ioiÂ° to 104Â° F. (38.4Â° to 40Â° C.) â€” severe headache and marked bodily pains;
nausea and vomiting, together with the other symptoms usual at the beginning
of an acute infection, and very pronounced prostration may be present. The
fever lasts from two to six days and may be of remittent or intermittent type;
in certain instances the elevation of the temperature may be the only symptom
and rarely the patient may exhibit a continuously high temperature lasting
for several weeks and which closely reseml^les that of enteric fever; the pulse
is rapid and may, in severe types of the disease and in the aged, become feeble.
During the course of the disease various skin eruptions, erythematous or even
purpuric, may appear and simple pharyngitis may be present. As the tem-
perature approaches the normal at the termination of the disease, sweating
may occur and the symptoms gradually subside.
The disease manifests itself in one of several types which are very prone to
merge into one another.
a. The catarrhal type is characterized by symptoms referable to the mucous
membranes of the respiratory tract and conjunctivae. At the onset the symp-
toms of coryza with sneezing, nasal discharge, a feeling of fulness in the head,
sore throat, hoarseness and conjunctival injection, are present. In the milder
instances of the disease there may be no further symptom.s, but more often
there is bronchial inflammation, with cough, at first dry, later with muco-
purulent and sometimes very copious expectoration; rarely the sputum is
dark and blood-stained. Various pulmonary complications may ensue.
h. The nervous type begins with severe headache, pains in the bones and joints
and extreme depression and prostration; rarely there may be convulsions.
In some instances there are symptoms resembling those of meningitis, such as
photophobia, hypersensitiveness to sounds, pain in the back of the head and
stiffness of the neck. Delirium may be present. The nervous symptoms
40 THE INFECTIOUS DISEASES.
gradually subside after a few days but during convalescence there is a marked
tendency to mental depression and neuralgia in various parts of the body.
c. The gastro-ititestinal type is evidenced by nausea and vomiting at the
invasion, or abdominal pain, distention and diarrhoea; the symptoms may be
so severe as to suggest appendicitis or peritonitis. Jaundice and splenic
enlargement may be present.
Complications and sequelae. Of these one of the most common and
serious is pneumonia due to the influenza bacillus alone or to a mixed
infection. It is rarely if ever of the lobar form^ usually being catarrhal or
lobular, and is frequently fatal. Pleurisy is not a common complication but
when it occurs is likely to become purulent.
Bronchiectases may occur. Circulatory complications may appear. Peri-
carditis is rare; less so is endocarditis which may be of malignant type. In a
few instances the influenza bacillus has been grown from the vegetations.
Myocarditis may occur and functional cardiac disorders, such as palpitation,
irregular heart action, bradycardia and tachycardia are frequently met.
Sudden cardiac failure may cause death. Thrombosis and phlebitis have
Peritonitis, cholecystitis and septicaemia are rare sequelae; nephritis and
orchitis have been noted.
Complications referable to the nervous system are not infrequent and
among them may be mentioned encephalitis, meningitis â€” the bacilli having
been demonstrated in the fluid withdrawn by lumbar puncture â€” cerebral
abscess, myelitis, neuritis of various types, and paralyses. Mental disorders
such as melancholia or even dementia may occur. Optic neuritis and iritis
have been described; otitis media and dizziness due to affection of the labyrinth
are possible consequences.
It is of the utmost importance to keep in mind the fact that an attack of
influenza is very prone to render any latent disease active and to increase the
intensity of any slight organic afJection that may be present.
The diagnosis of influenza during an epidemic is usually easy and may be
confirmed when doubtful by the detection of the causative bacillus in the
The prognosis is usually good. Death may take place from the complica-
tions, particularly from pneumonia.
Treatment. The prevention consists in the avoidance of exposure to
cold and wet during epidemics and of association with patients suffering
from the disease. Isolation of patients should be carried out whenever prac-
ticable and the sputum and nasal discharges should be disinfected and des-
troyed. When influenza is prevalent it is well to practise spraying of the
oral and nasal cavities with some mild antiseptic such as liquor antisepticus.
So long a? we are ignorant of any specific agent which will abort an attack
or mitigate the severity of the infection we must formulate a treatment for
each type of the disease.
In treating the respiratory form of epidemic influenza we should first
bear in mind the fact that the prostration, fever and systemic disturbance
are out of all proportion to the extent or severity of the disease as evidenced
by physical signs; secondly, that, granted a moderate involvement of respiratory
area or even a disease stationary so far as extent of tissue is involved, this is no
guarantee as to prognosis in an individual case. The logical deduction
from this observation is that we are dealing with an infectious process in
which prostration is marked and in which supporting treatment is urgently
needed. The patient should be kept in bed, while the fever persists, in a room
of equable temperature, not too hot, and his diet should be of fluids and as
nutritious as possible. The bowels should be opened by means of repeated
fractional doses of calomel followed by a saline. If the patient's temperature
must, in the physician's opinion, be lowered this may be effectually accom-
plished by means of the application of an ice water coil placed over the heart
or by sponging with cool water. In most instances the fever may be allowed
to run its course undisturbed. Antipyretic drugs, for their influence upon
this symptom need not be given. The use of morphine for the pain is likely
to interfere with nutrition, dam up the excreta and leave the patient in worse
condition than before its employment.
The treatment of the respiratory system consists first in relieving the irri-
tation of the nose and throat by means of a spray of ten drops (0.66) of eucal-
yptol, 10 grains (0.66) of menthol to an ounce (30.0) of albolene. One of the
alkahne antiseptic sprays should be first used in order to dissolve the accu-
mulations of mucus as much as possible and render the mucous membranes
clean in order that the full soothing effect of the oily spray may be evidenced.
The bronchitis necessitates the administration of an expectorant which
does not distiu"b the heart. Here we may give ammonium carbonate in
doses of from 5 to 10 grains (0.33-0.66) and repeated as frequently as the
condition may require, each dose to be given in two ounces (60.0) of milk.
The exhibition of this drug will relieve unnecessary coughing, will remove
much of the oppression of the chest, will fortify the heart and has the single
disadvantage of being prone to disturb the stomach after five or six days.
If the ammonium carbonate is not well borne, strychnine, either as good-
sized doses of tincture of nux vomica or strychnine sulphate or nitrate, should
be administered. With the strychnine not only is a stimulant effect exerted
on the heart muscle and respiratory center, but also an improvement in
nutrition resulting from the drug's action on the spinal cord. In administering
alcohol the previous habits of the patient and the urgency of the symptoms
must be considered; in most instances the patient is better without it.
When the physical signs and clinical symptoms indicate that pneumonia
42 THE INPECTIOUS DISEASES.
is present the patient should be bled from the less into the greater circulation
by the nitrites, preferably glyceryl nitrate in doses of y^ to -5V of a grain
(0.0006 to 0.0012) â€” and increasing and frequently repeated doses of strychnine
must be administered until convalescence takes place. In slowly resolving
pneumonias and for an obstinate bronchitis which persists into convalescence,,
no drug yields better results than creosote carbonate, 30 or 40 drops (2.0-2.66)
given in sherry several times a day.
In order to eliminate the toxins of the disease the skin, bowels and kidneys
must be kept active. The pains may be treated by the means described below.
In the gastro-intestinal form of epidemic influenza the pain, nausea and
vomiting require relief. At the onset of the infection the bowels should be
thoroughly evacuated by calomel given in frequently repeated small doses
(gr. |-o.oi6). Later intestinal antisepsis may be accomplished by the admin-
istration of the organic bismuth salts, the naphtholate, gr. v to x (0.33 to 0.66),
the iodophenolphthaleinate, gr, v to x (0.33 to 0.66) or the subgallate, gr. x to
XV (0.66 to i.o). High intestinal irrigations are great aids in the elimination
of toxins, not only by the bowels but by the kidneys as well. Frequently
rectal alimentation becomes necessary when the stomach is unable to retain
even liquid food.
In the nervous type the distressing pain particularly calls for treatment
and while quinine has been much lauded, the author considers that the results
obtained hardly warrant its administration to the extent that the severe
infection would seem to justify. Euquinine seems to be somewhat more
efl&cient although the statements made that it causes tinnitus are incorrect.
Its dose is from 5 to 15 grains (0.33 to i.o). The giving of the coal tar anal
gesics has the disadvantage that the drugs of this class that are sufficiently
analgesic are also to a greater or less extent cardiac depressants; consequently
their unrestricted employment is by no means advisable, and may be even
dangerous. It is possible, however, to reheve the pain of influenza to a
considerable extent, without dangerously depressing the heart or respiratory
system. This may be accomplished by alternating acetanilide or acetphe-
netidin, of which the untoward effects are neutralized by combination with
caffeine, with acetanilide and methyl salicylate or antipyrine sahcylate (sali-
pyrine), a combination of antipyrine and salicylic acid. Of this 10 grains
(0.66) may be given every 2 or 3 hours until the pain is relieved. Depression
may follow the use of this drug in certain instances and it should always
be employed with caffeine in consequence. Kryofine may also be used as
an analgesic in doses of from 5 to 8 grains (0.33 to 0.52) and may prove more
effective and less depressant than most of this series. Gelsemium often will
afford great relief from the headache and backache which are common in this
disease. It should be pushed until slight ptosis appears, when the Hmit
of its physiological activity has been reached. This drug merits a trial, since
the success, when attained, is brilliant although it is difficult to furnish exact
indications for its administration. At times the muscular pains if limited
to the back may be mitigated by means of a local application of cataplasma
kaolini. This should be spread in sufficient thickness over the painful area^
covered with a layer of muslin and kept hot. It is cleanly, retains its heat
for some time and is easily renewed. The meningeal symptoms should be
controlled by the use of the ice helmet and the application of cold to the back
of the neck.
Elimination of the toxins of the disease as has been previously stated should
be safeguarded. The neutralization of the infectious material in the intestine
should be brought about as has been already shown. Diarrhoea, if pres-
ent, should be considered beneficial. Warm baths relieve the muscular pain
and, when accompanied by friction, keep the skin in good condition and add
to the comfort of the patient. Not only should the presence of albumin and
casts in the urine be determined but the specific gravity, the urea excretion and
above all the quantity of urine passed should be carefully noted. For urinary
insufficiency no better treatment exists than continuous enteroclysis with
decinormal salt solution at a temperature of iioÂ° F. (43.5Â° C); this not only
aids renal elimination but is a cardiac stimulant of considerable efficacy.
The treatment of influenza in children is practically identical with that
of the disease in adults; doses should, however, be regulated in accordance
with the age of the patient.
CompHcations should be treated as when occurring independently.
Dm-ing convalescence the patient should avoid too early exposure to out-
door air and any possible risk of reinfection. Before going out for the first
time the temperature should have been normal for from five days to a week.
Nourishing diet and tonics such as codliver oil, iron, strychnine and the
vegetable bitters should be prescribed.
Synonyms. Breakbone Fever; Dandy Fever.
Definition. An acute, infectious disease occurring in warm countries,
characterized by severe pains in the joints and muscles, fever, and in many
instances by an erythematous eruption.
.Etiology. This disease occiU"S chiefly in hot climates and during the
warmer and more moist seasons of the year; it is common in the East and
West Indies but is seldom seen in the United States except along the coast
of the Gulf of Mexico. An epidemic occurred in Galveston, Texas, in 1879.
One of the affection's distinctive features is its rapidity of diffusion and its
proneness during epidemics to attack nearly all persons exposed. While
probably due to infection with a micro-organism, the specific cause of the dis-
44 . THE INFECTIOUS DISEASES.
ease has not yet been definitely isolated. It is probably not transmitted
through contact with patients or by means of fomites, the Aost approved
theory of its means of transmission being that certain gnats or mosquitoes
may carry the infection from one person to another.
Pathology. Little is known of the post mortem changes occurring in
this disease, deaths being very rare.
Symptoms. The onset of the disease is sudden, without prodromata and
after an incubation period of from two to five days. The invasion is marked
by a chill followed by a rise in temperature, headache, the ordinary symptoms
of beginning febrile disease and severe pains in the muscles, bones and joints.
The latter become hot, painful, red, tender and sometimes swollen. It is
this joint involvement which gives the affection the name "dandy fever,"
the gait being so modified that it is supposed to simulate that of a dandy.
The rise in temperature is rapid, its maximum being from 103Â° F. to 106Â° or
107Â° F. (39.5Â° to 41Â° or 41.5Â° C). In two or three days, usually in two, the
fever falls rapidly by crisis, with diaphoresis, diarrhoea, diiiresis and epistaxis.
With the initial rise in temperature an erythematous rash appears which
disappears synchronously with the fever. With the fall in temperature the
patient feels much improved although weak; the pains are diminished but to
some extent persist. After an afebrile period of from two to four days the
temperature rises again with a return of the severe pains. The temperatiire
is usually less high than in the preceding paroxysm but the pains may be
more marked. With the fever a roseolous eruption appears, first upon the
backs and palms of the hands and spreads thence over the entire body.
The macules are dark red, circular and about the size of a pea; they may be
elevated and are likely to be particularly in evidence about the joints. The
spots may coalesce. As the eruption fades, which takes place first upon the
hands and arms, then upon the body and finally upon the legs, there is a
fine desquamation. The entire duration cf the disease is about seven or eight
days, at the end of this time the rash has usually faded and rapid convales-
cence ensues. In certain instances, however, this may be protracted and the
patient meanwhile suffers from vague pains in the joints and feet and mental
and bodily weakness.
Lymph gland enlargement may be observed and the eruption may persist
for several weeks after apparent recovery has taken place. Delirium some-
times accompanies the fever and muscular atrophy has been noted consequent
upon an attack.
Complications are rare but relapses are not infrequent.
In epidemics the diagnosis of the disease is not difficult, isolated instances,
however, may be confounded with acute articular rheumatism.
Dengue is almost never fatal in patients of moderate power of resistance.
Death may occur as a result of other infections such as pneumonia, to which
MALARIAL FEVERS. ^ 45
the patient is predisposed on account of the weakening effect of the primary
Treatment. Isolation, in the Hght of our present knowledge of the prob-
able mode of trsSismission of the disease, need not be insisted upon, but the
access of mosquitoes to the patient should be prevented. Disinfection,
also, would seem to be unnecessary.'
Absolute rest in bed is an essential until the termination of the second
febrile stage. At the onset the bowels should be opened by means of frac-
tional doses of calomel followed by a saline, and throughout the disease the
emunctories should be kept active by the means suggested under the section
upon the treatment of influenza. The fever seldom needs special treatment
on account of its short duration but in instances of hyperpyrexia (105Â° to
107Â° F. â€” ^40.5Â° to 41.5Â° C.) cool sponging or one or two tub baths may be
employed. These should be given according to the methods set down for
use in enteric fever.
The pains may be controlled by the employment of the means indicated
in those of influenza, together with the salicylates and aspirin 15 to 20 grains
(i.o to 1.33) every two or three hours until the desired effect has been pro-
Tincture of gelsemium is said to relieve the pain and to lessen the cardiac
excitability; 8 drops (0.52) may be given every three or four hours until the
pain is relieved or until the depression of the pulse rate and the incidence of
ptosis indicates that the physiological limit has been reached. Opium is
seldom necessary for the pain. Excessive nervous symptoms may be controlled
by means of the bromides. In a word the treatment of this disease is entirely
symptomatic, no specific having yet been discovered.
The diet during the fever should be wholly fluid. During convalescence
tonics should be prescribed and strength-giving foods given in digestible
Synonyms. Chills and Fever; Fever and Ague; Paludism; Paludal Fever;
Definition. Malarial fever is an infectious disease occurring in several
types: a. intermittent, in which the febrile paroxysm is quotidian, tertian
or quartan; h. continuous with remissions; c. pernicious; d. chronic malarial
.Etiology. This disease is less common in the very young and in aged
persons than in young and middle-aged adults; it occurs more frequently in
the white than in the negro race and is most prevalent in low lands especially
in damp and swampy districts along the sea coast. It is more frequently
46 THE INFECTIOUS DISEASES.
observed in the tropics and the warmer portions of the temperate zones.
In the latter the affection is rare in the spring, most of the cases occurring in
the late summer and autumn. In the tropics it is most common in the months
corresponding to the spring and fall.
The specific cause of the malarial infections is a micro-organism, the hcsmo-
cytozooUf hcsmatozodn or Plasmodium malaricB. The hczmatozobn malaria
is a parasitic body developing within organism of all the varieties of anopheles â€”
the common mosquito â€” and transmitted to man through the sting of this
insect. The parasite circulates in the blood of man, the intermediate host,
and occurs in three forms, each causing a definite and different type of
The hsematozoon of tertian fever when seen soon after a chill is a small,
hyaline body, rounded or irregular in shape, and is seen within the substance
of a red blood cell. Its life cycle is of about 48 hours duration, and consists
of the following process: It first increases in size, exhibits amoeboid move-
ment and fine granules of pigment develop within it, while the red blood cell
becomes larger and paler in color. The pigment gradually assembles itself
at the center of the organism and in about 48 hours segmentation takes place.
This process consists of the division of the original body which now fills
nearly the whole of the red cell into 15 or 20 spores, resembling the original
hyaline body. These are set free in the blood, each in its turn, to prey upon
a red blood corpuscle. At this time the chill is manifested. Other fully
developed organisms may not undergo segmentation. These are larger than
those which sporulate and contain pigment granules in active (Brownian)
movement. These are a sexually different type of the parasite. In the
quotidian type of malarial infection there are two sets of tertian or three sets
of quartan organisms in the blood which sporulate upon different days caus-
ing a chill every 24 hours.
The quartan variety of the hsematozoon in its earliest form closely resem-
bles the tertian type but as it develops the amoeboid movement is more sluggish
and the grains of pigment are coarser and the Brownian movement is less
active. It increases gradually in size, the pigment is seen at its periphery
and on the third day its division into radially arranged segments, 6 to 12 in
number, is noted. After a 72 hour interval of development sporulation takes
place. Here as in the tertian type fully developed bodies may be observed
which do not break up. These also represent a sexually different form,
The (Bstivo -autumnal organism is smaller than the preceding forms and
contains less pigment. Its full size may be less than half that of a red blood
cell. Early in the disease only small hyahne bodies containing, it may be,
a grain or two of pigment are to be found in the peripheral circulation. The
more mature forms are usually found in the blood of the viscera, particularly
MALARIAL FEVERS. 47
the spleen, and the bone-marrow, and the corpuscles containing them may
be distorted or crenated and are of brassy color.
The characteristic forms of the aestivo-autumnal type of the parasite which
are crescent-shaped, ovoid or spherical, are seldom seen until the infection
has been present for a week or more. These contain near their centers groups
of coarsely granular pigment. The crescentic and ovoid bodies do not sporu-
late and represent the gametocytes. The sexual forms of each type of the
organism, entering the stomach of the mosquito when an infected individual
is bitten, are fertilized there and after developing, the spores which result may
be transmitted through the insect's bite to a human host and then undergo
a further cycle of development.
Pathology. In acute infections there is a diminution of the number
of red cells and haemoglobin in the blood as a result of the disintegration of
the former due to the development of the organism. The spleen is enlarged
and may rupture, especially if subjected to traumatism. The parasites
are present in the blood.
In pernicious malaria there is marked anaemia, the red cells are distorted
and degenerated and contain the parasite within their substance. These
are also found in the marrow and this structure and the spleen may be pig-
mented and the seat of a marked phagocytosis. The spleen may be the seat of
moderate enlargement only and is usually dark in color and soft in consistency
if the disease is the result of a recent infection. The liver is the seat of acute
degeneration (cloudy swelling). If cerebral symptoms are marked the brain
is congested and the blood in its capillaries contains numerous haematozoa,
with severe intestinal symptoms the parasites may be numerous in the capil-
laries of the intestinal tract.
In malarial cachexia the anaemia is pronounced, the spleen is much enlarged,
weighing at times 8 or lo pounds, its capsule is thickened, it is slate colored
on section and contains pigment. Its connective tissue framework is in a
state of hyperplasia. A like condition obtains in the liver. Melanin may be
deposited in the connective tissue beneath hepatic capsule. The kidneys
may be swollen, contain pigment and in some instances may be the seat of