discovered it in the tonsils and thyroid 
body. 
The liver is often affected; the tubercles are found sometimes 
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 miliary 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 
been noticed that it first appears in the neighborhood of blood-vessels 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 Ville- 
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. Brunniche 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. TUBERCULOSIS. 
311 
Albuminuria is very common, and peptonuria is not rare. 
The consciousness is often obscured at an early period; the patient 
pays no attention to things, or is furiously delirious. 
As in acute septic endocarditis, so in general miliary tuberculosis, 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 splenic 
tumor, and diarrhoea, I found at the autopsy general miliary tuberculosis, 
old circumscribed foci in the lungs, splenic tumor, and old tuberculous 
ulcers of the intestine; and such cases are quite common in Zurich. 
The diagnosis being sometimes very difficult, much value may be 
assigned to an observation of Weichselbaum, which has been confirmed 
by Meisel, Lustig, Ulacaris, and Dontrelepont, 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- 
quire close search. Riitimeyer obtained splenic juice by puncturing a 
living patient with a Pravaz syringe, and in one case found tubercle 
bacilli; this organ is said by Weichselbaum and Lustig to be especially 
rich in the bacillus. 
The local symptoms depend on the organ chiefly attacked. In many 
cases (especially when the lungs are affected), we have little else except 
severe coughing, continuing day and night, uncontrolled by narcotics, 
and soon followed by violent pains in the muscles of the breast and ab- 
domen in consequent of the violent exertion. 
There may be symptoms of bronchial catarrh—extensive sonorous 
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 as to resemble the sputa of 
fibrinous pneumonia. The disease began with spitting blood, in a case 
of Litten’s.j 
Dyspnoea is often prominent; breathing is excessively accelerated, 
and often orthopnceic, while physical examination shows no cause for 
the acceleration. (Irritation of vagus fibres by miliary tubercle?) 
There are sometimes attacks of rapid breathing, having a superficial re- 
semblance to asthma. 
Cough and difficulty of breathing may be associated with great 
cyanosis, and this symptom becomes of especial importance when dis- 
ease of the bronchi and alveolar spaces cannot be demonstrated. 
There may be a total absence of local thoracic symptoms. The per- 
cussion sound is sometimes tympanitic, a sign that the tension of the 
lung-tissue is diminished, and in correspondence with this we may hear 
the cracked-pot sound, usually in the subclavian fossa. 
The symptoms of old consumptive disease may be so prominent that 
we overlook general miliary tubercle of the lung. In this case, we find 
tubercle bacilli in the sputa, which would not be the fact in uncompli- 
cated miliary tuberculosis, as bacilli are not expectorated until the 
nodules are softened and break into the air passages. 
In miliary tubercle of the pleura, Jurgensen 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 pleurisy; 
in this case the discovery of bacilli in the exudation would be of especial 
diagnostic value. The exudation is often hemorrhagic. 312 
TUBERCULOSES. 
General miliary tuberculosis may be concealed behind the symptoms 
of pericarditis, peritonitis, or meningitis. 
Traces of albumin in the urine do not necessarily point to miliary 
tubercle in the kidney, for this symptom is often found where there is 
only general infection and fever. Neither does the existence of tuber- 
cle bacilli in the urine allow us to assume miliary tubercle in the kid- 
ney; on the contrary, it would point to chronic tubercle with ulcerative 
destruction. Rosenstein refers many cases of anuria in children to 
miliary tubercle in the kidneys. 
Precisely the same holds good in regard to tubercle bacilli in the 
stools. 
Prominent importance must be attached, not only to the bacilli as 
Fig. 59. 
Tubercle of the choroid. After Jaeger. 
demonstrated in the blood, but to those of the choroid, for the latter 
can easily be recognized during life with the ophthalmoscope as yellow 
washed-out spots (see Fig. 59). The symptom is not, unfortunately, a 
constant one, and can only be counted on when the disease extends to a 
great many organs. 
Manz first saw choroid tubercle in the living subject; it was afterwards de- 
scribed by Graefe and Leber, Cohnheim, Frankel, Steffen, Bouchut, and others. 
One should persevere in the examination from day to day, for it often happens 
that tubercle becomes visible in twelve hours. Sometimes we find only 
one, or a few tubercles; at other times they are very numerous. Cohnheim 
found fifty-two in one case at the autopsy. The tubercle must (as Graefe and 
Leber state) have reached a certain size before it is visible to the ophthalmo- 
scope; it must also have caused atrophy of the superjacent pigment, and must 
lie close to the retina. Litten once observed the formation of a crater-shaped TUBERCULOSIS. 
313 
•depression, 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 tubercle 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 disease is most frequently confounded with: 
a. Acute bronchial catarrh. 
Pay attention to the severity of the general symptoms and the loss of 
strength, 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 often wanting, while in intermittent fever quinia 
produces rapid effects. 
c. Typhoid fever. 
In tubercular disease, the temperature is usually les3 elevated: distinct stages 
of the complaint are not seen; meteorism, roseola, and diarrhoea are usually 
absent; bronchitic symptoms at the beginning are more prominent. 
d. Uraemia. 
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. 314 
TUBERCULOSIS. 
8. Tuberculous Inflammation of the Cerebral Membranes. Meningitis 
Tuberculosa. 
I. Etiology.—Tuberculous meningitis is simply a distinct variety 
of miliary tuberculosis. It may be a consequence of general miliary 
tuberculosis, or the miliary tubercle may be mainly confined to the soft 
cerebral membranes; the latter is the more unusual case. 
There are two very distinct stages in the development of the disease. 
In the first, miliary tubercles appear upon the meninges without excit- 
ing inflammatory symptoms, while in the second the disease develops 
into tuberculous meningitis by the supervention of inflammatory pro- 
cesses. Morbid disturbance may be absent in the former case. 
The causes are identical with those of general miliary tuberculosis; 
any tuberculous cheesy deposit may lead to general infection, and, in 
consequence, to an outbreak of general tuberculosis or to miliary tuber- 
culosis of the soft meninges. A very frequent cause, especially in chil- 
dren, is the tuberculous cheesy change in lymphatic glands; most fre- 
quently those of the trachea and bronchi. Doutrelepont recently 
described the outbreak of tubercular meningitis after lupus; an observa- 
tion of great importance, as presenting a kind of auto-inoculation, since 
the tubercle bacillus is found in lupus. There are a few cases in which 
no source of infection could be shown, so that it seems as if in some cir- 
cumstances the meninges, like the fauces, larynx, intestine, and kidney, 
might be primarily affected. Compare etiology in the preceding 
chapter. 
Children are much the most frequently affected, especially from the 
second to the sixth year; after that period, the disease grows more and 
more rare, and after the fortieth year it is exceptional. 
The male sex is oftener affected than the female. The disease is 
more frequent in winter and spring than in warm weather. 
II. Anatomical Changes.—As in purulent meningitis, the bones 
of the skull contain a great deal of blood, and the dura mater is very 
tense. Nodules of miliary tubercle may sometimes be seen on the surface 
of the latter, especially in the neighborhood of the middle meningeal 
artery, and also in the tissue of the. dura itself. The sinuses usually 
contain much blood, in part coagulated. Raising the dura, we find its 
inner surface dry, and often dotted with little extravasations of blood. 
The convex surface of the hemispheres is strikingly prominent, the 
convolutions are broad and flattened, the sulci obliterated. 
The pia mater is usually very dry and deficient in lustre. Its blood- 
vessels are very full, and many can be traced to the finest ramifications. 
Very fine, transparent knots of tubercle may be seen here and there on 
the vessels; they are more distinctly seen when the pia is stripped off 
and held up against the light. Streaks of pus are seen on both sides of 
the larger vessels in the pia. 
The changes in the pia and the subarachnoid tissue are usually well 
advanced at the base of the brain. The space between the optic chiasma, 
pedunculi cerebri, and pons, especially, is in a state of oedemato- 
purulent infiltration. In the course of the sylvian artery the tubercular 
eruption and the infiltration are usually very pronounced; this region 
should be carefully examined in cases that are not well marked. The 
inflammatory products usually have an cedemato-purulent character; 
less commonly they are sero-purulent or fibrino-purulent. The tuber- 
cles are not all gray and transparent; many have an opaque centre, and TUBERCULOSIS. 
315 
others are undergoing cheesy metamorphosis. Diffuse cheesy tubercu- 
lous thickening and deposits in the pia are also sometimes seen. 
The ventricles are often widely dilated, but not always with fluid, and 
not always in equal degrees. The fluid is usually serous, or serous and 
flocculent, seidom purulent. Cadaverous 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- 
cles. 
On the upper surface of the cerebellum, tubercles and gelatino-puru- 
lent infiltration of the pia are usually very marked. 
Schultze notes the important fact that tuberculosis of the meninges, 
or tubercular spinal meningitis is usually found if that part is ex- 
amined. 
The substance of the brain and cord may be involved. 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 
affected, and the convexity may be preferred. Local tuberculosis of the 
meninges is rarer. Such cases prefer the region of the arteria fossae 
Sylvii; when the left artery is affected and the circulation is interrupted, 
they cause aphasia, alexia, agraphia, and hemiplegia of the right side. 
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 
unaffected. There was hydrocephalus. Death occurred within thirty 
hours, with attacks of loss of consciousness and twitchings of the face. 
We do not enter on a microscopic description of tubercle in this place. Most 
authors state that it originates in the adventitial lymph-sheaths of the vessels of 
the pia, especially those of the veins, the endothelium being the part first in- 
volved. As it grows, it contracts the vessels proper. The internal and middle 
coats are often infiltrated in places with round cells. The tubercle may grow 
through the wall proper of the vessel; or in other spots it may contract the vessel 
and thus lead to thrombosis by compression. The true pathognomonic sign is al- 
ways, not the giant-cell, about which there has been so much dispute, but the tu- 
bercle bacillus of Koch. 
Tubercle has often been seen in the walls of the blood-vessel, especially in the 
inner coat. Ziegler states that the older view, of which Rindfleisch is the chief 
representative, of 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 examination of the substance of the brain and cord shows that 
the tuberculous deposit often extends along the sheaths of pia mater into the 
brain and cord, producing diffuse infiltration, and often foci of softening in the 
vicinity. 
The frequent preponderance of the basal affection has given rise to the term 
basal or basilar meningitis, as contradistinguished from the purulent meningitis 
of the convexity, but it is better to avoid these terms, as exceptions are too numer- 
ous to the supposed rule. 
Tuberculous meningitis is also called acute hydrocephalus—a name which is 
unsuitable, because dropsy of the ventricles is sometimes absent in the disease 
in question, and is by no means exclusively confined to it. 
III. Symptoms.—The clinical phenomena are essentially like those 316 
TUBERCULOSIS. 
of the purulent form, depending as they do upon inflammatory nisus 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 first unquestionable menin- 
gitic symptoms appeared. I remember a case in which the only child of 
parents 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 the 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 only at the beginning, but in other cases is repeated many times 
a day during the entire sickness. Cases with meteorism and diarrhoea 
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. The Cheyne-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 only 
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. Gnandinger reports 
several cases: in one, the rectal temperature fell to 28.6° C. before death. 
Rise 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. Conjugate 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 
vagus). The skin may display unusual irritability of the vaso-motors, 
so that slight irritation is enough to cause protracted redness. Roseola 
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 (Yol. IV. p. 212) are of great diagnostic importance. Neuritis and 
neuroretinitis occur simultaneously or independently; also apoplexy of 
the retina. tuberculosis. 
317 
It is fashionable to divide this disease into stages—that of irritation, 
of increasec cerebral pressure, and of paralysis. We think this incorrect 
and artificial; the symptoms of different stages almost always run side 
by side, and symptoms of paralysis and irritation frequently alternate in 
the same organ, as is seen in the pulse. 
There are some singular cases, as when the disease opens with para- 
lysis, or one or several attacks of aphasia, followed by paralysis of the 
face and extremities. 
IV. Diagnosis.—The close resemblance between purulent and tuber- 
lar meningitis involves the danger of confusing them in diagnosis. 
Notice that the tuberculous disease develops more slowly, is more insidi- 
ous in its progress, often has less fever or even none at all; add the evi- 
dence of hereditary tendency and previous scrofulosis, or tuberculous 
inflammations of the skin, bones, or joints. Some cases must remain 
doubtful, e. g., tuberculous disease of the petrous bone is not necessarily 
followed by tubercular meningitis, for the purulent form may occur. 
It is easy to confound the disease with typhoid fever, especially when, 
contrary to the rule, there is meteorism and diarrhoea, or roseola and en- 
larged spleen, for the rigidity of the neck may be found very fully 
developed in typhoid fever as a consequence of oedema 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 
bacilli in the stools. 
If the disease opens with paralysis or encephalitic symptoms, we may 
be inclined to infer embolism or thrombosis of the cerebral arteries rather 
than meningitis; here the important points are: rigidity of the nucha, 
and the state of the fundus oculi and the blood. 
V. Prognosis.—The disease probably always ends in death. Re- 
coveries are reported, but are doubtful. Dujardin-Beaumetz reports a 
recovery after choroid tubercle had been seen. 
VI. —Treatment as in purulent meningitis. Holm recommends 
benzoate of sodium (1 part : 10 of water; tablespoonful bvery two hours) 
as a remedy (!). 
9. Tubercular Peritonitis. 
I. Etiology and Pathological Anatomy.—Of the causes of tuber- 
culous inflammation, or of general tuberculosis of the peritoneum, we 
may repeat what was said under general miliary tuberculosis and tuber- 
culous meningitis The disease may develop as an independent dis- 
ease, or may be the consequence of a widely diffused general miliary 
tuberculosis. 
Miliary or submiliary gray nodules, rather than cheesy or partly 
calcified masses, are usually found. Inflammatory changes are often as- 
sociated, many adhesions between the intestines and the abdominal 
viscera (constituting the so-called adhesive tuberculous peritonitis) and 
effusions, serous, or more commonly hemorrhagic, very rarely purulent. 
Extravasations occur in the peritoneum, so that the individual nodules 
are seen surrounded by a hemorrhagic area, or at a later stage (when the 
coloring 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 examiner 
should look carefully at the omentum. In chronic cases, thickening and 318 
TUBERCULOSIS, 
crumpling of the omentum and mesentery occur, the omentum often- 
forming a rolled-up cord which crosses the abdomen from right to left 
Localized milary tuberculosis of the peritoneum must be distinguished from the 
general or disseminated form; it is found close to cheesy tubercles of the ab- 
dominal viscei-a, most frequently over tuberculous intestinal ulcers, in which 
case it often follows the lymphatics for long distances. The fact has no clinical 
importance. 
II. Symptoms and Diagnosis.—Our diagnosis depends on our 
power, in the presence of peritoneal dropsy, to assign a tuberculous 
origin to such dropsy; and in 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 may become acute. 
There is pain, swelling of the belly, diarrhoea or constipation, loss of 
appetite, vomiting, and continued loss of strength. Fever may be pres- 
ent or absent, the contracted omentum may 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 always 
be avoided in spite of all care, if the demonstration of the bacilli fails. 
The diagnosis of cirrhosis is favored by 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 usually 
comes as a consequence of progressive marasmus, or of asphyxia through 
increase of dropsy. 
III. Prognosis. 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 tuberculous pericarditis and pleurisy see Yol. 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 chronic tuberculosis of the lymphatic glands, strongly 
predisposing the system to inflammations which 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. It has been seen in prisoners living in gloomy, TUBERCULOSIS. 
319 
narrow cells, forced to spend a long time in a sedentary way—the so-called prison 
scrofula. It is much commoner to find it beginning with the first dentition 
(about the ninth month), and sometimes earlier. Chaussier described a con- 
genital form, in which a child was born with suppurating lymphatic glands (?). 
The constitution is very important, as in the case of consumption. 
Faults may be inherited, congenital, or acquired. There are scrofulous, 
as there are consumptive families; many inherit both 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 differed widely in age; or who were in a state of 
marasmus from consumption, cancer, tertiary syphilis, etc.; or were in a 
condition of wretched poverty; or were blood relations. Drunkenness of 
the father is said by many physicians to cause scrofula in the children. 
These facts are paralleled in the 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 potatoes, bread, and pud- 
dings with too little meat, scrofula easily occurs. 
Bad diet and unwholesome surroundings greatly assist the develop- 
ment of the disease; hence it is frequent among the lower classes of 
laborers, whose children spend their first 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 air. 
There are several reports of endemic scrofula in institutes for the blind and 
deaf-mutes, but which diminished when the pupils were obliged to take daily 
walks in the fresh air. 
Certain diseases of childhood, especially measles and whooping- 
cough, less frequently scarlatina and diphtheria, German measles and 
small-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 bacilli 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 
remove from the tropics to temperate climates. 
II. Symptoms.—Scrofulosis is to be specially feared for children who 
are predisposed by inheritance, or whose elder brothers or sisters have 
had 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 
are thick and turned up, the lower part of the nose is thick and shape- 
less, or pear-shaped, and as it were pendulous. The patients are lazy, 320 
TUBERCULOSIS. 
have a stupid, clumsy, almost vulgar expression, and are usually not 
remarkably lively. 
The eretliistic cases have a delicate, soft, pale skin, with bluish veins 
winding over the forehead and breast. The hair is usually blond and 
soft, the eyes 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 may be more required than internal medicine. We shall 
refer only to such symptoms as belong to the latter domain; we cannot 
even enumerate the others. 
Scrofulous (tuberculous) changes of the lymphatic glands are first 
betrayed by swelling, but not every swollen iymph gland is primarily 
tuberculous; for example, primary scrofulous inflammations of the skin 
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 large 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 flexible. The glands are flattened, and not tender. 
They 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 lymphatic 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 sterni, 
sometimes even by slight swelling at that point, 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 inflam- 
mation, are external signs of this condition. Suppuration may be pro- 
tracted, the fistulae do not close, but form ulcers with undermined TUBERCULOSIS, 
321 
swollen edges; and at last leave disfiguring 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 especial 
frequency, and very often accompanied by inflammatory swelling of the 
nearest lymphatic glands—secondary or sympathetic bubo. There is 
little to distinguish this from eczema in non-scrofulous persons, unless it 
be its great obstinacy and great tendency to relapses. Eczema of the 
skin often attacks the neighboring mucous membranes, especially 
those of the nose and 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 scrofulosis. 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- 
blains is another instance of the great vulnerability of the skin of scrofu- 
lous persons. 
Abscesses often form in the subcutaneous cellular tissue, which 
keep recurring, and may cause dangerous loss of strength. 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 
these formations is tuberculous. 
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 
is 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- 
purulent 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 
be due to tuberculous deposits. The vertebral column is very often 
attacked, causing kyphosis, gravity-abscess, perhaps peripachymenin- 
gitis, compression myelitis, etc. Or tuberculous inflammatory swell- 
ings appear on the bones of the fingers and toes (spina ventosa), or in 
other parts, as the ribs, sternum, 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 impetiginous 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; 
as opacity of the cornea (leucoma), or adhesion between the cornea and 
iris (synechia anterior). Horner associates lamellar cataract with scrofula. 322 
TUBERCULOSIS. 
The external meatus of the ear is sometimes inflamed and discharges; 
sometimes the middle ear is inflamed in connection with throat- 
catarrh; and sometimes the petrous bone is tuberculous, which destroys 
the organ of hearing permanently or leads to thrombosis of the sinuses 
or inflammation of the meninges and the brain. 
Scrofula is a chronic disease, often lasting many years. The changes 
often begin in one organ, and extend to others successively. In pro- 
tracted cases, leucocytosis has been observed; Horand states that he has 
seen the red corpuscles of the blood lessened in size. Remissions and 
exacerbations are common; the patient is often worse in winter when 
shut up in the house, and better in summer. 
Among the complications, miliary tuberculosis is 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 
glands of the abdomen may occur, known by the hard swelling of the 
liver and spleen, albuminuria, and oedema. Fatty liver also occurs. 
III. Anatomical Changes.—These are composed of various ele- 
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 bacillus is usually 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 hyperaemic, but in older ones the cheesy process becomes 
prominent. 
IV. Diagnosis.—This is usually easy if we regard the totality of the 
symptoms rather than any single one, or if we discover the bacilli. 
V. Prognosis.—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 senses may occur, and that general miliary tuberculosis is a threaten- 
ing possibility. 
VI. Treatment.—The etiology shows us what to do for prophylaxis. 
Blood-relations should not be encouraged to marry; marastic or con- 
sumptive or tertiarily syphilitic patients should not get children. The 
physician should forbid women of scrofulous or consumptive families 
to nurse their own children, especially when they themselves show signs 
of these diseases, or when they are younger than eighteen, or are anaemic. 
Let wet-nurses or good cow’s milk be then substituted. The food of 
children must be 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 concerns 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 Meran, Nice, or 
other mild climates. Mental overwork should be forbidden. 
Cod-liver oil is a very important remedy. Give about a dessert-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 lozenge may be taken directly afterwards. The remedy needs to be 
taken for months or years; it should be suspended for a week or two, TUBERCULOSIS. 
323 
every four or six weeks, to prevent unconquerable disgust. In the hot 
summer months, it will be best to leave it off, as it is liable to injure the 
appetite. The ferrated oil is desirable for pale children; the iodated oil 
seems to us to have no special value. 
It is not known what gives 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 erethistic 
form, but we do not accept this unconditionally. 
The preparations of iodine and iron, and iodine and iron baths, are 
next on the list. 
For the frequent combination of scrofulosis with rachitis, we prefer 
the powder given at p. 94, Vol. IV. Otherwise we advise 
R Syr. ferri iodati fl. 3 ij. 
Syr. simp fl. 3 ss. 
M. S. One teaspoonful three times a day after eating. 
Or, 
5, Ferri iodati saccliarati gr. £ 
Sacchari albi gr. viij. 
M. f. pil. no. x. 
S. One pill, three times a day. 
I have lately made trial of Fowler's solution, and am well pleased; I 
give it mixed with equal parts of bitter almond-water, three to five drops 
of mixture three times a day, after meals. 
For brine baths, dissolve two to five pounds of sea-salt or common 
salt in a full bath at 28° R., and let the patient remain in it twenty or 
thirty minutes daily; after which he should rest an hour in bed or 011 a 
sofa, in poor families the bath can be used several times by adding 
boiling water and some more salt when used. 
Natural brine baths 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 granular 
swellings, cold abscesses, scrofulous ulcers, and joint-diseases are much 
improved by a residence at the sea, while bone-tuberculosis is not influ- 
enced, and eczema and blepharitis are made worse. 
There is no lack of brine-baths {“ soolbiider ”). We mention the best 
known: Arnstadt (Thiiringen), Bex (Switzerland), Cannstadt (Wurtem- 
berg), Durkheim (Pfalz), Frankenhausen (Schwarzburg-Rudolstadt), 
Gandersheim (Brunswick), Gmunden (Austria), Hall (Tyrol), Hamburg 
(Prussia), Juliushall (Brunswick), Ischl (Salzkammergut), Kensington 
(Bavaria), Konigsdorff-Jastrczemb (Silesia), Kosen (Thiiringen), Kos- 
tritz (Gera), Kreuznach and Munster a. Stein (Rhenish Province),. 
Nauheim (Hesse-Darmstadt), Neuhaus (Bavaria), Rheme-Oeynhausen 
(Westphalia), Reichenhall (Bavaria), Rheinfelden (Aargau), Rothenfelde 
(Hanover), Salzdetfurth (Hanover), Salzhemmendorf (Hanover), Salz- 
schlirff(Hesse), Salzufeln (Lippe), Salzungen (Thiiringen), Schweizer- 
halle near Basle, Soden a. Taunus (Prussia), Soden a. d. Werra(Hesse- 
Cassel), Sodenthal (Rhenish Bavaria), Suiza (Thiiringen), Salzbad 
(Alsace), Sulzbrunn (Bavaria), Weisbaden (Nassau), Wittekind (Prussian 
Saxony). 
Among the iodine-springs we name Tolz and Adelheidsquelle, both 
in Bavaria. 324 
Preparations of baryta, antimony, and mercury are among the obso- 
lete remedies. Decoction of walnut leaves is recommended by recent 
authors. 
Local treatment is not given in this place; if suitable to the charac- 
ter of this work (e. g., as in eczema) it is given elsewhere. For glandu- 
lar swellings Novello has recently recommended tincture of tapya (one 
to ten drops three times a day). I have seen good results from chloride 
of gold and sodium (gr. three times a day in pill). Kapesser ad- 
vises the rubbing with soft-soap (schmierseife), which is also praised by 
others (Hausmann); from one-half to one and one-half tablespoonfuls 
are dissolved in lukewarm water, and the back and limbs are wet-rubbed 
with it twice a week for ten minutes, and then washed off with water. 
For tabes mesenterica we advise careful diet, cod-liver oil, decoction 
of quinia, and styptics, especially Colombo and eascarilla. 
SYPHLIIS. 
PART II. 
SYPHILIS. 
(Lues Venerea.) 
Public attention was first called to this disease at the end of the year 
1494, when it spread as an epidemic among the troops of Charles VIII., 
who were then besieging Naples. The pest very soon travelled thence to 
Spain, France, Germany, and other lands. Many have believed that 
the disease was previously unknown, and took its origin from floods, 
from an unfavorable conjunction of the stars, from protracted rains, and 
from the practices of the abandoned soldiery with their glandered 
horses. Many said it was brought from America bv the sailors of 
Columbus; others that it was an offshoot of leprosy. None of these 
views have prevailed; it is now with reason believed that syphilis was 
known in the oldest times, but became common among Charles VIII.'s 
military hordes whence it spread abroad. 
It soon became known that sexual intercourse was the means of 
transmission in almost all cases. When the clergy, and even secluded 
nuns, became affected, it did not seem necessary to suppose that the 
disease might exceptionally be carried through the air. 
The disease had at first a great variety of names; it furnished differ- 
ent nations with the means of giving each other a satirical thrust, as the 
names French, Neapolitan, Spanish, German disease, etc., show. The 
name of syphilis originated with Fracastorius in 1521, who invented and 
verified the legend that a herdsman of King Alcithous named Syphilus 
was punished by Apollo with the disease for refusing to pay him due 
honors. 
Gonorrhoea, soft chancre, and syphilis were at first considered one 
and the same disease; it was thought that the poison might cause purely 
local injury to one person, while another's constitution was completely 
undermined. This erroneous doctrine lasted till near the middle of 
our century. A correct view is obviously of far more than theoretical 
importance in this case. 
Balfour in 1767 first attempted to give to gonorrhoea a separate posi- 
tion as a local disease, but his views were not adopted. John Hunter 
in 1786 inoculated a well man with the purulent secretion of gonorrhoea SYPHILIS. 
325 
and produced syphilitic disease; of course, the case must have been one 
of masked chancre in the urethra. Although Benjamin Bell (1793) took 
Balfour’s side, it was reserved for Ricord (1831) to give to gonorrhoea its 
true position. 
Ricord’s scheme, however, identified the soft chancre and syphilis. 
Two of his pupils, Bassereau and Clerc, separated them, giving to soft 
chancre a place with gonorrhoea as a local disease. These views are not 
yet universally adopted. The “unicists” still believe that general 
symptoms sometimes follow soft chancre. 
Rollet explained a part of the difficulty by the “mixed chancre ”—a 
soft ulcer, which in a subsequent coitus is infected with syphilitic 
virus. It seems to heal within a short time, but after some weeks symp- 
toms of syphilis follow. 
The symptoms of syphilis have been divided into those of the 
primary, secondary, and tertiary periods (Ricord). The exceptions to 
this arrangement are frequent, as is the case with other diseases that 
have a typical course; but the scheme is of great use in practice. 
While the primary period is essentially confined to the development of a 
hard chancre, the secondary includes a great variety, mostly of superfi- 
cial affections, on the skin and mucous membrane; while the tertiary is 
signalized 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 Syphilis in the First and Second Stages. 
I. Etiology.—Syphilis is a highly contagious disease. It cannot be 
doubted that the poison exists in the blood of the patient, for when such 
blood is placed under the skin of well persons, intentionally or other- 
wise, they become syphilitic, almost invariabty. One source of contagion, 
therefore, may be the passage of blood directly from abrasions of the 
genitals of one party to similar abrasions in the other, during coitus. 
The secretions of all cutaneous syphilitic alterations of the first and 
second stages are contagious. Contagion by products of the third 
or gummous stage does not seem to occur, though views are not united on 
this point. During coitus, the secretion of condylomata lata may pene- 
trate into wounds of the well person; and in kissing, a similar disease of 
the lips may infect a crack in the lips of the well person. 
The physiological secretions of syphilitic persons, as tears, nasal or 
bronchial mucus, sweat, saliva, milk, and urine, are not infectious of 
themselves, but may accidentally acquire infectious properties. If, for 
example, the secretion of broad condylomata of the fauces mingles with 
the saliva, the mixture is not free from danger. 
Two physiological products are exceptions to this statement—the 
semen and the ovum. Both are almost always infected in syphilitic per- 
sons; it is matter of experience that such persons have no healthy chil- 
dren while they are under the influence of the disease. 
Sexual intercourse is the most frequent, though not the only external 
means of contagion. In many cases it occurs by accident. 
Among these accidents are kisses; the use of vessels for drinking and 
eating, of pipes and cigars previously employed by syphilitic persons, may 
also communicate the disease. Surgical instruments used unawares upon 
syphilitic patients and afterwards, without disinfection, upon well per- 
sons, may communicate it. It has repeatedly occurred in catheterism of 326 
SYPHILIS. 
the Eustachian tube, and also after the use of the lancet or the cupping 
knives. The use of razors previously employed by syphilitics 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 wound to check 
the bleeding. Bites and scratches from syphilitic persons have trans- 
mitted the disease. In glass factories, a sort of epidemic has repeatedly 
occurred, owing to the passage of the blow-pipe from mouth to mouth. 
This does not nearly exhaust 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. 
Mid wives also are often infected while conducting cases of labor, and 
themselves become sources of wide-spread 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 husband, 
but to all the women (more than one hundred) whom she attended in labor. 
Jean Beyer described a similar epidemic in 1725; forty women were infected in 
four months, and communicated disease to their husbands and children—in all 
eighty persons. Bleynic 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 lymph 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, asserted 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 blood cannot be detected by the naked eye. 
No prudent physician will use a child to vaccinate from, if there is the slight- 
est suspicion of hereditary syphilis, even though the danger of spreading be very 
slight. 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 oftener „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 flourishes 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 year’s more and more believe 
it to be due to schizomycetes. KLebs observed in the juice of the tissue of a hard 327 
SYPHILIS. 
chancre, besides found cells, certain rods. 2 to 5 ju (1 y«=0.001 mm.) long, 
moving slowly, which he cultivated with success and transplanted to apes. 
Baumann, and Martineau and Hamonie have described something similar, while 
Pisarewski and Aufrecht report round schizomycetes, micrococci. By a compli- 
cated process, Lustgarten has lately shown the regular presence of syphilis bacilli 
in syphilitic sclerosis, condyloma, gumma, and syphilitic excreta; experiments in 
culture and inoculation are wanting. His statements are confirmed by 
Doutrelepont and Schiitz and De Giaeomi, who give simpler methods. Doutrele- 
.pont states that he has lately found them in the blood and preputial sebum of 
patients. Alvarez, Cornil, and Tarvel say they have found them in the smegma 
of well men also. Lustgarten found his syphilis bacilli always inclosed in round 
cells, never free. The subject is not yet in a condition for decision. 
Bock and Scheel found syphilitic material active when diluted with one hun- 
dred parts of water; with five hundred parts it had lost its activity. When pre- 
served in lymph-tubes it loses its power in a week. Cold does not change it, but 
a temperature of 40° R. destroys it. 
It seems uncertain whether syphilis occurs in animals. It is said to have been 
observed in hares, and to have been produced artificially in apes. Some claim to 
have produced it in other animals by inoculation (?). 
After one attack, a person is protected against another, but cases are 
known in which reinfection occurred after some years. 
Syphilis and other infectious diseases (typhoid, pneumonia, erysipelas, 
etc.) do not exclude one another. It is often noticed that the symptoms 
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 coast of Jutland, Hol- 
stein, Pomerania, and also in the interior. This state is promoted by 
crowded quarters, lax morals, and indifference to disease. In large 
cities, especially seaports, it is especially common, as sensuality and ex- 
travagance are rifest there. 
II. Symptoms. —Syphilis is essentially chronic. Cases that have a short 
course, and sometimes cause death soon, are exceptional. Relapses are 
common, sometimes returning at intervals during life. 
The following is an outline of the course of the disease. Directly 
after infection, nothing is perceived for some weeks (the so-called stage 
of incubation); after which a hard knot or ulcer with cartilaginous 
edges appears at the point of infection—the ulcus durum. The neigh- 
boring 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 in 
the general circulation. A series of exanthemata now appear, usually 
called syphilides, and forming secondary stage; the first stage 
being that of the development of the hard chancre. 
A tertiary period often occurs, especially in neglected cases. While 
the broad condyloma is the chief and the commonest affection of the 
skin and mucous membrane in the secondary stage (called the condylo- 
matous stage), the gummous tumor of the skin and mucous membrane, 
often found in internal viscera, belongs to the tertiary, and bv its break- 
ing-down causes dangerous symptoms. 
A stage of marasmus and sequelae 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 in- 328 
SYPHILIS. 
oculation; the shortest time was ten days, the longest forty-four, but 
Sigmund has observed as long as fifty-six days. 
The hard chancre (ulcus durum), also called primary or initial 
sclerosis, or Hunterian chancre, is the first manifest alteration. It is 
most commonly seated on the sexual parts; in men on the outer or inner 
surface of the prepuce, the anterior border of the prepuce, the skin 
of the penis, the point of junction between the inner lamella of thg 
prepuce and the coronary sulcus; less frequently on thefraenum, 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 
commissure, rarely on the prepuce of the clitoris, the mons, or vaginal 
part of the uterus. 
As the hard chancre merely shows where the poison first entered and 
began to act, there is no difficulty in understanding how it is found on 
such spots as the lips, etc. American physicians (Taylor, Knight) have 
lately spoken of chancre of the tonsils as not very rare. 
In typical cases, there is a single hard lump, usually of longish form, 
resembling cartilage in consistency, and quite sharply defined. Its size 
Fig. 60. 
Ring-shaped hard chancre of the prepuce, with superficial ulceration. Author’s observation. 
Zurich clinic. 
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 between 
two fingers. The skin over the lump grows thinner and redder, and 
gets a peculiar glazed look. A slight secretion is sometimes found ou 
the surface of the lump, which is 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 even crater-shaped loss 
of substance, with the edge retaining its cartilaginous hardness; or gan- 
grene or phagedaena, 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 the form described occu r. If rhagades change to hard 
chancres, the shape, is longish and flattish. On the glans we often see flat- 
tened chancres. They seem of the hardness of parchment, thin like paper, 
and may easily be overlooked (ulcus durum foliaceum, s. papyraceum, s. 
pergamentarium). Hard chancre often develops in a hair follicle, often 
taking a papulous form, easily confounded Avith acne by the inexperienced. 
Hard chancre, left to itself, may last many months unchanged. SYPHILIS. 
329 
When it begins to disappear, the centre becomes more and more depressed, 
like a pit or a navel. Absorption often is complete and leaves nothing 
behind, but white cicatrices surrounded by a brownish ring of pigment 
may arise if ulceration was present. 
Absorption is often imperfect, leaving a red thickened place, less 
hard than before, which may at times swell and harden again—a change 
which may precede other relapses on the skin and mucous membrane. 
The hard ulcer may have relapses like other symptoms of syphilis— 
ulcus durum redux. 
Among the complications we name phimosis, balanitis, posthitis, bal- 
ano-posthitis, and paraphimosis, which easily occur when the hard 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 ulcer is seen. 
When a hard ulcer is seated at 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 may be mistaken for clap, but pressure on the 
urethra commonly detects a hard knot. In women, the chancre often 
loses its specific character in a short time, changing to a broad condyloma, 
so that we then have general syphilis, and the primary symptoms seem 
wanting. 
The histology of the initial sclerosis is explained by Biesiadecki, Auspitz, and 
Unna. The blood-vessels of the cutis are to a certain extent the point of origin. 
An accumulation of round cells first forms in the adventitia. Some of them pass 
into the surrounding connective tissue and infiltrate it. In the mean time thick- 
ening and sclerosis of the connective-tissue fibrils, and proliferation of the cells, 
take place. By degrees, thickening and nuclear proliferation attack the middle 
and inner coats of the arteries. The endothelium 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 wide-open passage. These changes begin in the upper 
vascular regions and gradually extend deeper. 
The epidermis is not untouched. The papillae are first observed to extend 
deeper into the skin than is normal. The cutis-tissue becomes increasingly 
infiltrated with round cells, and the individual papillae are laterally compressed 
and attenuated. Single round cells pass into the deeper layers of the epidermis, 
and at last nests of round cells form. The syphilis bacilli may form an especially 
important component (see Fig. 61). 
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 the penis, the lymphatics of the dorsum penis are often changed 
into hard, 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 
pressure; the skin above them is neither hot nor red. This is the 330 
SYPHILIS. 
multiple indolent bubo; if patients walk about much, or poke and rub 
the inguinal region, secondary inflammation may supervene. 
Indolent buboes often last for months and years; their remains often 
persist for a lifetime; a careful examination will show that remissions and 
increase in the swelling are common. Other changes are the caseous, 
calcareous, and amyloid degeneration (Virehow). 
If hard chancre is situated on other parts than the genitals, the nearest lym* 
pkatics also swell. In the case of the lips, we find a painless lymph gland, greatly 
Fir. 61. 
Syphilis bacilli in an initial sclerosis. After Lustgarten. 
swollen, either behind the angle of one jaw, or (as in three cases of mine) under 
the chin, forming a projection like a pigeon’s egg. In the case of the fingers, the 
corresponding cubital or axillary glands swell, etc. These points must be applied 
in doubtful cases for the diagnosis of hard chancre. 
After the formation of the hard ulcer and adjacent indolent buboes, 
a period of repose (“second period of incubation”) seems to follow, not 
at all fixed in length, but averaging six or seven weeks; so that new 
symptoms may be looked for from the ninth to the eleventh week after 
impure coitus. In a few fortunate cases, the disease seems to end with SYPHILIS. 
331 
the first symptoms. Other patients have undergone some change during 
the second period of incubation; they are pale and depressed, often 
seem hypochondriacal, and, in a general indefinite way, feel sick. 
The secondary period often begins with an eruptive fever, which 
may even be preceded by a chill, or several slight chilly sensations. The 
fever may last longer than a 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 malignaacutissima” by G-uibot; 
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 be enorm- 
ous—the so-called strumous bubo. Internal lymphatic glands seem to be 
also subject to swelling. 
It was once thought that swelling of lymphatic glands of certain 
regions occurred only in syphilis, and was, therefore, of diagnostic value; 
this includes the enlargement of occipital and cubital glands; but the 
point is not sustained. 
The histological changes of indolent buboes consist of thickening of the trabec- 
ular connective tissue and increase of the cellular elements. In the lymph 
sinuses the endothelium is swollen, and its nuclei are increased. The adventitia 
and media of the vessels are infiltrated with round cells. The capsule of the 
lymph glands is usually thickened. 
Absorption (spontaneous or under treatment) implies fatty change of the cells 
and gradual absorption of the detritus. The cheesy and chalky changes often 
exist, and even suppuration may occur sooner or later. 
The secondary stage is further marked by alterations of the skin and 
mucous membranes, to the former of which the term syphilides is 
(unjustly) restricted, although the changes are fundamentally the same 
in both. 
'The cutaneous disorders include erythematous, 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, from 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 at the edge of the hair. At first they become white when 
pressed with the glass pleximeter; 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 hypersemia. The number of spots varies 
greatly. The same is true of the duration; under specific treatment 332 
SYPHILIS. 
they sometimes disappear in a few days. Yet I have often seen the 
roseola become more distinct in the first days of treatment by inunction, 
disappearing very quickly afterwards. Slight desquamation may follow 
their disappearance. 
In examining for roseola, let the patient strip and stand for a minute or two; 
the effect of the air is to contract the blood-vessels of the sound parts of the skin, 
and bring the eruption into relief. Do not confound the common venous mot- 
tlings with syphilitic roseola. 
Diffuse syphilitic erythema is much rarer than the circumscribed 
roseola, and usually lasts but a few days. 
Condyloma latum is the chief of the papular syphilides, and the 
most important for diagnosis. It is so regularly met with that Ricord 
gave its name to the secondary stage of syphilis. 
In men, it is most frequent on the penis and scrotum, more rarely on 
the glans and inner lamella. In women, it is especially frequent on the labia 
majora. In both sexes, it is frequent on the arms, the inner surface of 
the thighs, the inguinal flexure, the navel, the folds of the breast, axilla, 
angle of the mouth, naso-labial groove, eyelids, and even the ears. 
They also appear in the bed of the nails, and between fingers and toes 
(ulcers between fingers and toes may always be suspected as syphilitic). 
Where skin lies against skin, we often find broad condyloma dupli- 
cated on the 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, especially, on the labia majora, the inner surface 
of the thigh and labia or scrotum, the anus and the mammary folds. 
The secretion is highly contagious; when inoculated upon a healthy 
person it causes a hard chancre followed by general syphilis, 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 large 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 use 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, 
which keeps 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 extravasated blood, and not parting with the 
color when pressed. 
The histology of broad condyloma includes infiltration of the cutis with round 
cells, dilatation of the blood-vessels, penetration of the adventitia with round 
cells, and proliferation of the papillae of the cutis; also the epithelial papillae of 
the rete Malpighii press farther forward, and the epidermis disappears. 
Aufrecht and Lustgarten claim to have found micrococci. Aufrecht describes SYPHILIS. 
333 
cocci which generally lie two together (diplococci), rarely in threes, and are 
colored intensely by fuchsine; Lustgarten showed bacilli. 
Syphilitic lichen and psoriasis are also included in the papular 
eruptions. 
Syphilitic lichen presents groups of small, brown-red knots, of the 
size of lentils; syphilitic psoriasis, large flat knots, covered with thin 
scales of epidermis. Thick scales with the lustre of mother-of-pearl or 
asbestos, as in psoriasis vulgaris, are rarely seen. The syphilitic form of 
psoriasis (contrary to the non-syphilitic) usually 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 the'palms and soles often departs from the usual type. We 
first see red spots shining through the epidermis; these continue to rise, 
the epidermis grows thin, and at last falls out in the region of the papule 
almost as if cut with a punch, while the latter shows a surface at first 
shining, afterwards scaly. In other cases, psoriasis has the form of ex- 
tensive horny thickening of the epidermis, which has been called psoriasis 
cornea. 
Vesicular syphilides are not very frequent in acquired syphilis; they 
are known as varicella syphilitica and 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, and often contain a clearer 
and more serous fluid. They are found rather often between the fingers 
and on the palms and soles. 
The pustular syphilides include acne and impetigo or ecthyma. In 
syphilitic acne, there is inflammation of the sebaceous 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 
during the remainder of life reveals to the experienced eye the previous 
occurrence of syphilis. 
The syphilitic affections of the mucous membrane closely resemble 
those 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 hyperaemia, like that of the outer skin. The broad 
condyloma is important; it is most commonly 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 lips and tongue. People with bad 
teeth often have it on 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 of the tonsils, with subsequent cicatrization, and may even cut off 
the uvula. 
The above affections do not by any means complete the list. There 
are other cutaneous diseases. In many cases the skin loses its usual 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 the 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. Gummata may form on the periosteum beneath 
the bed, by which the bed and nail are raised up; if the gummous tumor 
breaks down, the ulceration readily extends to the bed and substance of 
the nail. 
The fasciae and tendons are often the seat of pain or of tenderness on 
pressure, especially if any eruptive fever attacks the patient. Severe 
pain sometimes occurs in the bursae 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-defined spots 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 the 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 rhinoscopic and laryngoscopic 
examination. 
Syphilitic catarrh of the fauces may cause inflammation of the Eusta- 
chian tube, and injury to the hearing. Moos and Roosa 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-choroiditis, 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. Inflammatory SYPHILIS. 
335 
changes of the cornea sometimes occur, taking the form of gray spots of 
the size of pins’ heads, and called keratitis punctata by Mauthner. 
Severe nervous disturbances occur in many cases. Fournier showed 
that circumscribed anaesthesia is common, especially on the hands and 
forearms. Many complain of violent neuralgia. Facial palsy has been 
seen. In a case of my own, chorea appeared soon after an eruption of 
syphilitic roseola, but disappeared under a course of mercury. Many 
suffer from obstinate sleeplessness; others are greatly depressed. 
If a rational treatment is pursued, tertiary symptoms may often be 
avoided, but not always. Many of the older authorities state that 
syphilis has no tertiary symptoms, but that what are called such are 
merely consequences of the 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 had 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 
symptoms, the gumma or syphiloma leads among the tertiaries; whence 
Ricord proposed the name of gummous period. Special detail of symp- 
toms will begin later on. 
All tertiary symptoms lead to a protracted course, and often last for 
many years. One organic system after another may be attacked; scarcely 
are the symptoms conquered in one place when they break out anew in 
another. Injuries or bad habits sometimes determine the attack to a 
special organ: thus, persons who overstrain the mind are more liable to 
cerebral syphilis; drinkers, to that of the liver, and so on. 
A final stage of marasmus is especially apt to come in neglected cases. 
In order to produce it, it is not necessary that there should have been 
tertiary symptoms, with suppuration and loss of fluids. The patient 
becomes pale, loses strength, keeps his bed, and at last dies of weakness, 
if help is not obtained in time, 
Among the sequelae are amyloid degeneration of almost any of the 
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 a 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 
is carried from the deeper layers of epidermis into the cutis by wandering 
cells. I once saw hypertrophy of the entire skin, a sort of ichthyosis, in 
a man—keratosis syphilitica; it is not rare on the palms of the hands 
and soles of the feet, often combined with painful rhagades. 
The most dreadful thing about this disease is that we can never be 
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 a fact that wounds often heal badly in persons with latent 
syphilis, and do not begin to cicatrize until antisyphilitic treatment has 
been adopted. Relapses after a thorough treatment, adopted perhaps at 336 
SYPHILIS. 
the time of the first secondary symptoms, are almost the i ale. They most 
frequently occur as mucous patches on the mucous membrane of the 
mouth and fauces. The relapses 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 
sharply defined hard base- and causes sympathetic buboes, usually of 
one side only; while the hard chancre is painful, and causes tenderness 
and inflammation of one, or a few only, of the lymphatic glands. 
Many 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., 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 doubted, 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 squamae 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, 337 
SYPHILIS. 
and nose is often misunderstood, and resists all treatment until mercury 
or iodine relieves the patient. We very often have occasion to decide 
whether whitish or grayish spots on the mucous membrane of the mouth 
and fauces are syphilitic relapses or not. Smokers and persons with de- 
fective or pointed teeth often have such spots; persons who have had the 
mercurial inunction for syphilis, and irritated their mouths by frequent 
washing with chlorate of potash, may have similar appearances, not 
specific in their nature. 
The diagnostic difficulties become almost insuperable when tertiary 
symptoms appear, and no previous history of syphilis can be obtained. 
The severest affections of the nervous system—chronic heart disease, 
pseudo-phthisical affections of the air passages, stricture of the oesopha- 
gus and rectum, disease of the liver and kidney, etc.—or chronic disease 
of bones, muscles, and joints, may be produced by tertiary syphilis. The 
importance of correct diagnosis in such cases is immense. After many 
years of fruitless treatment, a course of mercury or iodide of potassium 
may accomplish most brilliant results; in doubtful cases, these remedies 
should at least be tried. 
Certain coarse anomalies may lead our 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. 
IY. Prognosis.—Tn acquired syphilis, this is so far favorable, as 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 very frequent; 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 
dangerous; 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 vital organs. 
Y. Treatment.—In respect to prophylaxis, the principles stated 
under gonorrhoea (Yol. IY., p. 249) apply. To prevent accidental con- 
tagion, disinfect instruments 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 
lymph that has no tint of blood, etc. After an impure connection, 
there is little use in washing with carbolic acid, vinegar, 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 
state the plan which has been serviceable to us in a very large number of 
cases. 338 
SYPHILIS. 
For hard chancre, order two and a half drachms of emplastrum mercuri- 
ale, to be spread on the sticky side of adhesive plaster in a layer as thick 
as the back of a knife, reserving a border all around for the plaster 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 
soften and disappear very soon. Softening is not sufficient; there must 
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. 
i 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 
agree 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 secondary 
symptoms at all occurred, or those that appeared were unusually mild. 
We advise the use of an inunction cure with 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 carefully washed on the next day, before the new part is 
touched. If a bath is inadmissible, lukewarm water and soft soap are 
used. When thirty doses are used, we may 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. 
Neglect of this rule easily causes inflammation of hair-follicles, which 
protrude as nodules, lumps, and pus-bladders, making the so-called 
eczema mercuriale. 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, especially at the beginning, make sure by the eye 
and the touch that the rules are observed. 
While the inunction cure is in progress the patient is to gargle after 
each meal with chlorate of potash (1 : 20). 
Patients must not smoke; they must keep the teeth clean, especially 
if any are defective. Prescribe for this purpose: $ Ossium sepias pulv., 
| iss.; Magnesiae carb., Sapon. medic., aa 3 iiss.; 01. menth. pip., gtt. 
v. M. S. Tooth-powder. 
All these precautions are intended to prevent mercurial stomatitis. SYPHILIS. 
339 
Many patients complain of a disagreeable metallic taste in the mouth be- 
fore "the stomatitis appears; then there is salivation; the gums swell and 
grow soft, the teath feel loose, and in fact they are so; epithelium is 
thrown off and ulcers form; the breath is fetid, and adhesions may oc- 
cur between the cheek and tongue which will be very hard to remove by 
a subsequent operation. The cheek is especially apt to be sore where 
the crown of a molar tooth touches it. Many persons are so sensitive to 
mercurials that a much smaller dose than one drachm produces mercurial- 
ism. 
In addition to mercurial eczema, ptyalism, and stomatitis, albuminuria may 
result from mercurial inunction. I have seen this twice within the past year in 
women; Fiirbringer states that he has observed it in eight per cent of his patients. 
The amount of albumin is usually small. The sediment is often wanting. Sus- 
pension of treatment arrests the trouble more or less rapidly. Mercurial diar- 
rhoea sometimes supervenes, and may take a dysenteric 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 go out 
daily, taking all pains to avoid dampness and taking cold, to which the 
mercurial treatment renders one subject. Cold baths and douches are to 
be avoided; woollen underclothes are to be worn in winter, to avoid colds 
as far as possible. 
During the secondary period, the medicine and diet remain at first 
the same as above. Many direct the use of iodide of potash in addition 
to the inunction (five per cent solution, one tablespoonful three times a 
day), but we do not much like this combination, having often seen an 
abundant and unpleasant eruption of furuncles follow it. We never 
found that the symptoms of syphilis receded more rapidly, or were 
longer in relapsing, under this method. 
Broad condylomata of the skin can be removed very quickly by 
sprinkling with common salt, and just afterwards with powdered calo- 
mel. Where two surfaces of skin are in apposition, insert cotton batting, 
to prevent friction. 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, but to pay strict attention 
to themselves, and 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 
the mouth and throat, internal mercurial treatment usually suffices. 
We prefer the yellow iodide, and, to avoid diarrhoea and pain, Ave like to 
combine with opium. (IJ Hydrag. iodidi flav., gr. viij.; Opii, gr. v.; 
Pulv. et succ. glycyrrhizas, q. s. ut ft. pil. no. 30. S. Three times a day, 
one pill after eating.) 
During summer, baths of brine, iodine, and sulphur are useful. 
While mercury is one of the most valuable remedies in primary and 
secondary syphilis, iodine preparations are of special use in the tertiary 
stages, especially iodide of potassium (five per cent solution, one table- 
spoonful three times a day). Mercurials, however, are not superseded; 
they often act very quickly. Gummous ulcers of the skin often heal very 340 
SYPHILIS. 
quickly under the influence of mercurial plaster; chronic bone disease 
improves surprisingly during inunction, etc. 
Iodine preparations, especially with iron, are the chief remedies for 
syphilitic cachexia and amyloid degeneration: e. g.,fy Potass, iod., Ferri 
lact., aa 3 iiss.; Quininse hydrochl., gr. xv.; Pulv. et succ. glycyrrh., q. 
s. ut f. pil. no. 10J. S. Three times a day, three pills, after eating. 
Baths of brine, iodine, sulphur, are very useful at this period. 
It may be useful 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 indurated 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), Ile- 
bra (1860), and Scareno (1865) first used subcutaneous injections of mer- 
curials. A silver canula is required. The best spots 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 painful; 
gangrene and death have once occurred. To lessen the painand inflam- 
mation, J. Mftller 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 Schutz a solution of hydrargyrochloride-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. 
Corrosive sublimate is the basis of many unduly praised systems of treatment, 
of which Dzondis’ is the best known. It irritates the stomach, cannot be given 
in solution or powder, and must always be taken on a full stomach. (B Hydr. 
chlor. corr., gr. iss.; Pulv. et succ. glycyrrh., q. s. ut f. pil. no. xxx. S. Three 
times a day, one pill, after eating.) 
Calomel is unsuited for continued use, as it irritates the stomach and intes- 
tine. It may be given in powder or pill, one-half grain twice a day. The binio- 
dide also has irritating effects upon the mucous membrane of the intestine. ($ 
Hydr. iodid. rubri, gr. iss.; Pulv. et succ. glycyr., q. s. ut f. pil. no. xxx. S. 
Three times a day, one pill.) 
Blue ointment and regulus of mercury have been given in the form of pill. 341 
SYPHILIS. 
Many physicians strenuously oppose the giving of quicksilver in any form for 
syphilis. Such “cranks” recommend also the treatment by hunger, purgation, 
sweating, and particularly decoctions of woods. Guaiac, sarsaparilla root, and sas- 
safras are used this way. Sarsaparilla forms a chief component of Zittmann’s de- 
coction, which is made of two strengths, the patient taking 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 made 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 aural 
diseases. 
2. Tertiary Syphilis of the Skin, Muscles, Fascice, Joints, and Bones. 
I. Symptoms axd Diagnosis.—G-ummata 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 brown 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 
find an ulcer of considerable depth, with step edges, and a greasy, tal- 
lowy coating—striking points which can be of use in distinguishing these 
from similar non-s}Tphilitic 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. Ulcerating 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 thin. 
Gummata of many other organs are often associated with those of the 
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, which 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 mucosae, as a 342 
cause of which he assumes gummous tumors, though without support- 
ing his view by autopsies. Slight injuries often form the starting-point 
of the affection. 
The sheaths of tendons have been the seat of inflammatory swelling 
or circumscribed swellings—hygromata syphilitica—in a few cases. The 
fasciae may also become the seat of gummata. 
Joint disease is often connected with syphilis. Gfummous and in- 
flammatory processes near the articular ends of bones may involve the 
joints in the affection; or else gummous knots may develop in the sub- 
serous tissue of joints, causing pain, swelling, impairment of function, 
or even suppuration and ankylosis. Symptoms of chronic hydarthrosis 
may appear; in other cases, symptoms resembling those of acute rheu- 
matism may occur very early. 
The bones are often affected by tertiary syphilis, but the affection 
SYPHILIS. 
Fig. 62. 
Ulcerating gummata of the cranial bones in a woman aged 43. Author’s observation. Zurich 
clinic. 
may occur so 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 firm 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. 
Gummata proceeding from the medulla may in like manner cause gradual 
thinning of the bone-substance, so that very slight external causes some- 
times produce fracture. Gummata of the bones sometimes soften and 
burst externally, causing further destruction of the bone-substance. The 
scalp sometimes seems 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 pulsating meninges are seen. Caseous and 
calcareous alterations sometimes occurs in gummata. If gummata are SYPHILIS. 
343 
caused to diasppear by antisyphilitie treatment, depressions of the bones 
often remain in their place, to which the thinned skin seems to be ad- 
herent. 
Ostitis and periostitis sometimes occur in syphilitic patients, not 
originating in the breaking down of gumma nodes, but of a more general 
character. Periostitis usually begins in the inner layers of the periosteum, 
and forms at first an infiltration which may be pitted by pressure, but 
afterwards ossifies and forms 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, 
causing myositis deformans. 
In other cases, periostitis causes the formation of pus, abscesses, or 
fistulae; or gradual absorption takes place. Dactylitis syphilitica, a disease 
of the phalanges of the fingers, often causes considerable swellings—spina 
yentosa syphilitica. 
Spontaneous fracture has often been seen in syphilitic patients; 
syphilis, like many chronic diseases, leading to atrophy and fragility of 
bone—osteopsatyrosis. 
Bone syphilis is one of the most dreaded forms. It tortures the 
patient with pain, sometimes lasts during the whole of life, causes marked 
and permanent deformity, and often renders a patient unable to labor. 
Danger to life is less imminent; but long suppuration of the bones may 
lead to amyloidosis, and extensive syphilis may involve the cranium, 
meninges, and brain. It is not always easy to recognize the disease; it 
is liable to be confounded, for instance, with tuberculous processes. 
Bone syphilis is one of those diseases which have often been said to be 
due, not to syphilis, but to mercurials. This view is refuted by the fact 
that the disease occurs in patients who have never used mercurials. Yet 
this drug certainly has great influence on the bony system. Trustworthy 
authorities have reported the finding of globules of mercury in the bones of 
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 action 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- 
cury, mercurial plaster, baths of iodine, brine, and sulphur. Ulcerative 
processes are often found to disappear with surprising rapidity under the 
influence of the plaster. Surgical interference maybe needed: necro- 
tomy or trepanation; and in general, syphilitic disease of bone or joint 
belongs to surgery rather than to internal medicine. 
• 
3. Syphilis of the Nose. 
I. Symptoms and Diagnosis.—The hard ulcer on the outside of the 
nose is usually on the tip or the alge, but is rare. 
The mucous membrane very often shares in the changes of the second 
period. There may be diffuse erythema, or hyperaemia in patches, or 
broad condylomata, which break down, and sometimes lead to necrosis 
and loss of substance in the mucous membrane, cartilage, and bone. 
Burning, dryness, heat in the nose, stopping-up of the passages, abun- 
dant, sometimes ill-smelling discharge from the nose, subjective percep- 
tion of bad smells, and sometimes ozsena, often accompany the condition 344 
SYPHILIS. 
described; the causes for which can be easily discovered with the rhino- 
scope. 
Gummous disease of the nose usually belongs to the later stages; it 
sometimes proceeds from the outer skin, sometimes from the mucous 
membrane, or from the cartilages or bones. The breaking down of gum- 
mata causes loss of skin, easily confounded with tuberculosis of the 
skin (lupus), sometimes with cancer, and leaving unpleasant deformities 
of the nose after cicatrization. Gummata on the mucous membrane often 
render the passage impervious, or during decay cause a stinking dis- 
charge, or involve the cartilage or bone. Gummata of the cartilages are 
not common. If they break down, a hole or fissure connecting the two nos- 
trils maybe formed, without much subsequent damage; or, if the damage 
is extensive, the front of the end of the nose sinks in, and both nostrils 
form one hole. Gummata 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. Gum- 
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 
floor of the nostrils is often attacked bv 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- 
sema of the skin. A bad-smelling discharge—ozaena 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; but 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 ozsena 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—fliinitis syph. atro- 
phica—with atrophy and retraction, which is associated with obstinate 
ozaena. 
II. Treatment.—Besides the constitutional use of iodine and mer- 
cury, local treatment is very important. For ulcerations of the outer 
skin, we recommend mercurial plaster. For destruction of the inner sur- 
faces, the nasal douche; using carbolic acid (two per cent), sublimate (one- 
tenth per cent), or thymol, followed by pencilling with B Potassii iod., 
gr. xv.; Iod., gr. iss.; glycerini, fl. 3 ij-, or a snuff powder of equal 
parts of calomel and alum, or iodoform. Surgical operations are included, 
as necrotomy, or plastic operations after the disease is arrested and 
healed. 
Fig. 63. 
Piece of bone discharged 
spontaneously in syph- 
ilis of the nose. Nat- 
ural size. Author’s ob- 
servation. SYPHILIS, 
345 
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 very 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 Tiirck, thirty 
years) before the larynx is attacked. 
The outbreak of syphilitic changes may be favored by accidental in- 
juries to the larynx, including colds, or very loud speaking. I have 
found 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 gummata. 
Many refer chorditis vocalis hypertrophica inferior (see Yol. 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 oedema 
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. 
Syphilitic 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 may be 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. 
Many 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 hyperaesthesia 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, rarely, 346 
SYPHILIS. 
it forms the only relapse of syphilis. If the intensity is great or the 
duration long, it causes ulceration. The ulcers are usually small and 
most commonly situated on the true vocal cords and arytenoid car- 
tilages. 
Broad condyloma of the mucous membrane of the larynx consists of 
white elevations, most frequently seated on the true vocal cords, next on 
the arytenoid cartilages, posterior wall of the larynx, and ary-epiglot- 
tidean folds. The elevations look like the broad condylomata of the 
pharyngeal mucous membrane. 
If proper treatment is not given, the surface ulcerates, and the 
ulceration may spread. 
Gerhardt and Roth have given the first thorough description of condyloma of 
the laryngeal mucous membrane. Some (Lewin, Waldenburg) incorrectly deny 
the existence of broad condyloma in the larynx. 
Tiirck gives two cases in which pointed condylomata appeared on the mucous 
membrane of the larynx of syphilitic patients and disappeared when treated mer- 
curially, though the pointed condyloma has no direct relation to syphilis. Papil- 
lary excrescences, sometimes formed on the edge of syphilitic ulcerations, must 
not be confounded with pointed condylomata. 
Fig. 64. 
Fig. 65. 
Circumscribed multiple gummata, after Mandl. 
Syphilitic stenosis of the larynx, due to the 
formation of a diaphragm between the 
two vocal cords. Author’s observation. 
Gammons syphilis of the larynx is a late symptom. The tumors are 
sometimes distinct and circumscribed, and have the size of a pin's head, 
a pea, or more; at other times they form a diffuse nodular infiltration of 
the mucous membrane (see Fig. 64). In either case they may cause 
symptoms of stenosis. The favorite seat is the epiglottis; the disease 
often passes directly from the fauces to the epiglottis. This organ is 
often converted into an irregular globular or roller-shaped mass which 
gives no trouble, and may even be discovered accidentally at the laryn- 
goscopic examination, as I have twice found in men who applied for a 
certificate for life insurance. Gummata may occur on the vocal cords 
and other parts of the mucous membrane of the larynx. 
Several clinical stages may be distinguished. Schech names four : 
that of infiltration, of softening, of destruction, and of absorption. 
When a gumma begins to ulcerate, great devastation may occur; cica- 
trization may take place on one side while ulceration extends on another, 
forming a serpiginous ulcer. The ulcerative process is usually chronic, 
but Frankl has described the case of a new-born child in whom barely 
three weeks elapsed from the first hereditary symptoms in the larynx to 
death. 
The chief danger lies in the consecutive changes, and increases with SYPHILIS. 
347 
every delay in treatment. The first consecutive changes are the ulcera- 
tive process and its results. 
Dangerous bleeding is rarely caused by ulceration, though Tiirck has 
published a case. 
In many cases, ulceration causes oedema of the glottis; or extends to 
the perichondrium and involves danger 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-glossus 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 (see Fig. 65). Or, the increasing 
retraction of the cicatrix 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. Diagnosis.—If the patient is known to have had syphilis, 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 syphilitic infection (and menclacia syphilitica is 
almost proverbial), and if indications are absent, the diagnosis may be 
difficult in case of ulcerative processes. It may be impossible to distin- 
guish tuberculous ulceration, unless the bacilli of tubercle can be shown. 
Josset-Moure has paid special attention to this point of diagnosis. It is 
a very important fact that syphilitic 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 
usually 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. 
Phthisis and syphilis of the larynx are sometimes combined, in which 
case it is impossible to draw a line between the two. 
IV. Prognosis.—This is always serious, for, though it is often pos- 
sible to control the processes, yet the residua are often not free from 
considerable danger. The result will be better, 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 compels 
the patient to wear a canula in the trachea all his life. 
V. Treatment.—This includes prophylactic, the general, and the 
local remedies. 
Patients 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 specific 
treatment must be ordered at once. 
The local treatment may include (for catarrh) inhalations of a weak 
solution of sublimate (gr. § vi.). For condylomata of the mucous 
membrane, insufflation of calomel into the larynx (Calomel, gr. xxx.; 
Pulveris acaciae, 3 ij., once a day). For gummata and ulcerous processes, 
paint the interior once a day with iodide of potash, gr. xv.; iodine, gr. 348 
SYPHILIS. 
iss.; glycerin, fl. 3 ij.; or with dilute tincture of iodine; or let dilute 
solution of iodide of potash be inhaled (gr. viij.-xv. : fl. 3 vi.). 
Complications and sequelae are partly subjects for surgical treatment. 
5. Syphilis of the Trachea 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 the 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-sypliilitic 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 destruction. 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 
cicatricial wrinklings, or the trachea sinks together. In case of stenosis, 
the larynx makes shorter 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 Yol. I., p. 244. The greater the longi- 
tudinal extent that is affected by stenosis, the more trouble and danger, 
even though the stenosis may not be very considerable. 
Swellings in the neighborhood of the trachea have been found which 
receded when treated specifically, so that we may speak of syphilitic 
peritracheitis. The danger consists in compression of various organs, 
especially the trachea, or suppuration and destruction. Perichorditis 
of the bronchi seems to be similar; and the growth of connective tissue 
may extend 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 SYPHILIS. 
349 
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 ex juvantibus, 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 may appear anatomically in two forms, a diffuse infil- 
tration or circumscribed gumma-nodes. The syphilitic infiltration of 
the lungs prefers the middle part of the lungs; in Grandidier’s experi- 
ence, the 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 dry 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 years before. 
The disease may express itself by symptoms like those of commencing 
tuberculous consumption. Langerhans gives the case of a young man 350 
syphilis. 
who had symptoms of catarrh of the right apex, with haemoptysis; he 
had had impure coitus some time before; there was no hereditary syphi- 
lis in the family. A long residence in a southern climate did no good; 
several copious bleedings occurred. A complete cure was obtained by 
treatment with injections of sublimate. I saw an officer some months 
ago who had been sent to Davos, for condensation of the lower half of 
the left upper lobe, as a consumptive patient. There was no expectora- 
tion. Slight febrile movement in the evening. Emaciation progressive. 
Syphilitic infection some years before. Swelling of the clavicle and the 
right elbow, in the third month of his residence at Davos. Mercurial 
inunctions quickly caused the bone-disease to disappear. The fever 
disappeared in a week. Great appetite and rapid gain in weight. 
Healthy complexion. Complete recovery. 
A third series of cases present the clinical symptoms of advanced 
consumption; those of infiltration being sometimes prominent, those of 
cavities at other times; but the sputa contain no tubercle bacilli. 
III. Diagnosis, Prognosis, Treatment.—The diagnosis is not 
easy; 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 preparations. 
Appendix.—Diffuse or circumscribed gummata are seen in the mammae, which 
are dispersed by pencilling with iodine, rubbing in ointment of iodine or mercury, 
and the internal use of iodine and mercury. 
7. Syphilis of the Digestive Tract. 
I. Symptoms.—In the early stages of syphilis, the mucous membrane 
of the mouth, is often the seat of erythematous and condylomatous 
changes which often lead to ulceration and loss of substance. 
The same is seen on the tongue, occasionally roseolar spots. At a 
later date, gummous nodes often appear on the tongue; as distinguished 
from cancerous knots (which they resemble), they are solitary, not pain- 
ful, and do not (like cancer) cause hard swelling of the nearest lympha- 
tic glands. If early and suitable vigorous treatment is given, they may 
usually be dispersed, otherwise they soften and suppurate for a long time. 
Langenbeck and Hutchinson observed a transformation to cancer. 
It was formerly believed that numerous depressions and incurvations 
of the surface of the tongue were due to syphilis. This view is as little 
justified as that, that thickening of the epithelial layer of the tongue, 
giving a thick and almost horny covering (psoriasis linguas), is connected 
with syphilis. Both conditions may be found in inveterate smokers. 
Gummata sometimes appear on the organs of the throat (see Yol. IV., 
p. 334, 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 change, besides which, abnormal adhesions and closure 
of this region are hard to remedy. The condition is equally unpleasant 
Avhen 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. SYPHILIS. 
351 
If gummata proceed from the submucous or periosteal tissue of the 
hard palate, they are first perceived by the firm soft swelling, and some- 
times by increased redness of the mucous membrane. In case of suppura- 
tion and opening, abnormal communication between the mouth and nose 
is often formed, causing disturbance in eating, drinking, and speaking. 
Cases of gummous tumors in the salivary glands are described. 
Gummata occur in the submucous tissue of the oesophagus and the 
perioesophageal connective tissue, which, by suppurating and cicatrizing, 
lead to stricture. 
Gummata of the gastric 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, wdiich is only 
arrested by specific remedies (syphilitic catarrh?). 
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 diarrhoea. The stools are usually composed of purulent, 
sometimes bloody masses; the finger detects cicatrices on the walls of the 
rectum. These things may easily be confounded with chronic dysentery, 
especially if tenesmus is present. 
Besides gummata, broad condylomata have repeatedly been observed 
in the lower part of the rectum. 
II. Treatment.—Local and general measures, based on the usual 
principles, are often assisted by surgery. Symptomatic treatment is often 
required, as passing a sound for stricture. 
8. Syphilis of the■ Liver. 
I. Anatomical Changes.—Severe disease of the liver is not rare; 
it almost always belongs to the later period of acquired syphilis, and is 
considered one of the so-called tertiary symptoms. But it is also found 
in children—as a rule, associated with hereditary syphilis. 
The anatomical changes of hepatic syphilis are not always the same; 
they include syphilitic perihepatitis, hepatitis, and diffused interstitial 
hepatitis, gummous hepatitis, syphilitic cirrhosis, and amyloidosis. 
For cirrhosis and amyloid liver, see Vol. II., pp. 201 and 213. 
Syphilitic perihepatitis is marked by tendinous thickening of the 
serous coat of the liver and formation of adhesions of connective tissue 
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 cases, it is distinguished from common peri- 
hepatitis only by the existence of lues in other regions, or by the exces- 
sive thickness of the affected tissue. It often causes the formation of 
depressions of the surface by cicatricial contraction of the new tissue, 
especially where it extends into the interior. 
Diffuse interstitial syphilitic hepatitis, also called by E. Wagner diffuse 
syphiloma, is the commonest form of hereditary syphilis of the liver. In 
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 flint (Gubler) or that of sole 352 
SYPHILIS. 
leather (Trousseau). No lobular markings are seen—a condition usually 
but little observed in the liver of new-born 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 cells, 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 Rindfleisch, Hayem, and Baillard 
Lacombe) also in the lymph-vessels. The liver cells become fatty and granular, 
and perish. 
In gummous 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 of 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 large 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 Yirchow 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 gumma 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 dryr, 
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 mto 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 
variety. 
Schiippel describes three cases as peripylephlebitis syphilitica, in 353 
SYPHILIS. 
which the formation of syphiloma was very closely connected with the 
course of the larger portal branches. 
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 existence of constitutional syphilis. 
In syphilitic perihepatitis, peritonitic friction murmurs have been felt 
and heard; 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, 
jaundice, and changes in the volume and superficial character of the 
liver. 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 ascites, by 
suffocation; in rare cases, it is connected with symptoms of acute yellow 
atrophy of the liver. 
III. Diagnosis.—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. 
IY. Prognosis.—This is generally unfavorable. This is partly due 
to the fact that the patient does not usually come under treatment till he 
has reached a condition of profound marasmus, so that nothing more 
than symptomatic treatment is possible. Gfummata 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. Treatment. —If the existence of this disease is probable, use 
iodide of potash, and mercurials—the 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 Yol. IY., p. 
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 mercury 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 hypereemia and hyperplasia of the cells of the spleen, and 354 
include the cases which Virchow called soft syphilitic tumor of the 
spleen. 
Interstitial syphilitic lienitis has a chronic development and long dur- 
ation, and is a late symptom. The organ is enlarged, hardened, and a 
section shows it to be crossed by uncommonly broad 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 in the liver, making it doubtful whether the 
splenic disease is a consequenoe 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 just the size of a pin’s head. When fresh, they have a grayish 
color; afterward they become drier, yellowish, opaque, and crumbly. 
They are rarely encapsulated in connective tissue. They 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 microscope, endarteritis and endophlebitis oblit- 
erans, hyperplasia of the connective-tissue framework, and abundance of round 
cells scattered through the latter. Zenker found tablets of cholesterin; pigment 
crystals occur. 
Amyloid spleen belongs rather to the marasmus which syphilis causes 
than to syphilis itself. 
II. Symptoms and 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. Syphilis 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, i. 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 important to 
know whether a nephritis is syphilitic or not; the prognosis will be 
more favorable if we can expect to control the disease with mercury and 
iodine. 
Gummata are developed in a few cases; but they 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 thirty in one kidney), may be most abun- 
SYPHILIS. 355 
SYPHILIS. 
dant in the cortex or the medulla, and may cause great contraction, 
leaving little of the normal kidney remaining. 
Treatment as for liver and spleen. 
Appendix.—For the relation of syphilis to haemoglobinuria and albuminuria, 
see Yol. II., p. 252. 
11. Syphilis of the 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 the testis. Cases of the 
latter sort may be confounded with cancer, but they are not painful, 
either spontaneously or on pressure, and cancerous degeneration in 
the neighboring lymph-glands of the groin is absent. We distinguish 
syphilitic sarcocele from tuberculosis by the fact that the latter always 
begins in the epididymis. G-ummous 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. 
Gi-ummata occur in the corpus cavernosum penis, causing sometimes 
loss of substance, cicatrization, and angular deformity. 
The epididymis is rarely 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, syphilis 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 Yol. 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 
SYPHILIS, 
than in any viscus except the liver. In the majority of cases, percepti- 
ble changes belong to the late forms of syphilis, and must 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 after infection; Fournier 
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 in 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- 
syphilis 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 has 
demonstrated it in a child of two years. Virchow states that children 
may be born with signs of congenital encephalitis, arising under the 
influence of syphilitic infection of the parents and children; but Jastro- 
witz’s investigations of the history of its development have thrown doubt 
upon this. 
II. Anatomical Changes.—These chiefly 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; they 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 how 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; inflammation 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, but impli- 
cating the surrounding parenchyma to a greater or less extent. Very SYPHILIS. 
357 
considerable disturbance of the brain may result from this. The start- 
ing-point of such growths may not be discoverable. The meninges are 
often adherent, thickened, and everything so mixed together that it is 
impossible to draw distinctions. 
When the gummous growth is an infiltration of the meninges, the 
latter are thickened, sometimes gelatinous and juicy, sometimes snow- 
white and of cartilaginous hardness. 
Many believe that syphilis causes real inflammation of the meninges, not dis- 
tinguishable from ordinary meningitis, at least not anatomically, though perhaps 
remarkable for a tendency to chronieity. Most recent authorities properly deny 
this. Much has also been said of the effect of hypersemia of the meninges and 
brain in causing many disturbances; but this is little understood. 
Fig. 66. 
Syphilitic endarteritis of the arteria fossae Sylvii, afLer Baumgarten. 1, enw, endarteritic growth ; 
2, n t /, new-formed tunica fenestrata; 3, atf, old tunica fenestrata; 4, g m, gummata in the 
adventitia; a v, adventitia; m s, muscular coat. 
Petrow accounted for the disturbance of circulation in the meninges and brain 
by anatomical changes of the sympathetic nerve, but this will not stand before 
unprejudiced criticism. 
Syphilis of the cerebral arteries involves two processes, gummous 
formations, and endarteritis, the former seated in the adventitia and 
media, the latter (corresponding with its name) in the intima. 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 originate independently. 
Syphilitic diseases of the vessels, to whichever form they belong, are 358 
SYPHILIS. 
chiefly found on the great arteries of the circle of Willis. The basilar 
artery and that of the Sylvian fossa are especially attacked; hence symp- 
toms of disease of the pons or implication of the third frontal con- 
volution and island of Eeil (aphasia) are strikingly frequent in cases of 
cerebral syphilis. The affection often embraces many vessels, and ex- 
tends centrally towards the heart on the trunk of the common carotid, 
while peripherally it spreads to some of the vessels of the cortex. 
The changes in question are discernible by the naked eye. The ves- 
sels are thickened, gray, gelatinous or tallow-yellow and opaque, round 
(not flattened like normal vessels), and presenting an open cavity when 
cut, instead of falling together. Transverse sections show the thicken- 
ing of the vascular walls with especial distinctness, it may have gone 
to the extent of almost closing the vessel, or there may be "a thrombus 
at the contracted part, which has caused necrotic softening of the part 
of the brain that is supplied by the vessel. The entire circumference is 
often involved; in other cases, the thickening is circumscribed, and may 
project inwardly like a button. It is evident how disturbance of func- 
Fig. 67. 
Syphilitic endarteritis of the basilar artery; 1, enw, endarteritic growth; 2, tf, tunica fenes- 
trata; 3, ms, muscular coat; 4, av, adventitia. Enlarged 90 diam. Author’s observation. 
tion occurs, and also, how much more important a complete closure is 
than a partial one. The locality is important, for a blocked artery of 
the cortex may have its place supplied by anastomosing vessels, while 
one at the base of the brain leads to irreparable loss. Thickening may 
go to the extent of converting a vessel into a solid round cord, without the 
intervention of a thrombus. 
Microscopical examination of the blood-vessels of the brain shows accumulation 
of round cells in the media and adventitia. Giant cells are found among them, as 
in gummata of other organs; afterwards the tumors may become cheesy. 
Baumgarten’s illustration (Fig. 66, 4, gm) shows that gummous processes may 
sometimes be united with those of endarteritis, though the latter may exist inde- 
pendently (Fig. 67). In endarteritis, a formation composed of branched cells, and 
sometimes containing round cells, pushes in between the endothelium and the 
tunica fenestrata in the tissue proper of the intima. On account of the strong 
tendency to proliferation and obliteration of the vessel, C. Friedlander has pro- 
fiosed the name endarteritis obliterans, but we prefer the term endarteritis pro- 
iferans. It is undecided whether the new cells originate exclusively from the 
vasa nutritia of the media and adventitia, that is, have emigrated (Baumgarten), 
or from a proliferation of the endothelium of the vessel (Heubner), but I have 359 
SYPHILIS. 
repeatedly found the media and adventitia uninjured when the endarteritis was 
most pronounced. The process is sometimes terminated by the forming of a new 
endothelium on the inner surface of the growths and a new tunica fenestrata on 
the outside (Fig. 66, 2, nf/and 3, atf). 
We must not suppose that endarteritic changes are characteristic of syphilis. 
They occur in other organs in a great variety of circumstances, as in the vicinity 
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. 
Cerebral aneurism has been connected with syphilis. Aneurism of 
the aorta, or gummous and thrombotic changes of the heart muscle, may 
affect 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 of 
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. 
Psychical 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. Syphilophobia 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 the 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 thoughts. 
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. Bodily and mental 
excitement, and excesses in Baccho at Yenere usually render 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. 360 
SYPHILIS. 
Numbness, and many sorts of parsesthesia, are frequent; they occur 
in many different nerve-districts, sometimes distinctly circumscribed. 
Paralysis of certain cerebral nerves deserves special attention. The 
motor oculi is most frequently affected; the abducens next. Some- 
times both are paralyzed at once; perhaps one in one eye, the other in 
the other. Such paralyses may disappear spontaneously, or may be re- 
lieved very rapidly by iodide of5 potash (after 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. 
The 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 
hearing, usually on one side only; or the sense of smell or sight suffers. 
The ophthalmoscope may show the latter to be purely functional (with- 
out visible changes of the optic papilla and retina), or associated with 
neuritis (J. Jakobson), neuro-retinitis, or atrophy of the optic papilla. 
In one case, endarteritis proliferans of the arteria centralis retinae was 
demonstrated anatomically. 
Liebreich and Forster report a rare form of syphilitic retinitis, comprising ex- 
travasation 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 
muscles; they 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 patient suddenly falls, the consciousness may be lost, or almost 
wholly retained; hemiplegia has occurred. The latter is often 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 by 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 paralysis 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 
consciousness being 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 Yol. 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 quickly after the use of mercury. 
Cerebral 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. 
IY. 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 ozaena, scrofulosis, 
or rachitis, for all these things are often connected with syphilis on the 
part of the parents, especially the father. 
In default of these signs, we 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 hereditary basis for that disease or other neuroses, 
whether it originated in childhood or adult age, whether injuries of the 
head, or cysticercus of the brain, can be taken into account. Originat- 
ing in adult life, and accompanied by perversion of 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. 
Y. 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 Ave 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 3 iv. of ungt. hydr. cinereum is 
the best method of administration. If coma or other severe symptoms 362 
SYPHILIS, 
threaten, we increase the dose to 3 iiss. or more. It is very 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 focus of dis- 
ease. 
After an energetic inunction course, let the patient take iodide of 
potash for weeks, or even months { 3 iiss. : 3 vi., one tablespoonful three 
times a day an hour after eating). Seguin recommends as much as 
oz. of the iodide dissolved in water, one and a half hours before eating. 
I have often seen brilliant success from the waters in Tolz and Adel- 
heidsquelle-Oberheilbrunn, and Aix-la-Chapelle; sool-baths and indif- 
ferent warm springs (Wildbad-Gastein, AVildbad-Wurttemberg, Pfaf- 
fers, Ragaz, Teplitz, Schlangenbad) have also been praised. 
As purely symptomatic treatment, electricity is used for paralysis. 
14. Syphilis of the Spinal Cord. 
I. Etiology.—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 
iodine or mercury is undecisive, for they are often valuable in non- 
syphilitic 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 
rarely associated with spinal disease; the primary affection is said to have 
been connected with it. The anti-inercurialists say that those syphilitic 
patients who have been treated with mercury are most liable to it. Wo- 
men are less liable than men, perhaps because the latter are exposed to 
other injuries which influence the outbreak of the disease. 
II. Anatomical Changes.—Diseases of the cord may be caused by 
syphilis directly or indirectly, or may be functional in their nature. The 
indirect affections are secondary to disease of the bones or meninges— 
usually exostoses and carious processes of the vertebrge, or inflammation, 
thickening, orgummata of the meninges—which affect the cord by com- 
pression or by transference of the inflammation. The proper source of 
the changes sometimes lies farther off; for instance, syphilitic ulcers of 
the pharynx may extend back and cause disease of the vertebrge, men- 
inges, and spinal cord. These changes are almost always chronic in their 
course. 
Among the direct affections of the cord we have to name myelitis, tabes, 
sclerosis, and many would add atrophic paralysis and progressive muscular 
atrophy. There are a few cases of gumma of the cord. The syphilitic 
nature of these affections cannot be determined anatomically, though 
considerable implication of the membranes of the cord, with extensive 
thickening and adhesion, must be suspicious. The myelitis which some- 
times occurs in the form of many small disseminated foci (Westphal) SYPHILIS. 
363 
are chiefly due to endarteritic thickening with more or less complete 
closure of the arteries, as was described under cerebral syphilis. 
We sometimes have to do with purely functional disorder, as Weid- 
ner in particular has shown, under Gerhardt'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 spinal 
paralysis has repeatedly been brought in connection with syphilis. 
III. Symptoms.—There is scarcely anything characteristic of syphilis. 
It was once thought that a predominance of motor and absence or slight 
development of sensory disturbances were characteristic, but this is cer- 
tainly incorrect. There is sometimes compression-myelitis, sometimes 
various forms of myelitis or tabes,-multiple sclerosis, progressive muscu- 
lar atrophy, atrophic paralysis, unilateral lesion of the cord, or tumor of 
the cord. We must cherish a suspicion of syphilis if there is a history 
of it and if cicatrices are seen on the skin 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 unobserved during life, 
because concealed behind symptoms of cerebral syphilis. 
IYr. Prognosis.—More favorable than in non-syphilitic cases; but a 
permanent and complete cure is not very common. Relapses often hap- 
pen if the treatment is broken off too early. 
V. Treatment.—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 us from 
persevering. 
15. Syphilis of the Peripheral Nerves. 
Peripheral nerves are seldom the seat of gummata; they are more fre- 
quently compressed or infected by syphilitic formations of the meninges 
or bones, muscles or fascise. The symptoms are anaesthesia, paraesthe- 
sia, neuralgia, spasms, and paralysis, but it is astonishing what extensive 
changes may occur without functional disturbance. 
A functional character, rather than anything anatomically demon- 
strable, seems to belong to the neuralgias sometimes observed at the on- 
set of secondary symptoms or precursory of them. 
16. Hereditary Syphilis. 
I. Etiology.—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. 
Syphilis is inherited from either parent. We cannot infer from 
which one it comes, from the organs affected in the child, as von Baren- 
sprung once taught. 
If the father or mother has primary or secondary symptoms at the 
time of procreation, the child will certainly have syphilis ; if both par- 
ents have it, assurance is redoubled. If both have tertiary symptoms 
exclusively, the child usually is not born with syphilis, but is apt to be 
weak and atrophic, is liable to have scrofula, consumption, and tubercu- 
lous meningitis at a later period, and often dies early. 364 
SYPHILIS. 
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 father 
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. Grunfeld, for example, reports a perfectly healthy 
child born of a father who was syphilitic at the time of procreation, no anti- 
syphilitic treatment having been given the mother. I have seen the same in a 
syphilitic woman. Hutchinson reports 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 transmissibility grows 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 the 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, in 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 
(Yol. 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; Avhence 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 physician 
can thus often Avin the lasting gratitude of unhappy parents. 
In other cases, children are born alive, but die quickly Avith infantile 
athrepsia. They are wretched creatures Avhen born, Avith pale, sunken 
faces, Aveak, bleating voice, sleepy, and weak in suckling. The skin is 
poor in fat, leathery, and Avrinkled; the skin of the palms and soles thin 
and shining, as if glazed; 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 children are born Avell, 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 broad, condylomata in 
places where two surfaces are in contact; for this we look principally at 
the anus, groin, scrotum, navel, arm-pit, corner of the mouth, behind 
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 condyloinatous 
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 
d’emblee. 
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 
disease, as in acquired syphilis, may lead to great contraction of the 
larynx. Such changes are found even in the trachea and bronchi. It 
is not always easy to distinguish such disease from tubercle (scrofula). 366 
SYPHILIS. 
The disease is sometimes concealed behind unusual symptoms, e. g., 
ascites of doubtful origin, explained after death by affections of the 
liver and portal circulation. 
Sometimes the sin of the parents is avenged by other diseases. Ter- 
tiary syphilis on the part of both parents at least predisposes children to 
such disease as tuberculosis, or chronic hydrocephalus, chorea, idiocy, 
epilepsy, etc. 
III. Anatomical Changes.—These are of great weight in deter- 
mining the nature of the disease, especially when the parents deny pre- 
vious infection. 
Of special value as signs are certain diseases of the epiphyseal ends of 
bones, and the ends of the costal cartilages, which appear with some 
regularity, and are sometimes the only sign of syphilis. The portion of 
epiphyseal cartilage lying close to the bone is much proliferated (zone of 
lime infiltration), and not bounded by a straight line, but forming 
notches and zigzags against the epiphysis. This may afterwards break 
down, so that epiphysis and diaphysis are 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 
foetuses; 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 alone 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. 
Gummata 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 bv 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-Hirschfeld has described interstitial proliferation of connective 
tissue in the pancreas. Forster described the like in PeyeFs patches. 
In the cortex of the suprarenal capsules, there are often found small 
multiple cheesy gummata. The kidneys also may contain nodules of 
gummata; also cysts. 
The bones of the skull may exhibit inflammation and necrosis, and 
the meninges may be thickened. For congenital encephalitis, see Vol. 
III.,p. 238. 
IV. Diagnosis.—It is often easy to recognize hereditary syphilis. 
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 
snuffles, with purulent discharge, and rhagades in the corner of the 
mouth. 
Hutchinson has pointed out two signs of previous hereditary syphilis 
visible in later years: a deformity of the two upper inner permanent 
incisor teeth, and disease of the cornea. 
Deformity of the cutting teeth he refers to stomatitis, connected 
with syphilis, which makes the inner upper incisors lie, not parallel to 
each other, but converging or diverging. Their free edge is notched, SYPHILIS. 
367 
and gradually breaks off, forming a deep semilunar gap. These teeth 
are shorter than the others. The Germans place little faith in this 
indication. 
Of Hutchinson’s keratitis interstitialis diffusa (parenchymatosa, s. 
profunda), we can only say that it is very probably referable to past 
hereditary syphilis. 
Y. Prognosis.—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 healed. We may also 
give the mother iodide of potash (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 be 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 
syphilis is noticed during pregnancy, she must have a course of inunction 
with biue ointment, to avert the danger of infecting the child as it 
passes through the vagina and vulva. 
For hereditary syphilis, 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 putash (1 : 40). 
Bathe the child daily in water at 28° R. (95° F.) in which 3 ij. of sub- 368 
LEPROSY. 
limate is dissolved. A wooden tub must be used, 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 R lodi puri, gr. iss.; potassii iodidi, gr. xv.; 
glycerini puri, fl. 3 ij. M. 
PART III. 
LEPROSY. 
Elephantiasis Grcecorum. 
I. Etiology.—Leprosy can be traced back to the most ancient times 
in Egypt and India; 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 have 
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 
Rou 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, and 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 such. There is often an intermit- 
tent fever, and the symptoms may then be mistaken for those of ma- 
laria. LEPROSY, 
369 
The skin is most frequently affected with gradual development of 
infiltrations and nodular elevations—lepra cutanea (tuberosa s. tubercu- 
losa). In other cases, individual nerve-trunks are first attacked with 
leprous infiltration and ganglionic swellings, producing sensory, trophic, 
and motor disturbances—lepra-nervorum (s. ansesthetica). Many cases 
are mixed forms; the tuberculous is often the basis, with the nervous 
supervening; the converse is rather less frequent. The mucous membrane 
of the throat, larynx, and trachea, the blood, lymphatic glands, testes, 
liver, spleen, and especially the conjunctiva and cornea, may be the seat 
of leprous disease. 
The prodromal symptoms, resembling intermittent fever, often last 
a year or two, before the first signs of tuberculous leprosy appear. At 
first erythema appears, sometimes turning pale, again leaving brownish 
spots. The spots by degrees become hard and infiltrated, turning at last 
to large knobs and humps. The flexibility of the skin and the propor- 
tions of the body suffer from these processes. The face assumes an 
indifferent expression, the eyelids, nose, and ears seem thickened and 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 
spontaneously, and continual advance and retrogression may be observed. 
Febrile movement often precedes the outbreak of new nodes. 
While these processes are going on, the mucous membranes of the nose, 
fauces, larynx, 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-epiglottidean folds, true and false vocal cords, 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 inguinal glands are especially common. 
Loss of hair, especially of the brows, occurs. Leprous nodes and in- 
filtrations of the conjunctiva and cornea may occur, and finally cause loss 
of the eye. 
Leprous disease in the liver and spleen has been hitherto found of no 
clinical importance. 
In lepra nervorum, the diseased peripheral nerves may be felt as 
thickened, tender cords, knotted in places. Districts of the skin are at 
first comparatively hyperaesthetic, but afterwards become very anaesthetic, 
and not in respect to touch and pain only. Trophic disorders are often 
added. Bullae, like pemphigus, called pemphigus leprosus, often appear; 
Gerhard and Muller have demonstrated large numbers of lepra-bacilli in 
their contents. Pigmental anomalies of the skin, white or brownish spots, 
are common. Want of secretion from the sweat and sebaceous 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—lepra 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- 
tion of the skin, mucous membrane, and certain viscera, with round cells, 
or the formation of knots of round cells. Many of these cells are very 
24 370 
LEPROSY. 
large (so-called lepra-cells) and have vacuoles in their interior. They 
constantly contain leprosy bacilli. These are fine rods, one-third to one- 
half as long as red blood-corpuscles, and extremely like the bacilli of 
tubercle. They are rarely found free, but usually inclosed in cells, 
where they often cluster in thick balls (see Fig. 68). 
Unna reports that the leprosy bacilli always lie free, and that the lepra cells 
are sections of lymphatic vessels. 
In the fresh state they move actively. 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 Yol. IV. They are distinguished from tubercle bacilli by 
the fact that they liquefy coagulated blood-serum, which the others do 
not do, and that tuberculosis of the iris does not follow inoculation 
Fig. 68. 
Leprosy bacilli. 
in the anterior chamber of the eye. They take aniline colors very 
quickly; tubercle bacilli do not. 
Spores are often seen in them, one at each end; three or four spores 
in one; or a rod looking as if turned into spores. The bacilli have been 
demonstrated in the skin, mucous membranes, peripheral nerves, 
lymphatic glands, testis, liver, spleen, and eyes; also in the blood, usu- 
ally inclosed in white blood-corpuscles. 
Virchow lias described the spleen as swollen and filled with countless 
white and gray granules, shown by the microscrope to contain great 
numbers of leprosy bacilli. 
IV. Diagnosis, Prognosis.—The diagnosis is usually easy, es- 
pecially in persons from the tropics.- In the early stages, leprosy may 
easily be confounded witli malaria. 
Cures have been reported; but the prospect is hopeless. 
V. Treatment.—Strict confinement of the sick certainly does most 
to restrict the disease. When it is developed, douches and inunctions DIPHTHERIA. 
371 
with mercurial, iodine, or ichthyol ointment are most to be recom- 
mended. It is said that creasote and salicylic acid have been known to 
do good when given inwardly. Patients ought, above all, to leave in- 
fected regions. 
PART IV. 
DIPHTHERIA. 
Diphtheria is an infectious disease which occurs most frequently as a 
local affection of the throat, but may also attack other mucous mem- 
branes, as those of the larynx and nose. Attempts have been made 
to demonstrate the virus, but as yet not with decisive certainty; it 
may even be true that there are various forms of schizomycetes which 
cause diphtheria. From the analogy with the other infectious diseases, 
it seems certain that the cause must be of this nature. 
We wish to state, however, that we are using the term diphtheria in 
its strictly etiological 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 exudation is for the most 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 
exudations are common, which lie on the surface, and can be removed 
easily and without essential loss of substance. Virchow has termed the 
latter class of alterations croup, restricting diphtheria to the former. 
In the etiological sense, both conditions are the same. 
It would be 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- 
ment 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, which 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 Reiiner, a similar case caused by swallowing 
muriatic acid. Laryngeal croup has occurred after extensive burns. 
Croupous inflammation of the oesophagus has been caused by swallowing 
caustic ammonia. Kozlakoflf and Strieker produced croup of the gastric 
mucous membrane in rabbits by introducing dilute ammonia into the 
stomach. Croupous changes of the gall-ducts are sometimes caused by 
the irritation of gall-stones; and croup of the pelvis of the kidney, 
ureter, and bladder may be caused by stone, or the use of irritating 
balsamics and diuretics. Croupous disease, therefore, has two forms 
—the diphtheritic and the non-diphthentic—as regards causation. 
Primary bronchial croup is another case of the non-diphtheritic form. 
Diphtheritic processes, in the anatomical sense, are not always diph- 
theritic as regards causation; this seems especially true as regards many 
affections accompanied by necrosis, developed during many infectious dis- 
eases, and often termed pseudo-diphtheritic. Vice versa, infection with 
diphtherial virus occurs which does not lead to diphtheritic or croup- 
ous changes of the mucous membrane in the anatomical sense, as will be 
explained under the next heading. 372 
DIPHTHERIA. 
1. Diphtheria of the Fauces. 
(Angina maligna. Angina memhranacea. Synanche s. Cynanche Con- 
tagiosa. ) 
I. Etiology.—There can be no doubt 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 vessels or instruments 
that were not cleansed, by being coughed upon, etc., and even by being 
in the same room. Physicians have often been inoculated with the virus 
through accidental scratches. Successful experiments on animals also 
show the infectious nature of the disease. Trousseau made unsuccessful 
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 become 
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- 
demics. Such houses often have a bad site, imperfect 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 changing 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 diphtheria have even been allowed to continue to 
suckle their infants—though I have known of a mother infecting her 
new-born 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. 
One 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 of 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- 373 
grounds, etc., favor the spread of the disease. Lifeless objects, and 
probably also intermediate persons, may carry it. Food from infected 
places, e. g., milk (Klebs), has often spread the disease. It occurs in 
animals (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 
fauces, in a purely primary form, becoming generalized afterwards, or 
whether the reverse is the case. 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- 
ence more rarely—the reverse occurs. It is not impossible that these two 
courses represent different poisons. A primary generalized affection 
may represent infection through the respiratory tract or the gastroin- 
testinal tract, by eating infected food or by inhaling the air of a sick- 
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 
epithelial coat through which a continual passage of amoeboid cells nor- 
mally takes place. 
Of the nature of the diphtheritic poison nothing certain is known. It is suspected 
to consist of schizomycetes, which are certainly found in the products; but among 
the many forms of fungi it is very hard to find the right ones. Klebs attempted 
to distinguish two varieties of throat diphtheria botanically, which he called the 
microsporine and the bacillary forms. They differ also clinically. Loffler, a pro- 
found student of the subject, is inclined to see the fungus in certain bacilli which 
are about as long as tubercle bacilli, but twice as thick. They are often composed 
of several members, bent or straight. Slight knotty thicke ings are often seen at 
the points of contact. The ends of the rods are stained more deeply with alkaline 
solution of methylene-blue than the other parts. Loffler cultivated this fungus 
purely, and successfully transplanted it to animals. 
Secondary diphtheria of the throat is a consequence of infectious dis- 
eases. It is most frequent in scarlatina, but occurs in measles, Ger- 
man measles, whooping-cough, typhoid fever, small-pox, and erysipelas. 
Loffler has shown that in scarlatinal diphtheria of the throat the same 
organisms are found as in primary diphtheria, but it is not certain that 
this is always so. The nature of secondary diphtheria of the fauces 
needs further study. 
In what follows, only the primary affection is discussed. 
II. Symptoms.—The incubation period usually lasts from two to 
seven days. A longer period than this is commoner than a shorter 
one; many extend 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 concomitants: cold, livid skin, shivering or 
rigor, vomiting, convulsions, delirium, loss of appetite, thirst, etc.; on 
the next day, the fever is less or has gone, the diagnosis of ephemera is 
made, and ascribed to errors of diet, but diphtheritic changes of 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 of the disease, I give 
an account of a case that I lately saw in consultation. A strong hoy of 
four years, ill for a week. No special complaint except slight shivering. 
Appetite entirely gone. Pallor and loss of strength increasing. Sleepi- 
ness. For twenty-four hours, very feeble heart-sounds, with irregular 
DIPHTHEKIA 374 
DIPHTHERIA. 
rhythm; striking want of fulness of pulse. Cause unknown. At the 
consultation, all the throat and part of the tongue and cheeks were seen 
covered with a thick diphtheritic layer. Death occurred in ten hours 
with symptoms of paralysis of the heart. Thus, in throat-diphtheria, 
local troubles 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 less pain 
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 of 
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 catarrh 
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 the 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. 
Diffuse 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 
addition to the elements above named. 
The parts affected sometimes become a brownish, fetid, soft, and DIPHTHERIA. 
375 
pulpy mass. The stench is such that the diagnosis of septic diphtheria 
can almost be made with the nose. Extensive gangrene of the parts 
around may originate in the diphtheritic parts. 
Swelling of the submaxillary lymphatic glands is usually observed in 
all forms of diphtheria; those behind the angle of the lower jaw are most 
constantly swollen and painful, forming a sympathetic bubo, i. e., one 
due to absorption of products of diphtheritic inflammation by the lym- 
phatic vessels and the nearest glands. They prevent the motion of the 
jaw, make movements of the head difficult, 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 submaxillary 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 from 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 membrane 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, light 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 
very serious, 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. Rhagades 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 the local. We must 
especially avoid the error of supposing that cases with slight visible local 
disease are always light. 376 
DIPHTHERIA. 
The bodily temperature hardly ever fails to be elevated, though not 
always to the same degree; in some, rising far above 40°; in others, but 
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 often 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 sign. 
There is quite often a moderate swelling of the liver and spleen, with 
sensitiveness to touch. 
Advanced leucocytosis 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 have 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. Hemoglobinuria and hematinuria 
(Salkowski) also occur. Acute nephritis may be accompanied by a 
greater or less amount of anasarca, but this is not common—much less 
common than in scarlatinal nephritis. Anuria is sometimes associated, 
but uremia rarely. 
Cloudy opacities have been repeatedly found in the urine, composed of 
schizomycetes—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- 
vation may make the breathing irregularand sighing. 
In many cases, sudden attacks of fainting occur, sometimes causing 377 
DIPHTHERIA. 
death directly. They are apt to take place when the patient rises quickly, 
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 
sloughing 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. 
Erysipelas of the face has been seen. Erythema nodosum occurs as a 
sequela. Calimani states that he has found diphtheritic alterations of 
the bed of the nail, which he considers an absolutely unfavorable symp- 
tom. 
Swelling and pain of the joints are rare; in my own cases, the knee 
has been affected, but the small joints of the fingers and toes have also 
been attacked not infrequently. Acute articular rheumatism may 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. Anaemia, 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 accompanying 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 
specially affects adults, children between two and six being more rarely 
attacked. 
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 eje often suffers, especially as to the apparatus of accommoda- 
tion. The patient loses the power of reading or 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 of 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 changes of accommodation. Bilateral para- 
lysis is probably of a peripheral origin. 
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 378 
DIPHTHERIA. 
occur under the influence of diphtheria. Amblyopia and transitory 
amaurosis are mentioned, probably connected with nephritis. 
Paralysis of the oesophagus sometimes occurs, causing great difficulty 
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 aryepiglottici. 
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 paralysis of 
the inferior laryngeal nerve, coughing does not occur, and the foreign 
substances may enter the lungs, causing a variety of pneumonia, with 
gangrene or abscess of the lungs. 
Sometimes only those fibres of the vagus are paralyzed 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 (Guillemant). 
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 angesthesia. 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. 
Residual 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. Remak 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 observation whether kidney diseases become permanent. 
III. Anatomical Changes. —Numerous hemorrhages are very often 
found in the serous membranes, and in a great 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, hyperasmia, 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 corpuscles and micrococci have been observed. DIPHTHERIA. 
379 
The heart cavities are sometimes much dilated, and the tissue lax. 
The right auricle especially may contain thrombi adherent to the walls, 
which may cause embolism. In spots, the heart-muscle is dull-yellow, 
from fatty change of the fibres. With the microscope, we often find 
extensive changes: groups of micrococci, Assuring of muscular fibres, 
Zenker’s degeneration (Rosenbach), proliferation of nuclei in the mus- 
cular fibres, and disappearance of muscular substance with deposit of 
pigment (Leyden). On the endocardium, fresh inflammatory changes 
are sometimes seen. Klebs found interstitial changes in the lungs. 
The changes in the spleen are like those in the lymphatic glands. 
The liver has been found fatty. The gastro-intestinal tract often has 
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 may be of normal 
size, or swollen and enlarged. They are sometimes thickly dotted with 
hemorrhages; at other times they are pale and gray-yellow. In the 
lightest cases, the changes seemed confined to granular cloudiness of the 
epithelium cells of the convoluted tubes. If the disease progresses, inter- 
stitial changes are added. In the urinary canals of the medullary sub- 
stance free desquamation of the epithelium, and in places dilatation of 
the canals occur. Swelling and multiplication of the epithelial cells 
and nuclei of the vascular loops in the Malpighian capsules also occur. 
Extensive fatty degeneration with increasing interstitial nuclear prolifera- 
tion finally appears. 
Schizomycetes have been repeatedly described in the blood-vessels, Malpig- 
hian capsules, and urinary canals, and the connection between throat-diphtheria 
and nephritis has been supposed to be that the kidney, in the act of excretion of 
the parasites, suffered irritation of its tissues. Fiirbringer does not confirm this. 
In the brain and cord, meningeal and parenchymatous bleeding is 
not rare. The microscope shows more. Klebs found the adventitious 
lymph-sheaths of the vessels full of schizomycetes, while in the cord 
Dej&rine observed an accumulation of colorless corpuscles in the same 
places. This author states that in the spinal cord swelling of the gan- 
glion cells of the anterior cornua, disappearance of the processes, and 
finally destruction of the ganglionic cells, and nuclear proliferation in the 
neuroglia of the gray substance take place, and are the cause of para- 
lysis. 
In the majority of cases, the palsy is probably due to changes in the 
peripheral nerves, which may be quite extensive, as in one of Meyer’s 
cases. Parenchymatous degeneration and atrophic appearances are 
sometimes associated with multiplication of nuclei, formation of fat- 
granule cells, and vascular dilatation in the interstitial tissue. P. 
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 and 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. Loffler’s 
diphtheria bacilli are found arranged in little groups somewhat below 
the surface of the membrane, surrounded by numerous cells; they never 380 
DIPHTHERIA. 
work into the tissue of the mucous membrane, and have 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 during epi- 
demics. 
Nephritis or specific paralysis sometimes enables us to infer previous 
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 younger 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. Treatment.—The strictest isolation of patients from well per- 
sons must be carried out. In epidemics, all persons with apparently 
simple catcirrhal 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 world before the clothes and 
bed-clothes 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. 
Physicians 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.: § 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 pencilling, 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, tannin, alum, etc. d. Balsams—turpentine, DIPHTHERIA. 
381 
cubebs, copaiba, eucalyptus, etc. e. Antiphlogistics—bits of ice to swallow, ice- 
cravat, inunction of mercurials, calomel, leeches. /. Bromine and iodine prepa- 
rations—their vapors for inhalation, iodide of potash internally, tincture of iodine 
for pencilling, g. Solvents of the membrane—lime-water, lactic acid, neurin, 
pepsin, trypsin, papayotin, tetramethylammonium-hydroxyl, tetramethylen-am- 
moniuin-hydroxyl, etc. h. Chlorate of potash internally and as a gargle, quino- 
line, pilocarpine, peroxide of hydrogen, inhalation of caustic ammonia, i. 
Emetics. 
2. Laryngeal Diphtheria. 
(Diphtheritic Croup, Angina Membrancea, A. Laryngea, A. Polyposa, 
Cynanche Stridula, 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 fungus; 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 considered as primary. The younger a child 
is that is attacked 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; Loffler 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 pyaemia. 
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. 11 is very common on the coasts of Scotland, England, 
France, and Holland, the Baltic sea-coast, in many towns on the Swiss 382 
DIP1ITHEKIA. 
lakes, as Geneva, and in certain parts of Switzerland and Savoy. Craw- 
ford states 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 the 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 the epithelium cells 
of a child’s larynx are less resistant. 
Boys are attacked oftener than girls; according to Riihle, in the 
ratio of 3 : 2. 
The constitution has some influence. It is not true that the healthiest 
children are oftenest attacked; but scrofulous and ricketty children—or 
children whose parents were old, or phthisical, or marastic—are often 
attacked. 
Hereditary influences are said to have been observed in many fami- 
lies, several children of one family being attacked within a rather long 
period of time, but this hereditary influence may be interpreted as a 
predisposition to this class of diseases. The same is true of the state- 
ment that children with moist eruptions of the skin often suffer with 
croup when the exanthem is cured. 
II. Anatomical Changes.—They are almost always equivalent to 
those of croup in the anatomical sense; consisting of a formation of 
coagulated fibrinous exudation on the surface of the mucous membrane. 
It very rarely happens that such a formation does not occur if the 
symptoms of croup exist during life; it is assumed in such a case that 
the mass is expectorated shortly before death. 
The consistency of the exudation varies from that of thick, creamy 
pus to that of a hard, firm membrane; the latter may be four millimetres 
thick. 
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 usually begins on the posterior lower surface of the epi- 
glottis, extends laterally over the inner surface of the ary-epiglottic folds 
and arytenoid cartilage, and thence enters the larynx. If the exudation 
is diffusely distributed, it is usually thickest on the posterior wall of the 
larynx. 
The exudation is usually yellowish or vellowish-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 difficult 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. They swell in concentrated 
acetic acid or fluid 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 383 
DIPHTHERIA. 
fibrous, in which round cells are distributed. The cells lie in nests or rows, insucl 
a way as to form a sort of alternation of cell-containing and cell-less layers. A few 
red corpuscles are seen. 
On the mucous membrane, the epithelium is gone, and more or less recogniz- 
able parts of it cling to the false membrane. Wagner first described a peculiar 
swelling and change of the epithelial cells, which he called croupous metamor- 
phosis. He inferred that the membranes originated chiefly from this metamor- 
phosis, and were, so to speak, an epithelial product. This view has been much 
contested, and most authors properly assume that the fibrinous mass of exudation 
comes from blood-vessels, the fibrin being at first fluid and afterwards coagulating 
on the surface of the mucous membrane. 
Weigert’s late researches show that the epithelial cells of the mucous membrane 
have some influence upon the process of coagulation, since that cannot take place 
unless the epithelium first perishes and enters the condition called coagulation- 
necrosis. A coagulated exudation, therefore, is not formed unless chemical or 
thermic influences (non-diphtheritic croup) or schizomycetes (diphtheritic croup) 
involve the protecting epithelial coat and cause coagulation-necrosis. 
In describing the anatomical processes, we have anticipated the actual 
course of events, for croupous changes in the larynx do not begin as such, 
but always have an initial catarrhal stage. Redness, swelling, and in- 
creased secretion, and sometimes bleeding, are the chief signs, and they con- 
tinue even after false membrane begins to form. (In the dead body they 
often disappear.) These conditions tend to raise and throw off the false 
membranes from their bed by the formation of fresh layers underneath ; 
if the latter coagulate, the result may be a stratified 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 oesophagus, 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 submaxillary, cervical, 
tracheal and bronchial glands, and in the glands of the mesentery, 
swelling of the intestinal follicles, and enlargement of the spleen are 
very 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 
hypersemia in almost all the organs. There are also very frequently small 
extravasations in many of the viscera, and in the serous cavities there may 
be accumulations of bloody transudations. 
III. Symptoms.—The characteristic symptoms seldom appear sud- 
denly, but are usually preceded by warnings for some days. The child 
is fretful, will not play or eat; there is 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 the larynx, the child complains of pain in 
swallowing or moving his 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 is, 
the greater the danger of secondary affection of the larynx; if there are 
deposits on the uvula, palate, and back of the throat, the case is 
serious. 384 
DIPHTIIEEIA. 
The special characteristic of the disease is the narrowing of the laryn- 
geal passage, which does not become manifest until the glottis 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 evening 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 stridor of croup. It can often 
be heard at a great 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 auxiliary inspiratory muscles. 
The child cannot usually lie on his back, but 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 the 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 dyspnoea 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 followed 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 DIPHTHERIA. 
385 
the vocal 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 happen that the free edges of the 
vocal cords may be drawn together bv suction during a hasty inspiration, 
so as to close the opening like a valve and threaten suffocation. 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 andslo vvly; 
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 mechanical 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, the respira- 
tion becomes easier. If they cannot be removed, death 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. 
Spasm of the glottis-muscles has been thought to be a cause of these sudden 
attacks, but paresis is the condition of which the laryngoscope informs us. Rud- 
nicky 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 throat 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 neck, due to violent efforts 
at breathing. 
Emphysema of the skin sometimes spreads from the wound after trache- 
otomy. 
The barking cough usually 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 
DIPHTHERIA. 
above components increases. Albumin is often present, and casts, 
liyaline or dotted with fat-granules, are found in the sediment. 
Croup has a great influence on the temper. Children may be ordi- 
narily obedient and quiet, but as soon as they fall ill, they become 
capricious, cross, and disobedient. The examination requires great skill 
and patience, and the administration of medicine often becomes very 
difficult. 
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. 
Death 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-gray, 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. Diagnosis.—The laryngoscope presents the means of making a 
certain diagnosis, but is not likely to be generally resorted to, under the 
circumstances. We must rely on symptoms of the stenosis of the larynx, 
rapidly developed. The acute, non-croupous varieties of stenosis of 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 Yol. 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 find fibrinous mem- 
branes 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. 
b. 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. DIPHTHERIA. 
387 
e. The prognosis, finally, depends on the correct and decisive action 
of the physician, for any neglected point may cause irreparable injury. 
VI. Treatment.—Prophylaxis is of much value. A reasonable system 
of hardening the body may prevent a tendency to colds or sore-throat. 
At places where diphtheria prevails epidemically, prophylactic gargling 
with salicylate of soda is advisable. Bed-chambers and living-rooms 
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 larynx breaks out in the family, the affected children must be strictly 
isolated and, if possible, placed in another house; isolation cannot be 
considered complete unless the sick and the well members are under dif- 
ferent systems of housekeeping. 
The treatment has two chief objects to fulfil—to relieve existing ste- 
notic symptoms, and to conquer the inflammation—and the two run 
together. For removing the croupous membranes we may use emetics 
or solvents. 
Emetics will fail when carbonic-acid narcosis is strongly marked; yet, 
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 dessertspoonful every 
ten minutes until it acts; ipecac, gr. viiss., with tartar emetic, gr.£, 
divided into three parts, one every ten minutes till it acts; or if the child 
resists, hydrochlorate of apomorphia by subcutaneous injection (gr. iss.: 
3 iiss., £ 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 has 
been practised when no mechanical indication existed. As blocking of 
the glottis may occur at any time, an emetic should be 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 
most confidence; it is inhaled every hour or two from Siegle’s apparatus. 
Biermer warmed it to increase its effect. Inhalation of lactic acid or 
alkaline solutions are of still less use. Muriatic acid and bromine vapors 
have been used in the same way. 
To relieve inflammation, put the patient in a room, the temperature 
of which is kept steadily at 14° K. (634° F.). The air of the room is kept 
moist by saucers of water set on the stove, or a two-per-cent solution of 
carbolic acid or lime-water is sprayed about the room ever hour or two. 
Give abundance of wine, milk, thin egg soup, and wine soup. 
The success of internal antiphlogistic treatment is small; we simply name 
the chief remedies: a. (Locally) Ice compresses around the neck and leeches to the 
region of the larynx, or better, the manubrium sterni, to avoid severe bleeding 
from cervical veins; also, derivative friction, sinapisms, blisters, b. General 
blood-letting, c. Friction with mercurial ointment; calomel and sublimate inter- 
nally. d. Hydropathic packing, e. Enemata of vinegar water. /. Pencilling the 
mucous membrane of the larynx with concentrated solution of lunar caustic 
(1; 8) (Bretonneau), etc. 
If dyspnoea increases in spite of our efforts, 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 operation 
would be much less, if the right moment were not so often passed by. 388 
DIPHTHERIA. 
We cannot wonder at failure when a child is already half dead before the 
operation; but the public have a tendency to lay the blame on the oper- 
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 recoveries. 
Sann6 “ 4,603 “ 24.0$ “ 
Duchek “. 1,678 “ 25.0$ 
Monti “ 2,608 “ 25.0$ 
Bartels and Wilms found in 330 “ 31.3$ “ 
Kronlein & von Langenbeck found in 504 “ 29.0$ “ 
Certain symptoms may require special treatment. High fever may 
require antipyretics; the best is antipyrin (gr. 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 douche will make the pa- 
tient draw deep breaths and remove obstacles to the passage of air. 
3. Nasal Diphtheria. 
I. Etiology.—This affection may be primary or secondary. 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 the throat; and is favored by chronic inflammation of the 
Schneiderian membrane, and by scrofula or rickets. It is not very 
rare in new-born children as a result of puerperal infection. 
II. —Symptoms, Diagnosis, Anatomical Changes.—The mu- 
cous membrane is greatly swollen, which, with exudation, very 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 choame. 
The discharge is abundant, and may contain mucous, muco-purulent, 
bloody, or brownish ichorous masses, the latter often having 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 throwm out. 
There may be deep destruction of the mucous membrane, bone, and 
cartilage, and obstinate bleeding. 
The submaxillary lymphatic glands are usually enlarged and sensitive 
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. : 
3 iij.), sublimate (gr. iss.: fiij.), or lime-water; in small children, 
syringe out the nose and use weaker solutions. If there is a discharge, 
insert a cotton plug and oil the nose and upper lip with borated or car- 389 
DIPHTHERIA. 
bolized vaseline (5 per cent). A general stimulant treatment is very 
important. 
The list of remedies given on page 380 is applicable here, with special adapta- 
tions. 
4. Diphtheria of the CEsophagus. 
I. Etiology.—The primary form is very rare; Wunderlich described it, and 
Steffen reported a case in 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 
oesophagus. Cancer, tuberculosis, Bright’s disease, suppuration in the joints and 
urinary passages are sometimes accompanied by secondary diphtheria of the 
oesophagus. 
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 
masses of sprue, easily recognized by the microscope. 
III. Anatomical Changes.—They comprise fibrinous deposits, sometimes 
•within, sometimes on the mucous membrane of the oesophagus; 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 always 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 pyaemic 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), sometimes 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 pysemic 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 neai’ly parallel fibrillated masses of fibrin, containing red corpuscles, 
pus-corpuscles, epithelium and gland cells, and sometimes micrococci. 
The mucous coat is usually swollen, liyperaemic, 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 diagnosis may be made, if we can exclude 390 
ZOONOSES. 
the larynx, throat, and oesophagus as sources. Prognosis absolutely unfavorable. 
Treatment symptomatic. 
6. Diphtheria of the Intestines. 
We repeat all that was said of diphtheria of the stomach. When dysentery is 
termed a diphtheria of the mucous membrane of the colon, we must remember 
that the expression is used in its anatomical, not its etiological sense. 
7. Diphtheria of the Gall-ducts and Gall-bladder. 
All the points which bear upon diphtheria of the stomach apply here. There 
are no symptoms, or icterus is produced 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 FROM ANIMALS TO MEN. 
1. Trichinosis. 
(Tricliiniasis.) 
I. Etiology.—Any one who eats flesh containing trichi nse which have 
not been killed in the process of cooking, is in danger of infection by 
trichinae. The muscle trichinae are usually inclosed in capsules; they 
enter the stomach, the capsules are dissolved by the gastric juice, and the 
trichinae are set free. They grow rapidly in the upper part of the intes- 
tine, and develop into intestinal trichinae. 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-trichinae, 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 Muller. In Wurttemberg, Haberlein 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 noj 
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 ZOONOSES. 
391 
seems to favor the spread of trichina among them, it being the practice to give the 
offal from the slaughter house to swine. 
Eulenberg states that in 1877 2,057,272 swine were slaughtered in Russia, of 
which 701 were found trichinous, exactly 0.04 per cent. Billings reports examin- 
ing 2,701 swine in Boston, in 1880, of which 154 were trichinous, or 5.7 per cent. 
This coincides with the percentage (4.0) found in American hams and sides of 
bacon (Eulenberg). 
If restrictions, or a veto, are laid on the importation of such wares, the Ameri- 
cans need find no fault. 
The origin of trichinae in the pig has been much discussed. Some 
think he is the headquarters of trichinae, and that uninfected beasts ac- 
quire them by eating the droppings of the infected. It is found that all 
the pigs in one pen are often infected together. Infection by eating flesh 
of slaughtered beasts is rarer in this country. 
Others believe that the rat is the original haroorer of trichinae. It is 
known that rats infest the pens, and that swine eat them; and trichinae 
occur very frequently in rats. Zenker, however, thinks the contrary, 
that rats become infected by eating the dung of swine. Rogner, at Hof, 
found trichinae in one pig, and also in all the rats that were caught in 
the same house; while the rats in neighbors’ houses were free. Most re- 
cent authors, nevertheless, regard the rat us the source of trichinae in 
swine, but do not wholly deny the occurrence of infection between 
swine. 
Some other small wild animals harbor trichinae, as the mouse, fox, ham- 
ster, badger, etc.; cats obtain them from mice and rats. 
The experimental infection with trichinous flesh is successful in the 
case of other animals, as the ape, calf, dog, rabbit. 
Goujon infected salamanders. 
The larvae of flies, eating trichinae, digest them, but if the larvae are 
eaten before the trichinae are killed by digestion, they produce infection. 
Colin says that beasts of prey that live on small rodents become infected, 
and so do birds and fishes that eat excrement. The infection may ex- 
tend still further, and the sources may become quite numerous. 
The flesh of wild boars has lately been found to infect man, and in 
many places inspection is required by law for this meat as well as for the 
domestic sort. The wild animal eats some of the small creatures which we 
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 Hedersleben and Hett- 
stadt; in the former place 334 cases occurred (Kratz). In Brunswick, in 
1882, an epidemic broke out which affected 254 persons (Blasius). In 
Emmersleben, near Halberstadt (1883), there was an epidemic of 250 
cases (Brouardel). 
The mode of infection has been studied since about 1860 by Leuckart, Virchow, 
and Zenker. In the human muscle, Hilton first described capsulated trichinae in 
1831, but took them for cysticerci. Paget discovered a spiral worm in the cap- 
sule, which Owen termed trichina spiralis. Herbst in Gottingen produced 
muscle trichinae in dogs (1851) by feeding them with trichinous flesh. 
The disease was known previously; there is good reason to refer certain early 
epidemics of rheumatoid, typhoid and sweating symptoms to trichinosis. This 
was directly proved at Hamburg by the autopsy of a man who survived an epi- 
demic in 1851, but died in 1861 (Tiingel). 392 
ZOONOSES. 
II. Anatomical Alterations.—Trichina spiralis is a round nematode worm. 
It exists in two stages, in the intestine and muscle. 
The intestinal trichina may be seen with the naked eye as a very fine yellow- 
white thread, slightly curved or rolled at one end. The females measure three 
to four millimetres, while the males only reach about 1.5 mm. They have a 
thinner head-end and a thicker tail-end. The number of the females is always 
considerably larger than that of the males. They are chiefly found in the begin- 
ning of the small intestine, and only few are found in the large intestine. In ex- 
amining the contents of the intestine, we dilute them freely with water and place 
Fig. 69. 
Fresh immigration of trichinae into human muscle. Section of muscle near the tendinous 
part. Moderate power. Heller. 
a drop under the microscope—unless the fine threads are visible to the naked 
eye. Weak powers are used (50-100 diameters) in order to give a larger field. 
If muscle-trichinae enter the stomach, and their capsule is dissolved; if they 
develop and copulate, it is seven days from the eating of the flesh before the fe- 
males bring forth living young. The process of parturition continues some weeks, 
and one mother may bring forth one thousand to thirteen hundred embryos, her- 
self dying from the fifth to the eighth week and being rejected with the excre- 
ment. 
The young brood at once begins to emigrate; it pierces the intestinal wall, ZOOM OSES. 
393 
sometimes turning aside at the serous coat and going between the layers of the 
mesentery to the retro-peritoneal connective tissue, and thence by the cellular tissue 
to the voluntary muscles; at other times piercing quite through to the peritoneal 
cavity and thence passing to the muscles through loose connective tissue; per- 
haps a part is carried to the muscles in the lymphatics and blood-vessels, as 
Virchow found trichinae in the mesenteric glands. They are sometimes found in 
the flesh of such small dimensions that it seems likely that they were carried there 
at once by the blood or lymph. 
When the young animals reach the muscles, they begin to develop into mus- 
cle-trichinae. They pierce the sarcolemma and take up their abode inside. Inflam- 
matory processes in the contents of the sarcolemma accompany this step. The 
contents become light-colored in the vicinity of the parasite, lose the transverse 
marking, become partly homogeneous, partly granular, and at the same time the 
Fig. 70. 
Fig. 71. 
Isolated muscular fibre with two trichinae. 
Dilatation ot' the sarcolemtna-sae. High 
power. Heller. 
Encapsulated muscle-trichinae with calcifica- 
tion of capsule. From Heller. 
sarcolemma nuclei multiply and are heaped up. The adjoining perimysium in- 
ternum is alsu inflamed, which is recognized by the fact that the muscles become 
clearer at such places, and acquire a gray-red or gray-yellow tint. Before the 
parasites are encapsulated, they are often found stretched out, or only partly coiled 
up (see Fig. 69). In isolated muscle fibres a distinct enlargement and thickening 
of the saroolemma-sac is present (see Fig. 70). 
The muscle-trichinae reach their full growth (0.7-1.0 mm.) within two weeks. 
As a rule, only one is found in one connective-tissue capsule, two, three, or 
four less frequently. The capsules are elliptic or lemon-shaped, and are composed 
partly of a chitin-like secretion from the animal, partly of hyperplasia of the 
neighboring connective tissue; the trichinae are found roiled up spirally in them, 
along with a granular substance. By degrees salts of lime are precipitated in the 
capsule, making it opaque, so that we sometimes have to dissolve the lime salt 
in acid before the rolled up pamsite is visible (see Fig. 71\ The same process may 
affect the trichinae, which men breaks into small pieces. At the poles of the 394 
ZOONOSES. 
capsules, outside of them, there is often an assemblage of fat-drops in old cases. 
The encapsulated parasite lives a great while. Klopsch gives a case in which a 
woman who certainly suffered from trichinosis in 1842 was operated on for cancer 
of the breast in 1866, when a piece of intercostal muscle was taken out and found 
full of calcified trichinae-capsules, in which the creatures had retained their life 
for fully twenty-four years. Vitality is recognized by the parasites moving when 
the microscopic preparation is warmed. Muller found the capsules calcified in 
two-year-old pigs. The capsules are easily seen with the naked eye, as they form 
yellow knots of the size of poppy seeds, sprinkled in the muscles (see Fig. *72). 
The capsule is dissolved in the stomach by the gastric juice, and the parasite 
is set free; it grows, and in two and one-half days becomes mature, that is, be- 
comes an intestinal trichina; it copulates, and in about five days brings forth 
living young. 
The muscles that receive the earliest and most abundant visitations are the 
diaphragm, intercostals, neck, laryngeal and eye muscles. The heart is free from 
the parasite. In the extremities they become fewer as the distance from the 
trunk increases. They are abundant near the insertion of the tendons, since the 
latter afford a natural obstacle to their further progress. 
Bodies of persons who have fallen victims to the disease are often oedematous 
and emaciated. The arms and legs, especially the arms, are strongly flexed. 
In the heart, liver, and kidney, we find cloudy swelling. Ecchymoses under 
the pleura, epicardium. and peritoneum sometimes occur; and more commonly 
on the gastric mucous membrane. The mesenteric glands are often swollen and 
ecchymosed. 
III. Symptoms.—In some cases, trouble in 
the stomach or intestine begins a few hours 
after eating tricliinous meat. The patient is 
sick, perhaps vomits, is sensitive to pressure 
over the stomach, and has diarrhoea. 
In most cases, the first days pass without 
much trouble, but about 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. 
They include local irritation of the gastrointes- 
tinal tract, local alterations in the muscles in- 
vaded, and general symptoms, the latter de- 
pendent partly on the changes in the digestive 
tract and muscular system, partly perhaps on an injurious element se- 
creted by the parasites in the capsules, and absorbed by the stomach. 
(Friedreich). 
Nausea, want of appetite, furred tongue, bad taste, and foul smelling 
breath, are almost always present. Thirst is increased, from the fever 
and the abundant sweating. Repeated vomiting is not rare, and diar- 
rhoea is usual; in many cases, they are so prominent as to form a “ chol- 
eriform” variety of the disease. Death from collapse may occur within 
a few days, though that is not very common. The epigastrium is usu- 
ally quite sensitive to pressure. 
The presence of trichinae in the muscles causes severe pain, easily 
mistaken for rheumatism, especially at the beginning of the disease. It 
is spontaneous, and is increased by light pressure. The muscles swell 
and feel hard and elastic. Very peculiar and extremely characteristic 
positions are gradually assumed by the limbs, and permanent flexed con- 
tracture is developed. In cases treated by me in Frerichs’ clinic, the 
elbows were bent at an acute angle, so that the patients were unable to 
help themselves. This condition improves very slowly. If the eye 
muscles are affected, the patient complains that it is hard to move the 
Fig. 73. 
Encapsulated and calcified 
inuscle-trichinee in the flesh. 
Natural size. After Heller. 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 laryngeal 
muscles produces 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° C. 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 (Colberg); 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 hyperesthesia and anesthe- 
sia; pain surrounding the body like a girdle (Kortum). Hemorrhage, 
urticaria, pruritus, furuncles, bed-sores, and pyemia sometimes occur. 
Loss of consciousness and delirium may appear early, with dry, dark 
lips and tongue, as in typhoid; this has been called the typhoid form of 
trichinosis. Eepeated 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 which resisted suitable remedies. 
Pleurisy occurs rarely; pneumonia less rarely; epistaxissometimes. 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, • 396 
ZOONOSES. 
oedema of the eyelids, sweats, sleeplessness, hoarseness, muscular 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 require strict antiseptic precautions. The wounds heal per- 
fectly smoothly, as I have often found. Examination of the faeces is 
harder and less promising. 
V. Prognosis.—It is serious, for we have no means of destroying the 
parasites after they enter the muscles, and many die after suffering great 
pain a long time. In the Iledersleben epidemic, 337 persons were at- 
tacked, of whom 101 died. The symptoms are severe in proportion to 
the number of the trichinae. 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: Kraemer 
showed that a person may have more trichinae in his muscles than the 
pig from which he was infected. Children are said to be affected less. 
VI. Treatment.—Prophylaxis is of the highest importance; it 
includes not only compulsory inspection of the pork, but previous 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 dead animals is used. 
Legal inspection is not a certain protection, for if an animal has only 
a few trichinas, they may be overlooked, even when thorough and re- 
peated tests 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 G0°. He 
found that three kilos of beef did not attain the temperature of 50° in- 
ternally until after an hour’s boiling; and required 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 G5°, in five hours 75°, in six hours 82°, and in six and three- 
fourths hours 8G° 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 trichime. Krabbe 
found trichinae still living after lying two wreeks in a five-and-one-half 
percent salt-brine. Colin and Fourment 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. g., compound infusion of senna; a teaspoonful hourly 
until from four to eight full discharges have occurred, and then give a 397 
tablespoonful of glycerin hourly till he has used about fifteen. Fiedler ob- 
served that trichinae quickly die in contact with glycerin, even if diluted 
with two or three parts of water. The quicker the treatment the better. 
If trichinosis is developed, nothing but symptomatic treatment re- 
mains. Friedreich recommends gr. xxx.;pulv. 
tub. jalap., 3 i.; ext. glycyrrh., q. s, ut f. pil. 30. Five pills three times 
daily; Mosler advises benzin (f. 3 i.-iiss. : 1 pint for enema) neither of 
which can destroy the trichinae. We think it most rational to try to de- 
stroy the creatures and their offspring and expel them by 5 Santonin, gr. 
-f; calomel, tub. jalap., sacch. alb., aa gr. viij. M. f. pulv. vi. S. One 
twice a day; but the value of this depends on not waiting too long be- 
fore applying it—at most four to eight weeks. 
Let the diet be strengthening. Give daily lukewarm baths, morning 
and evening, lasting thirty minutes, at 28° K. (95°). For sweating, 
atropia (gr. in a pill, morning and evening); for muscular pains, 
subcutaneous injections of morphia; and for sleeplessness, chloral hy- 
drate (Sij.-iv. per dose). Kortum uses salicylic acid, and advises not to 
use narcotics. Traube preferred friction with mercurial ointment. 
2. Anthrax. Malignant Pustule. 
I. ETIOLOGY.—This is the first of the infectious diseases that was proved to be 
caused by schizomycetes. It is most frequent in neat cattle, sheep, horses, and 
swine, next in deer, rarer in asses and goats. It can 
be transferred artificially or by accident to other 
animals, even to birds, fishes, and frogs (Oemler, 
Gibier). Graminivorous animals are more subject to 
it than omnivora, and the latter more than carnivora. 
In many places, it is endemic and destroys many 
beasts every year; in other places, epidemics occur 
occasionally. 
Human beings are always infected accidentally; 
usually by the blood, secretions, excretions, flesh, 
fat, urine, etc., of affected beasts coming in contact 
with the skin or mucous membrane; the infection can 
pass through (it is said) even if the surface is intact, 
but as a rule, a lesion of the surface is required. Those 
who have much to do with animals and their dejec- 
tions, as shepherds, stable boys, farmers, veterinari- 
ans, butchers, etc., are most liable to the disease. It is caught by performing 
autopsies on the diseased animals with cut fingers; by blood touching a cut 
finger while dressing the meat; by working in fat or hair from the animals; 
hence, it is found among leather-dealers, tanners, glovers, hat workers, wool 
workers, etc. It has been communicated by rags in paper-mills. 
The use of meat, milk, or butter from infected animals has caused the disease 
in some cases, but in others it has had no bad consequences; the poison may be 
destroyed by cooking, or by the action of the stomach; and if there are' no lesions 
of the mucous membrane, the poison may fail, at any rate, to enter the system. 
Insects that have been upon infected animals may convey infection. Blow- 
flies which wet their legs and proboscis with blood have been thought especially 
dangerous; but other insects seem to carry contagion. The symptoms are generally 
said to begin with stinging pain, but that does not prove that stinging insects 
convey the poison, for the same sensation occurs in cases where such stings can- 
not have occurred. 
Contagion from man to man is very rare, and has been even denied, though 
the blood and excrement of patients have transferred the disease to animals. The 
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 against another. 
The nature of the poison is known; it is connected with the bacillus anthracis, 
nrst seen by Pallender (1855) and Brauell (1857), correctly interpreted by Davaine, 
ZOONOSES. 
Fig. 73. 
Anthrax bacilli from the blood 
of a guinea-pig inoculated 
with anthrax. Magnified 650 
diameters. After Koch. 398 
ZOONOSES. 
and recently studied thoroughly by Koch. It is a fine, motionless rod, 5-20 n in 
length, 1-1.25 n broad (1 // = 0.001 mm.) (see Fig. 73). It is found in the blood, 
especially that from the finer vessels of the viscera, and in the inflammatory pro- 
ducts of the carbuncle and the oedema. 
II. Symptoms.—If infection has occurred, the first morbid change may occur 
within a few hours, but in other cases the period of incubation may last seven 
days. 
The chief visible symptoms are the carbuncle or oedema of the skin. At the 
autopsy, we often find disease of the mucous membrane of the intestine, which is 
similar to that of carbuncle. Intestinal symptoms sometimes predominate, or 
may exist alone. The intestinal disease has been described as mycosis intesti- 
nalis. 
Malignant pustule is most frequently observed on exposed parts of the skin, to 
which infection has readiest access. The symptoms usually begin with stinging 
pain, and many patients think they have been stung by an insect. The place is 
reddened and infiltrated, and soon forms a distinct papule. In the middle a 
vesicle rises, usually not tense, filled with serum or a hemorrhagic fluid. It 
bursts, and the papule becomes a nodule or knob, on the border of which a ring 
of fresh vesicles appears. In the middle of the nodule there is a bluish-black dis- 
coloration and gangrenous destruction. The vicinity is cedematous and erysipel- 
atous. Hard red cords (inflamed lymphatics) sometimes run from the spot, and. 
the neighboring lymphatic glands are often swollen and painful. 
By the end of the second or third day, general symptoms appear; high fever, 
rapid pulse, thirst, dry tongue, often hebetude, diarrhoea (sometimes with bloody 
discharges), swelling of spleen and liver, cyanosis, dyspnoea, and death by collapse. 
Tetanus sometimes closes the case. If the cause has been recognized in season, 
and the carbuncle rendered harmless, this general infection does not occur, and 
the patient recovers. 
(Edema sometimes makes its first appearance at the eyes, and then in other 
parts. There is often erysipelatous redness of the skin, wfith vesicular elevations 
in places; blood is effused under the skin; and gangrene occurs, and in other re- 
spects the course much resembles that of carbuncle, with which this oedema is 
often associated. 
The intestinal affection is associated with violent bloody diarrhoea, colic, pain 
in the abdomen when pressed, nausea, vomiting, chills, fever, increasing cyano- 
sis and dyspnoea, death by collapse. In most cases, there is also carbuncle or 
oedema. 
III. Diagnosis.—This is not always easy, and depends on the demonstration 
of anthrax bacilli in the contents of the pustule, in that of the oedema, and in the 
blood, but their absence is not certain evidence against anthrax. We also seek 
evidence of contact with portions of diseased animals. Finally, rabbits or guinea- 
pigs. when inoculated with the products of the inflammation, die quickly. 
V. Prognosis.—There is more hope in the cutaneous affection than in that of 
the intestine. In the former, success depends on an early and energetic treatment 
by excision and cauterization, before general symptoms appear; the prognosis is 
serious enough at any rate. 
VI. Treatment.—First and foremost, prevention of disease among animals 
must be attended to; for which books of veterinary surgery and public hygiene 
should be consulted. Great care must be exercised by those who have to do with 
living or dead animals who have had the disease, and in the handling of skins, 
hair, etc. The flesh and milk had better not be used for food, though they can 
be made harmless by great heat. 
The treatment of the carbuncle and the oedema belong to surgery. For the 
intestinal complaint Leube recommended quinia and carbolic acid internally; we 
should prefer calomel (gr. iij., twice a day) and injections of common salt (two 
per cent, twice a day). 
3. Glanders. 
(Maliasmus.) 
I. Etiology.—Glanders occurs most frequently in horses, less commonly in 
other monodactyla (asses and mules). It is communicable to other animals (except 
neat cattle), as sheep, goats, rabbits, guinea-pigs, mice, cats, dogs, etc. In 
menageries I have repeatedly seen lions attacked with glanders after eating the 
flesh of glandered horses: and the same in the case of the elephant. 399 
Lbffler and Schutz have lately shown that the cause resides in bacilli, which 
they discovered in the inflammatory products of the disease, cultivated them artifi- 
cially, and then transferred them successfully to well animals. Morphological, 
though not biological, observations of low organisms in the blood and the puru- 
lent discharges of glanders were made at an early period. 
Man is liable to infection, though not very prominently so. Cases occur most 
frequently among stable-boys, coachmen, veterinary surgeons, knackers, farmers, 
cavalry soldiers, horse-butchers, etc. Women are naturally less 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 horses with the skin or mucous membrane. It is also 
supposed that the sweat, saliva, tears, and urine may contain the contagious 
material, but only in case the specific disease has attacked the mucous membranes 
concerned, or when infectious matter is mingled with 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 
saliva of diseased horses. 
Eating the flesh of infected animals may cause the disease, especially when it 
is not cooked enough. 
Communication may take place between physicians and nurses in attendance 
on glandered 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 injury of skin 
or mucous membrane is necessary. 
II. Symptoms.—The stage of incubation usually lasts from three to five days, 
but is said sometimes to extend to weeks. 
The symptoms include nodes or diffuse infiltration, consisting of round cells, 
occurring on the akin and in the muscles, in the mucous membrane of the nose, 
frontal sinuses, throat, larynx, trachea and bronchi, and in the viscera, as the 
lungs, liver, spleen, kidneys, stomach (Wyss), and even in the central nervous 
system. Both nodes and infiltrations have a great tendency to caseous changes, 
suppuration, calcification, and a very slight tendency to cicatrization; if one spot 
begins to cicatrize, another continues to form new knots and infiltration, with 
destruction of tissue. Ulcers of the skin are thus formed, which continuously 
extend, so that the cutaneous disease has been popularly called the “worm.” 
There is an acute, a subacute, and a chronic form of glanders. While acute 
glanders usually terminates within a week or two, the chronic form lasts as many 
months or years, or even longer than ten years. Acute symptoms sometimes ap- 
pear, changing a chronic into an acute disease; the converse probably does not 
occur. 
Acute glanders often begins gradually. If the poison is received through a 
wound of the skin, a lump or ulcer appears, which soon becomes discolored, has 
a disposition to spread rather than heal, and discharges thin hemorrhagic pus, of 
an offensive smell. In the neighborhood there is often inflammatory oedema or 
erysipelas, and inflammation of the lymphatics and neighboring lymphatic glands. 
Similar 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. 
Chills and febrile movement sometimes occur, with a feeling of weakness, and 
pain in the muscles and joints. There may be swelling or suppurative inflamma- 
tion of joints. The appearance of the patient, with sordes on the lips and tongue, 
delirious and unconscious, may sometimes remind one of typhoid fevei\ 
If the mucous membrane of the nose is also attacked, the patient complains of 
burning, dryness, and pain in the forehead; thin, purulent bloody masses are dis- 
charged, sometimes with a foul smell. The septum narium may be destroyed. 
Ulceration and inflammation may extend to the mucous membrane of the 
mouth and throat; the submaxillary lymphatic glands swell, and sometimes form 
abscesses. Disease of the laryngeal mucous membrane and lungs are known by 
pain, difficulty in swallowing, hoarseness, cough with fetid expectoration, and 
perhaps oedema of the glottis. There is usually loss of appetite and constipation; 
in the later stages, diarrhoea. 
The liver and spleen are sensitive to pressure, and often enlarged. In the 
urine, albumin often occurs; leucin and tyrosin have been found (Ninaus). Death 
usually occurs from exhaustion. 
In chronic glanders, the symptoms are nearly the same, but take a slower 
course, with frequent remissions and exacerbations. 
ZOONOSES. 400 
ZOONOSES. 
III. Anatomical Changes.—We have mentioned them briefly. Numerous 
abscesses are often found in the body, occupying the skin, muscles, mucous mem- 
branes, lungs, liver, and spleen. Hemorrhage in any organ may occur. The 
nodes vary from the size of a lentil to that of a man’s fist, and much larger. Bone 
and cartilage are often involved in the breaking down of the lumps. 
IV. Diagnosis.—There is often a difficulty in distinguishing glanders from 
pyaemia, and in chronic cases from syphilis or tuberculosis. 
A possible opportunity for infection is to be most carefully inquired into. The 
diagnosis may, perhaps, be made more easily and safely by means of Loffler's and 
Schiitz’s bacilli. 
V. Prognosis, in acute glanders, almost always unfavorable; in the chronic 
cases, there are fifty per cent of cures. 
VI. Treatment.—Chiefly confined to the case of external disease; incision of 
abscesses, carbolic dressing, and carbolic injections for the nose and throat. Food 
light, but strengthening; alcoholic drinks. Iodide of potash, strychnia, mercu- 
rials, etc., are not likely to be of use. For the rest, purely symptomatic treat- 
ment. 
4. Actinomycosis. 
Originally confined to the bovine race, it occasionally attacks man. It is 
caused by a radiating fungus, actinomyces (see Fig. 74), which forms firm grains, 
Fig. 74. 
Actinomyces grain from a bronchiole (cut lengthwise) of a cow’s lung; a, epithelium of the 
bronchial mucous membrane; b, epithelioid cells; c, round cells. In the middle, the radi- 
ating fungus. Magnified about 353 diameters. From Marchand. 
that can be crushed, and gives to the diseased products a peculiar character. The 
fungus is probably one of the moulds. Actinomycosis is probably the same in 
man and in cattle; the fungus has been successfully inoculated from the former to 
the latter. In man, most cases produce multiple abscesses and pyaemia, but internal 
organs, as the lungs, bronchi, intestine, pleurae, peritoneum, and others, may be 
invaded. Israel has lately compiled thirty-eight observations, and has endeav- 
ored to form a clinical outline of the disease. A few cases seem to be different 
from the rest; but the majority begin at the mouth, air-passages, and intestine. 
Actinomycosis of the bronchial mucous membrane may cause putrid bronchitis; 
that of the lungs constitutes chronic infiltration of the lung tissue, leading to 
cavities, destruction, especially pleurisy and metastatic abscesses in other organs. 
Peritonitis and metastatic disease often accompanies actinomycosis 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 
symptomatic. 
5. Hoof-and-Mouth Disease. 
Aplithce Epizooticce. 
I. Etiology.—The ox, sheep, and pig are most frequently attacked: it is rarer 
in the goat, horse, or the dog, or fowls. An acute febrile disease, leading to the 401 
ZOONOSES. 
formation of vesicles on the mucous membrane of the mouth, also between the 
toes, and on the teats; it is communicable by the contents of the vesicles, and by 
the urine, dung, blood, and milk. 
Several cases are reported in the human race, usually after eating raw or in- 
sufficiently cooked milk, or in milkers who touched the udders of diseased ani- 
mals, covered with vesicles, with sore hands. Chance may cause infection in 
other ways, e. g., by the slaver falling on one. Eating butter or cheese may 
communicate the disease. 
II. Symptoms.—The period of incubation lasts three or four days; then fever 
occurs, and yellow vesicles form on the mucous membrane of the lips and tongue, 
more rarely on the hard and soft palate, which burst in a few days and leave ero- 
sions of the mucous membrane. There is a burning and heat in the mouth; some- 
times great swelling and trouble in swallowing. At nearly the same time vesicles 
appear between the fingers and toes, and around the nails. A vesicular erup- 
tion has been seen on the breasts; in a few cases, a general exanthem. Signs 
of gastro-enteritis sometimes occur, which, in connection with fever, may destroy 
small children. In the middle of the second week, the vesicles dry up, form thin 
crusts, and fall off without scars. The disease usually ends in two or three 
weeks. 
III. Diagnosis, Prognosis, Treatment.—In diagnosis, the history is of special 
importance. Prognosis is good; death is rare. Milk from diseased animals must 
not be used at all unless it is thoroughly boiled; cuts must not be soiled with secre- 
tions or excretions from diseased animals. For treatment, wash or pencil the 
mouth with chlorate of potash (1 : 30); or lime-water, a teaspoonful every hour if 
diarrhoea is present. Vesicles on the extremities are to be rubbed with fat and 
covered with salicylated cotton. 
6. Rabies, Hydrophobia. 
I. Etiology.—This disease is chiefly confined to dogs, but also occurs in cats, 
horses, oxen, sheep, asses and mules, wolves, foxes, hyaenas, badgers, martens, 
and jackals. It does not occur spontaneously; it is almost always spread by the 
bite of mad animals. Saliva and blood contain the infectious material, while 
flesh and milk have repeatedly been eaten without injury. 
Hydrophobia in man is usually caused by the bite of dogs; less often 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 clothes. Some lesion 
(perhaps a very trifling one) appears to be always necessary to receive the poison. 
A spontaneous occurrence of the disease has been affirmed, even for man, until 
very recently, but all the evidence is untrustworthy. Communication from man 
to man is not certainly known. 
Klebs suspects that the poison resided in brown schizomycetes, which he de- 
monstrated in the salivary glands of Professor Hermann, who died of hydropho- 
bia in Prague. 
II. Symptoms.—The period of incubation varies very much, but usually lasts 
from fifteen to thirty days, and oftener longer. It is said that the period has 
been protracted, not merely to one or two years, but from ten to thirty years, but 
the latter belongs to the realm of fable. A period of six months is established 
with certainty. 
There is usually a short stage of premonitory symptoms before the outbreak 
of the disease, lasting from one to three 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 sometimes (?). 
Pain often radiates from the wound over the whole extremity to the spine. There 
is deep depression of mind; the patient grows pale, restless, loses appetite and 
sleep, and is usually tortured by unspeakable anxiety about the disease. The 
pupils are enlarged, the gaze is fierce, and symptoms of the spasmodic stage soon 
appear. 
Spasms of inspiration may be among the first of these symptoms. These are 
deep, sighing, or sobbing inspirations, during which the patient becomes cyanotic 
and is greatly distressed for breath, and feels suffocated. Spasms in the act of 
swallowing occur when the patient tries to eat or drink. The sight, or even the 
thought of drink, or the mention of it, may pi-oduce attacks of such spasms. The 
patient is unable to swallow his saliva, which is secreted in excess, and has to 402 
ZOONOSES. 
eject it from time to time. ' The tendency to spasms of breathing and swallowing 
increases; at last a mere draught of air, jostling of the bed, mental excitement, 
or bright lights produce it. The temperature rises to 39°, 40°, and higher. The 
pulse increases in frequency, up to 100-120. Albumin and sugar have been found 
in the urine. Constipation is common. 
Psychical changes gradually develop; delirium, hallucination, and distinct 
attacks of rage. The patient is maniacal, striking, spitting, reviling those about 
him; if the attendants use force, spasms occur in some extremities, or general 
convulsions, and many make snapping movements like those of biting. Such 
attacks may recur at short intervals. In their free intervals the patient is con- 
scious, and begs pardon for his violence. 
Death may occur suddenly in such attacks, which vary between one-half and 
three-quarters of an hour. Or they cease, giving place to symptoms of collapse 
and death, which usually comes within two to four days. 
III. Anatomical Changes.—There is hardly anything characteristic. Rigor 
mortis is usually well marked. Decomposition usually begins very soon. The 
blood is remarkably thin and dark. Liitkemuller has found the white blood- 
corpuscles increased, and numerous microcytes. 
In the membranes of the brain and spinal cord, there is usually oedema, and 
often hemorrhage; the latter also in the substance of brain and cord, and the 
neurilemma of peripheral nerves. The follicular apparatus of the back of the 
tongue and the fauces has been described as swollen. The mucous membrane of 
the stomach and intestine has ecchymoses in places. The spleen has been noticed 
as swollen. In the liver and kidneys, parenchymatous cloudiness and fatty 
changes have been seen. The peripheral lymphatic glands have been occasionally 
found enlarged and ecchymosed. 
IV. Diagnosis.—The disease is easily recognized, especially when the history 
is clear. Though many authors in recent times have denied the existence of the 
disease, and have declared that it is merely tetanus, there exists this distinction, 
that in tetanus there are no complete intermissions; nor are there mental dis- 
turbances. 
V. Prognosis.—Bad; very few cases of cure are claimed. 
VI. Treatment.—Let prophylaxis be the first step. High taxes should lessen 
the number of dogs kept; a muzzle should be worn by every dog, so constructed 
as completely to prevent his biting; when hydrophobia appears, let all dogs be 
shut up strictly for at least six months. 
If a man is bitten by a mad dog, let him at once suck the wound, and have it 
cauterized as soon as possible by the hot iron or caustic potash to destroy the 
poison. 
If the disease appears, give narcotics energetically. Among the best means is 
continued chloroform-narcosis, during which the spasms cease. The injection 
of morphia, clysters of chloral and curare are less certain. The other narcotic s 
are probably too weak. No specifics are known, however loudly some may be 
praised. The calm assurance of the physician is above all important. 
Pasteur reports that inoculation is a protective to the human species. INDEX. 
Abscess of spleen, 45 
Acetonsemia, 73 
Acetone, 72 
Acquired syphilis, 325 
Actinomycosis, 400 
Acute articular rheumatism, 153 
etiology, 153 
symptoms. 154 
anatomical changes, 156 
diagnosis and treatment, 157 
Adenie, 10 
Ansematosis, 19 
Angina herpetiea, 134 
membranacea. 381 
Anomalous gout, 63 
Anthrax, 397 
Aphthae epizooticte, 400 
Arthritis deformans, 96 
gonorrheal, 245 
uratica, 57 
Articular rheumatism, 
acute, 153 
chronic, 158 
muscular, 159 
Arthromeningitis crouposa, 156 
Asiatic cholera. 221 
etiology, 221 
symptoms, 224 
anatomical changes, 233 
diagnosis, 235 
treatment, 236 
Asphyctic cholera, 226 
Bacilli of anthrax, 397 
of cholera, 221 
of glanders, 399 
of leprosy, 370 
of relapsing fever, 162 
of syphilis, 327 
of tubercle, 276 
of typhoid fever, 191 
Bleeders, 37 
Boat belly, 261 
Bones, softening of, 94 
syphilis of, 342 
Bovine lymph, 146 
humanized, 146 
primary, 147 
retrovaccination, 147 
Brain, solitary tubercle of, 307 
syphilis of, 355 
Buboes in soft chancre, 255 
Bubou d’erablee, 256 
Cartilages, gout of, 62 
Cerebro-spinal meningitis, 
epidemic, 258 
simple, 264 
Chancre, hard, 325 
mixed, 336 
soft, 252 
Chancroid, 252 
etiology, 252 
symptoms, 253 
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, 312 
Clap, 239 
Cocci of erysipelas, 128 
of gonorrhoea, 241 
Coma diabeticum, 73 
Comma bacilli, 221 
Consumption, pulmonary, 265 
Cri hydrocephalique, 261 
Craniotabes, 86 
Croup, diphtheritic, 381 
non-diphtheritic, 383 
Diabetes insipidus, 82 
• etiology and symptoms, 82 
anatomical changes and treat- 
ment, 84 
Diabetes mellitus, 68 
etiology, 68 404 
INDEX. 
Diabetes mellitus, symptoms, 69 
anatomical changes, 78 
diagnosis, 79 
prognosis and treatment, 80 
Diabetic coma, 73, 77 
ocular changes, 75 
Dolichocephaly, 86 
Diphtheria. 371 
of the fauces, 372 
of the larynx, 381 
of the nose, 388 
of the oesophagus, 389 
of tiie stomach, 389 
of the intestines, 390 
of the gall-ducts, 390 
of the urinary passages, 390 
Diphtheritic croup, 381 
etiology, 381 
anatomical changes, 382 
symptoms, 383 
diagnosis, 386 
treatment, 387 
Dysentery, 215 
etiology, 215 
symptoms, 216 
anatomical changes, 219 
diagnosis, 220 
treatment, 221 
Elephantiasis Graecorum, 368 
Endocardium, syphilis of, 355 
Enlargement of the spleen, 40 
Ephemeral infectious fever, 190 
Epidemic cerebro-spinal meningitis, 
258 
parotitis, 187 
Epididymis, syphilis of, 355 
Epididymitis, 243 
Equinola, 146 
Erysipelas, 124 
cocci, 128 
Essential pernicious anaemia, 19 
Exanthematic 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 
Fievre bilieuse haematurique, 175 
Garrod’s thread test, 59 
General miliary tuberculosis, 307 
etiology, 307 
anatomical changes, 309 
symptoms, 310 
General miliary tuberculosis, diagnosis, 
313 
treatment, 313 
Glanders, 398 
Glycosuria, 81 
Gonococci, 241 
Gonorrhoea, acute, 239 
etiology, 239 
symptoms, 240 
anatomical changes, 248 
diagnosis, 248 
treatment, 249 
Gonorrhoea, chronic, 246 
Gout, 57 
etiology, 57 
symptoms, 58 
anatomical changes, 64 
diagnosis, 66 
prognosis and treatment, 67 
Haematoblasts, 4 
Haematophilia, 37 
Haemophilia, 37 
Hard chancre, 328 
Hay fever, 185 
Heart muscle, solitary tubercle of, 307 
syphilis of, 355 
Heller’s test, 71 
Hereditary syphilis, 363 
Herpes facialis, 130 
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 anaemia, 19 
Infection spleen, 41 
Influenza, 184 
Inosituria, 72 
Intermittent fever, 167 
latent, 173 
pernicious, 174 
Intestinal diphtheria, 390 
phthisis, 299 
syphilis, 351 
Joints, deforming inflammation of, 96 
syphilis of, 342 
Kidney, syphilis of, 354 
tubercles of, 306 
Lactosuria, 82 
Laryngeal diphtheria, 381 
herpes, 135 
phthisis, 294 
syphilis, 345 
Laryngitis phlyctaenulosa, 135 
Larynx, diphtheria of, 381 
phthisis of, 294 INDEX. 
405 
Larynx, syphilis of, 345 
Latent gout, 63 
intermittent fever, 173 
Leprosy, 368 
bacilli, 370 
Leucocythaemia, 1 
Leukaemia, 1 
etiology, 1 
symptoms, 2 
anatomical changes, 7 
diagnosis, 9 
prognosis and treatment, 10 
Levulose, 72 
Lipaemia, 53, 76 
Liver, solitary tubercle of, 307 
syphilis, 351 * 
Lues venerea, 324 
Lungs, syphilis of, 348 
tuberculosis of, 265 
Lung-stones, 279 
Lymphosarcoma, 10 
Malaria, 167 
etiology, 167 
symptoms, 169 
anatomical changes, 175 
treatment, 176 
Maliasmus, 398 
Malignant lymphoma, 10 
pustule, 397 
Malum coxae senile, 96 
Mamma, syphilis of, 350 
Marsh fever, 167 
Measles, 99 
etiology, 99 
symptoms and anatomical changes, 
100 
diagnosis, 105 
treatment, 106 
Melanaemia, 11 
Melanoleukaemia, 4 
Mellituria, 81 
Meningitis, epidemic cerebro-spinal,258 
etiology, 258 
anatomical changes, 259 
symptoms, 260 
diagnosis and treatment, 263 
Meningitis, simple cerebro-spinal, 264 
tubercular, 314 
Meningotyphoid, 202 
Microcytes, 4 
Miliary tuberculosis, 307 
Mixed chancre, 336' 
Moore’s test, 71 
Morbus maculosus Werlhofii, 28 
Mumps, 187 
orchitis in, 189 
Muscles, syphilis of, 341 
Muscular rheumatism, 159 
Myoidema, 282 
Nasal diphtheria, 388 
Nephrophthisis, 302 
Non-diphtheritic croup, 383 
Nose, diphtheria of, 388 
Nose, syphilis of, 343 
tuberculosis of, 297 
Obesity, 51 
etiology, 51 
anatomical changes, 52 
symptoms, 53 
diagnosis and treatment, 55 
(Esophagus, diphtheria of, 389 
syphilis of, 351 
tuberculosis of, 299 
Osteomalacia, 94 
Osteopsatyrosis, 343 
Ovinola, 145 
Ozaena syphilitica, 344 
Paraphimosis, 243 
Peliosis rheumatica, 27 
Perisplenitis, 45 
Peritonitis, tubercular, 317 
Pertussis, 178 
Petechial fever, 118 
Pharyngeal diphtheria, 372 
etiology, 372 
symptoms, 373 
anatomical changes, 378 
diagnosis and treatment, 380 
Pharynx, diphtheria of, 372 
syphilis of, 350 
Phimosis, 243 
Phthisis laryngea, 294 
pulmonary, 265 
etiology, 265 
symptoms, 268 
anatomical changes, 287 
diagnosis, 289 
prognosis, 290 
treatment, 291 
enterica, 299 
pharyngea, 297 
Plague, 176 
Pneumonoconiosis anthracotica, 281 
Pneumotyphoid, 201 
Poikilocytosis, 4, 10, 15, 22 
Polyarthritis, acute, 153 
chronic, 158 
Polysarcia, 51 
Polyuria, 82 
Progressive pernicious anaemia, 19 
etiology, 19 
symptoms, 19 
anatomical changes, 24 
diagnosis, 26 
prognosis and treatment, 27 
Prostatitis, gonorrhoeal, 244 
Pseudoleukaemia, 10 
Purpura hemorrhagica, 28 
rheumatica, 27 
simplex, 27 
Rabies, 401 
Rachitis, 85 
Rectum, syphilis of, 351 
tuberculosis of, 302 
Recurrent typhus, 159 406 
INDEX. 
Relapsing fever, 159 
etiology, 159 
anatomical changes, 161 
symptoms, 162 
diagnosis and treatment, 167 
spirilli of, 163 
Remittent fever, 175 
Renal phthisis, 302 
Renotyphoid. 202 
Retinitis leukaemica, 5 
Rheumatism, acute articular, 153 
chronic articular, 158 
muscular, 159 
Rice-water stools, 226 
Rickets, 85 
etiology, 85 
symptoms, 86 
anatomical changes, 91 
diagnosis and treatment, 93 
Roetheln, 116 
Rubeola, 116 
Russian clap, 242 
Scarlet fever, 107 
etiology, 107 
symptoms, 108 
anatomical changes, 115 
diagnosis and treatment, 116 
Scorbutus, 31 
Scrofula, 318 
etiology, 318 
symptoms, 319 
anatomical changes, 322 
diagnosis and treatment, 322 
Scurvy, 31 
etiology, 31 
symptoms, 32 
anatomical changes, 35 
diagnosis and treatment, 36 
Sheep-pox, 145 
Small-pox, 136 
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 
Spirochgete Obermeieri, 163 
Spleen, diseases of, 40 
abscess, 45 
acute enlai-gement 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 
Splenitis, 45 
Sputum, examination of, 278 
Stomach, diphtheria of, 389 
syphilis of, 351 
tuberculosis of, 299 
Subsultus tendinum, 210 
Sugar in the urine, tests for, 71 
Summer catarrh, 185 
Sweating sickness, 135 
Syphilis, acquired, in the first and sec- 
ond stages, 325 
etiology, 325 
symptoms, 327 
diagnosis, 336 
prognosis, 337 
treatment, 338 
bacilli, 327 
tertiary, of the skin, muscles, fas- 
ciae, etc., 341 
of the digestive tract, 350 
of the kidneys, 354 
of the larynx, 345 
of the liver, 351 
of the lungs, 348 
of the nose, 343 
of the spleen, 353 
of the trachea and bronchi, 348 
Tabes mesenterica, 320 
Thorax, phthisical, 270 
rachitic, 88 
Tophi, 60 
Trichina, 392 
Trichinosis, 390 
etiology, 390 
anatomical changes, 392 
symptoms, 394 
prognosis and treatment, 396 
Trommer’s test, 71 
Tubercle bacilli, 276 
Tubercular meningitis, 314 
peritonitis, 315 
Tuberculosis, 265 
miliaris disseminata, 307 
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 
Typhus fever, 118 
etiology, 118 
anatomical changes, 119 
symptoms, 120 
diagnosis, 123 
treatment, 124 
Ulcus durum, 328 
molle, 252 
Urethritis blennorrhoica, 239 
Urinary organs, chronic tuberculosis 
of, 302 
diphtheria of, 390 INDEX. 
407 
Vaccination, 145 
Vaccine syphilis, 326 
Vaccinola, 146 
Varicella, 150 
Variola, 136 
Variolation, 145 
Visceral gout, 63 
Wandering spleen, 49 
Whooping-cough, 178 
Whooping-cough, etiology, 178 
symptoms, 179 
anatomical changes, 182 
diagnosis and treatment, 183 
Yellow fever, 237 
Zona, 131 
Zoonoses, 390