neck are stiff and movement causes an increase of the pain. The temperature
is not characteristic, it may not exceed 102Â° F. (38.9Â° C.) but in marked
infections it may reach 104Â° to 106Â° F. (40Â° to 41.1Â° C.) and may ascend
even higher just before death. Remissions are not infrequent. The pulse
in adults is at first not very rapid and is of good strength. Later it becomes
faster and weaker. In children it is usually rapid from the outset. In
certain instances the disease is characterized by a pulse of not over 60 or 70.
In the absence of pulmonary complications the respirations are not much
accelerated. Cheyne-Stokes respiration is sometimes observed.
The symptoms due to the nervous system are marked and of early appear-
ance. The skin is hyperaesthetic and the muscular rigidity increases as the
disease progresses, spasm of the neck muscles draws the head back and opistho-
tonos may be present; clonic spasms may occur especially in children, in whom
the onset may be marked by a convulsion. Strabismus, nystagmus and
facial contractions are common. As the exudate increases the symptoms of
pressure paralysis succeed those of irritation and there are paralyses of the
muscles of the face with ptosis, pupillary inequality and rarely paralysis of the
muscles of the body and limbs. Of symptoms referable to the special senses
photophobia, diplopia and auditory distiirbances, especially intolerance of
sound, are often preseni.
Delirium is an early symptom and may be violent. The increase in intra-
cranial pressure later results n, stupor and finally in coma.
The skin manifestations arc mportant although the eruption is by no means
constantly present. Herpes labialis is very frequent and herpetic eruptions
may appear elsewhere upon the face as well as upon the body and limbs.
The characteristic rash of the disease is petechial and often general. The
number of spots varies greatl}', in some instances only a few being noted,
while in others they are very numerous. They do not disappear on pressure.
98 THE INFECTIOUS DISEASES.
Other rashes such as erythema, urticaria, ecthyma, erythema nodosum,
pemphigus, and spots resembhng those of enteric fever may occur. Cutaneous
gangrene has been noted.
The tongue is at first moist and coated, later it may become dry; distressing
vomitin^ may persist throughout the disease. The bowels are usually con-
stipated but at times a diarrhoea may be present at the invasion.
The urine is usually scanty, high colored and contains albumin. At times
it is increased in quantity and contains glucose as a result of the pressure of
the exudate upon the cerebral centers.
Leucocytosis is a constant symptom and is often persistent.
Kernig's sign is constantly present as in all other conditions in which there
is inflammation of the spinal meninges. It is obtained by placing the patient
in a sitting position with the thighs flexed at the hips and the legs partly flexed
at the knees. The observer then attempts to extend the leg at the knee which
will be found impossible on account of the resistance of the flexor muscles.
If the thigh is not flexed upon the abdomen the leg can be straightened. This
phenomenon is explained upon the ground that in meningeal inflammation
the spinal nerve roots become irritable and the flexion of the thighs at the
hips when the patient is sitting tends to stretch the lumbar and sacral roots
and increase their irritability.
Babinski's reflex, a turning up of the toes, especially the great toe, conse-
quent upon tickling the sole, is not constant.
The course of cerebrospinal fever is very variable; death may occur within
a few hours or the disease may be prolonged for months. Fatal cases usually
die within the first week. If the patient survives for five or more days im-
provement may be expected, the temperature falls, the nervous symptoms
gradually clear and convalescence becomes established. This period is usually
long. Relapses are not uncommon.
The malignant form of the disease is very sudden in its invasion and while
there may be only slight rise in temperature the headache and nervous symp-
toms are pronounced, collapse with feeble and slow pulse and labored respi-
ration ensues to be followed by death, sometimes within 24 hours. A hsemor-
rhagic. eruption is usually present. Such cases are often seen at the beginning
of an epidemic.
A mild form of the disease sometimes occurs in which the presence of an
epidemic gives the only clue to diagnosis.
The abortive form is evidenced by pronounced and severe symptoms at its
onset; these cease suddenly and an early convalescence is established.
The intermittent form is characterized by a temperature resembling that of
pyaemia which exhibits remissions daily or every other day.
The chronic form. This designation is applied to a type of the disease
in which the course may be prolonged for several months. The patient suf-
CEREBEOSPINAL FEVER. 99
fers from headache, digestive irritability, marked emaciation and exhaustion
and remissions of the fever.
Complications. Of these pneumonia is one of the most frequent and it
may be difficult to determine whether it or the meningeal inflammation is the
primary disease. In the presence of an epidemic the problem is more simple
than at other times and when the headache, pain and stiffness in the back,
and nervous symptoms precede other manifestations the chances are in
favor of meningitis. Pleurisy, bronchitis, endocarditis and parotid inflam-
mation may occur. Arthritis is a common complication in certain epidem-
ics. The affection is usually multiple and the effusion may be either serous
The sequela of cerebrospinal fever are numerous and "often serious. Those
referable to the motor nervous system are facial palsy of varying extent and
paralyses of the limbs; these may be permanent but are usually temporary
only. Sequelae referable to the organs of special sense are optic neiu"itis
resulting in blindness, choroido-intis and keratitis; labyrinthine inflam-
mation resulting in deafness, otitis media and its complications. Speech
disturbances may occiu: and obstinate headache and muscular pains have been
noted. Chronic hydrocephalus, abscess of the brain and mental weakness
have deen observed.
The diagnosis during epidemics is usually not difficult but the recognition
of sporadic cases, especially those of atypical course is sometimes far from
easy. The diagnostic symptoms which are present early in the disease are
the headache, stiffness, with retraction of the head, of the muscles of the
neck and back, tremors and mental distin-bance, especially delirium. Pneu-
monia may be mistaken for meningitis but here we have a diminution of the
urinary chlorides, an absence of Kernig's sign, a rapid pulse and a preponder-
ance of the pulmonary symptoms over those referable to the nervous system.
With regard to the general differentiation of this disease, the presence of
Kernig's sign is an important point and the result of lumbar puncture should
usually confirm or disprove the diagnosis. This operation is simple, harmless
and needs no anaesthesia beyond that obtainable by means of the ethyl chloride
or aether spray, or at most a few breaths of chloroform. The patient should
lie upon the right side with knees drawn up and the left shoulder turned toward
the front. An aspirating syringe is used, the needle of which is introduced
one centimeter to one side of the median line and midway between the third
and fourth or the fourth and fifth lumbar vertebrae below the spinous process,
the thumb being placed as a guide between the spinous processes. The
needle should be directed sUghtly upward and inward, and at a depth of about
two centimeters in infants and from foiur to six in adults, should enter the
canal. The syringe now being detached from the needle the fluid is allowed
to flow into a sterile test tube. From i| to 4 drachms (6.0 to 16.0) are neces-
lOO THE INFECTIOUS DISEASES.
sary for chemical, microscopical and bacteriological examination. The fluid in
epidemic meningitis is usually turbid and may contain pus or blood; that in
tuberculous meningitis is clear in most instances. The meningococcus is
often present in the fluid of epidemic meningitis in considerable numbers.
The prognosis varies in different epidemics from 20 to 75 percent. The
mortality is very high in the prolonged cases, in yoimg children and in the
aged. The initial symptoms give no index of the probable subsequent course
of the disease and while a mild invasion may be followed by grave symp-
toms a severe onset may be succeeded by a rapid amelioration. Convales-
cence may be interrupted by recrudescences or relapses.
Treatment. Much in the way of prevention may be accomplished by the
establishment of proper ventilation, drainage and general sanitation.
In private practice the patient should be isolated, in order to secure the nec-
essary quiet as weU as to prevent contagion, in a properly ventilated room
which need not be darkened since bandaging the eyes accomplishes the same
The old method of treatment by blood-letting is seldom employed at present
but the pain may be relieved in robust patients by the application of wet
cups to the back of the neck; the use of the ice helmet and of ice bags ap-
pHed along the course of the spinal cord is to be recommended, and while
blistering is unnecessary, touching the skin of the nape of the neck with the
actual cauter}' may be beneficial. Elevating the head of the bed often makes
the patient more comfortable.
The plan of treatment by means of hot bathing as advocated by Aufrecht
is said to accomplish exceedingly good results. A hot bath at 104Â° F. (40Â° C),
lasting from 15 to 20 minutes is given once or twice daily or even oftener.
An ice bag is kept upon the patient's head and stimulants such as alcohol,
ammonia, etc., are given as indicated. While the temperature, muscular
rigidity and emesis are not markedly influenced by this treatment, it is asserted
that bathing after this fashion relieves the pain, lessens the restlessness and
delirium and may restore consciousness. Such complications as endocarditis
do not necessitate the intermission of this treatment. It may be safely stated
with regard to the hot bath method, that it does no harm, may benefit the
patient and may exert a favorable influence upon the course of the infection.
Lumbar punctiure, with or without the injection of antiseptic fluids, has
been employed in treatment as well as in diagnosis, by many cUnicians. The
opinions as to its efficacy differ to a marked degree. It may be asserted,
however, that, even though the procedure may not be curative, it does relieve
the symptoms due to pressiue and is worthy of employment for this reason.
The technique of the operation has already been described (p. 99). In
instances where marked pressure symptoms are present from 5 to 15 drachms
(20.0 to 60.0) may be withdrawn and the procedure repeated if necessary.
CEREBROSPINAL FEVER. lOI
Where only slight evidence of pressure is manifest not more than 5 to 7J
drachms (20.0 to 30.0) should be withdrawn.
Of the solutions used for intraspinal injection, following the withdrawal
of fluid by lumbar puncture, i percent, lysol is the most common. From
two to three drachms (8.0 to 12.0) have been injected with var}dng results
in the hands of different clinicians. Mercury oxycyanide solution has also
been employed. This form of treatment, while it may do no harm, has, tak-
ing everything into consideration, given no very remarkable results.
The hot bath treatment and that by lumbar puncture may be employed
in connection with one another.
The fact that there is a marked antagonism between the meningococcus
and the Klebs-Loffler baciUus has suggested the employment of diphtheria
antitoxin in the treatment of meningitis but unfortunately the results obtained
either by hypodermatic or intraspinal injections of antidiphtheritic serum
have not been sufficiently good to establish this treatment upon a firm basis.
The subcutaneous injection of mercury bichloride solution along the course
of the spinal cord has been recommended by several authors. The adult
dose is ^ of a grain (0.0 1) and that for children from yyo to ^s" of a grain
(0.0005 to 0.005). The injections are weU borne and may be repeated while
the temperature, pain and muscular stiffness persist. Angyan, who has
reported at length upon this form of treatment, while not asserting that it
influences the length of the disease, considers that by its use the symptoms
are favorably affected.
With regard to the general management of epidemic cerebrospinal mening-
itis and the relief of symptoms the following points may be given. The
bowels should be kept freely open throughout the disease by means of calomel
given in divided doses, by salines or by enemata. The patient should be
allowed plenty of water to drink which will increase the elimination of the
toxins through the kidneys. In instances of urinary retention the use of the
catheter may become necessary.
The nose and throat which are often inflamed should be sprayed and
irrigated with mild alkaline solutions and the frequent use of a mouth wash
wiU lessen the tendency to dryness of the tongue. In instances where there is
dysphagia feeding by means of the stomach or nasal tube or by rectum should
For the vomiting the patient should be given bits of cracked ice to suck,
cold should be applied to the epigastrium and feeding should be infrequent
until this symptom is under control. In obstinate cases the use of morphine
hypodermaticaUy mav become imperative. Vomiting due to pressure upon
the medulla may be relieved by lumbar puncture.
The nervous symptoms necessitate the employment of various analgesics
and sedatives. Cool packs and tepid baths, to which mustard may be added.
I02 THE INFECTIOUS DISEASES.
often, in the milder cases lessen the tendency to sensory, motor and mental
excitability and may induce sleep. Antipyrine is often effectual in checking
the headache and general hyperaesthesia and is also useful in lowering the
temperature and relieving the mental excitability. While not likely to cause
cardiac Repression, the drug should be given with care. Acetphenetidine may
also be employed. When these two drugs fail to control the nervous symp-
toms we may have recoiirse to codeine or morphine. The bromides likewise
may be administered in this connection. For the convulsions chloral should
be given per rectum and inhalations of chloroform may be prescribed. Where
these fail hypodermatic injections of morphine should be given.
In the later stages where cardiac weakness is pronounced free stimulation
by means of alcohol, ammonia and, in cases of collapse, by hypodermatic injec-
tions of camphor in oil, are indicated. Heart weakness may also be combated
by means of high hot saline irrigations given fer rectum and by hypodermato-
clysis with normal saline solution. The former procedure has the addi-
tional advantage of assisting in the elimination of toxins through the kidneys,
it being a vigorous diuretic.
Various other drugs have enjoyed, probably undeservedly, a vogue in the
treatment of this disease. Among them may be mentioned ergot, quinine,
physostigma and belladonna.
In chronic cases and in those which are left with meningeal thickenings
potassium iodide or the syrup of hydriodic acid should be given with the
intent to induce absorption.
The complications and sequelae should be treated as when occurring as a
result of other causes.
The importance of maintaining nutrition cannot be over-rated. During
the acute stage the diet should consist of milk, broths, gruels and other fluids;
later semi-solids, to be followed by ordinary diet, may be allowed. The use of
the stomach tube may be necessary.
Synonym. St. Anthony's Fire.
Definition. An acute febrile contagious disease characterized by intense
local inflammation of the skin, a remittent temperature and a tendency to
etiology. This disease is common, often endemic, and from time to
time epidemic. It is most common in the spring months and is very likely
to break out in old and improperly kept hospitals and institutions; it may
occur, however, under the best sanitary conditions. Poor general condition,
alcoholism and chronic diseases predispose to its incidence and certain indi-
viduals seem more prone to acquire the infection. One attack does not
confer immunity, on the contrary recurrences are frequent. Women, ^05/-
partum, and the subjects of recent surgical operations, even such procedures
as cupping, leeching and vaccination, are especially liable to acquire the
The contagium, while not very active, may be transmitted by contact with
a third person and by fomites, bedding, furniture, etc. While a solution of
the continuity of the skin would seem to be a necessary antecedent to infection,
idiopathic cases do occur in which no such manifestation is discoverable;
in such, however, it is impossible to state that a microscopical lesion has not
existed, although the possibihty that the contagium may reach the blood
stream by means of the respiratory or the digestive tracts must be considered.
The specific cause of erysipelas is a bacterium, the streptococcus erysipelatis,
one of the micro-organisms of the streptococcus pyogenes group.
Pathology. The inflammatory redness of the skin in erysipelas does
not persist post mortem but oedema and abscesses or blebs, if they have
occurred, are left behind. Microscopic examination reveals the presence
of the streptococci in the lymphatics and lymph spaces at the margin of the
inflamed area; they may be demonstrated in the lymph vessels of the structures
beyond the affected tissues as well. Associated lesions are metastatic abscesses
in the various organs and haemorrhagic infarcts of the lungs, kidneys or spleen.
Secondary septic pleurisy, pericarditis or endocarditis may be present. Acute
nephritis may be found; meningitis and pneumonia are rare.
Symptoms. The variety of erysipelas which usually confronts the physician
is that which occurs without previous discoverable lesion and most often
involves the head and face. The incubation period is given by various authori-
ties as being from i to 14 days. The onset of the disease is usually marked
by one or more chills, general malaise and anorexia, followed by a rise of
temperature. If the point at which infection has taken place is discoverable
it becomes red, a reddened, burning spot appearing usually upon the bridge
of the nose or upon the chin. This rapidly increases in size, becoming elevated
with a distinctly palpable margin, smooth, brawny, oedematous and hot to
the touch. The skin feels tense to the patient and the inflammation spreads
rapidly toward the forehead and ears, closing the eyes, thickening the lips and
ears and distorting the features. Blebs form upon the ears and eyelids;
these contain serum; the neck is rarely involved but the cervical glands are
swollen and there is marked leucocytosis. In the severe types deep abscesses
may form. The inflammation as it extends gradually diminishes in the parts
first affected, lasting about four days in one spot. If its progress becomes
limited the temperature falls by crisis and the symptoms disappear. Recur-
rences are not rare. With the fever, the pulse is rapid, there are headache
and sometimes cerebral symptoms, the constitutional manifestations being
due to the toxaemia resulting from the growth of the bacteria in the organism.
;I04 THE INrECTIOUS DISEASES.
Severe infections which are not uncommonly met in aged, debilitated and
alcoholic patients are characterized by marked prostration, cerebral symp-
toms and the appearance of the so-called "typhoid state" in which death
The mucous membranes of the mouth, pharynx and larynx may be involved
by extension from the skin, and laryngeal oedema may occur. Albuminuria
is common and haematuria has been observed.
Protracted cases may be met in which the inflammation wanders from
one part to another, gradually involving the whole body.
Complications are not common although such conditions as septic inflam-
mations of the pleura, pericardium and endocardium, bronchitis, pneimionia
and nephritis do occur.
Meningitis is very rare, septicaemia and pyaemia are more often seen.
The diagnosis is usually easy, the constitutional and local manifestations
being quite characteristic.
The prognosis in robust persons is good, the debilitated, those addicted
to alcohol, infants with erysipelas due to infection at the imibilicus, and the
aged furnishing the great majority of the fatahties.
Treatment. Isolation is a necessity, especially in hospitals. Siurgeons
and those engaged in obstetrical practice should not attend cases of erysipelas.
Frequent baths with boric acid solution (5 percent.) will remove the desqua-
mating epidermis and the bed and body linen should be changed at least
The patient should be kept in bed upon a liquid diet and the channels of
elimination kept freely opened by means of plenty of fluids to drink and laxatives
when necessary. If there is headache and severe general pain such anal-
gesics as antipyrine salicylate, gr. x (0.66) or acetphenetidine, gr. x (0.66) may
be prescribed. The cerebral symptoms if present may be controlled by cool
or tepid sponge baths, by the bromides or by morphine hypodermatically.
In feeble patients stimulation by alcohol and strychnine may be employed as
It is doubtful if internal medication can influence the infection in any way
but the tincture of iron chloride is prescribed by many in the hope that in some
way it exerts a specific action. A drachm (4.0) every three hours may be
given but a smaller dose â€” 10 drops (0.66) â€” will probably do the work quite
Injections of antiseptic solutions into the skin just beyond the margin of the
inflammatory area have been practised and seem to have a rational basis
for their employment. Two percent, phenol solution or 1-4000 mercury
bichloride solution may be used.
Of local applications that most popular at present is an ointment or solu-
tion of ichthyol of xo percent, strength, applied upon gauze and renewed
ACUTE ARTICULAR RHEUMATISM. 10$
several times daily. An ointment containing i part of phenol, lo parts
of ichthyol and 20 parts of lanoline is also recommended. Moist dressings
of I percent, phenol, i to 1000 mercury bichloride, equal parts of ichthyol,
glycerine and water, i to 1000 potassium permanganate and dusting with
equal parts of bismuth benzoate and starch have been suggested.
In the umbilical infection of the newborn, ichthyol in 10 percent, solution
or ointment or an ointment of -gV part of mercury bichloride, 10 parts of
cerate of lead subacetate and 40 parts of vaseline may be applied.
The use of Crede's ointment shotdd be accompanied by good results. It
should be well rubbed into the skin just beyond the inflammation.
The suggestion to lightly scarify the part before applying moist antiseptic
dressings would seem reasonable since by this means the germicide is able to
come into closer contact with the infective micro-organisms in the tissues.
Various observers have employed injections of antistreptococcus serum;
the results reported have in many instances been favorable and it is quite
possible that further experimentation with this treatment may establish it
as a routine method. This form of treatment does not seem to shorten the
disease but the injection of 5 drachms (20.0) of the serum in one or two doses
is said to lessen the severity of the symptoms and to cause a disappearance
of the albuminiuria.
The diet during the febrile stage should be of fluids only and as highly
nutritious as possible in order to maintain the patient's strength and powers
During convalescence the dietary should stiU be carefufly regulated and the
administration of tonics, such as strychnine, iron and quinine is strongly
ACUTE ARTICULAR RHEUMATISM.
Synonyms. Rheumatic Fever; Inflammatory Rheumatism; Acute Rheu-
Definition. An acute infectious febrile disease characterized by inflam-
mation of one or more of the joints.
-Etiology. The disease is most common during the cold and damp
months and in young adults, especially those of low vitality and whose occupa-
tions expose them to the inclemencies of weather. Extremes of cold are less
likely to predispose to the disease than a moderately low temperature accom-
panied by moisture. An hereditary tendency to the disease has been noted.