symptomatic. The organs of elimination, the skin, kidneys and bowels,
should be kept active by means of diaphoretics such as pilocarpine ^ to ^ of a
grain (0.008 to o.oii) given hypodermatically and with caution, and by hot
packs, by high rectal irrigations of hot saline, hypodermoclysis or intravenous
infusion. Stimulant diuretics are to be avoided; cardiac stimulation by
means of strychnine and the diffusible stimulants is often necessary.

NASHA FEVER.

Synonyms. Nasa Fever; Nakra Fever.

Definition. An acute infectious febrile disease characterized by nasal
congestion and localized swelling of the septum nasi.

.etiology. This affection occurs in certain districts of India. Adults
are most commonly affected, the disease being rare in children and old persons.
It is observed chiefly in summer and is predisposed to by lack of proper
nourishment, unhealthy mode of life and unsanitary conditions. Its specific
cause is not known although it has been considered a form of malarial infec-



CHOLERA. 55

tion. The facts that quinine does not influence its course and that the haem-
atozoon of malaria is not constantly found are not in accordance with this
theory of its causation.

Symptoms. The characteristic manifestations of this disease are hyper-
aemia of the nasal mucous membrane and swelling of the septum in particular.
It is ushered in by malaise, prostration, and general pains in the head, body
and limbs. The fever is seldom high and there may be a general eruption of
small rose-red spots. The febrile movement persists for from three to five
days when the temperature gradually falls and the other symptoms subside.
A fatal issue, preceded by sudden amelioration of the nasal manifestations
and coma, has been observed in rare instances. Immunity is not conferred
by an attack.

Treatment consists in employment of the means indicated to control like
symptoms occurring in other infectious fevers.

Puncture of the septal tumor is said to be followed by an amelioration of
all the symptoms.

CHOLERA.

Synonyms. Cholera Asiatica; Cholera Algida; Epidemic Cholera; Cholera
Maligna.

Definition. An acute infectious disease caused by a specific m'cro-organ-
ism and characterized by emesis, violent purging, abdominal cramps and
collapse.

.etiology. This disease for many years has been endemic in India and
from time to time becomes epidemic. Epidemics have also occurred in
other parts of Asia, in Egypt and in Europe whence it was first brought to
America in 1832. Since that time the disease has visited this country
at intervals, the last time being in 1892 at the time of a general Asiatic and
EiU"opean epidemic, when a few cases were reported in New York City.

The disease is met in all ages and both sexes, but children and old persons
seem most prone to acquire the infection. Cholera occurs more frequently
in low lying districts near the sea coast than in higher inland regions, it is
more common in warm countries and prevails during the summer months
in the temperate zones. The contagium is usually killed by the incidence
of frost. The infection is predisposed to by over-population, unsanitary
surroundings, bad personal hygiene, intemperance and any influence which
tends to reduce the resisting power of the human body.

The specific cause of Asiatic cholera is the comma bacUlus of Koch which
was discovered in 1884. It is found in the intestines of all persons suffering
from the disease, is usually accompanied by the colon bacillus and often by
the streptococcus. It is given off from the body in the dejecta. Rarely is



56 THE INFECTIOUS DISEASES.

it found in the vomitus. The disease is the result of the growth and propaga-
tion of the bacillus in the body.

Mode of Infection. The bacillus of cholera is taken into the gastro-
intestinal tract in drinking water or upon food. The disease is not contracted
by association with patients although by handling the patient's discharges
the hands may become contaminated and in this way the contagium may be
transferred to the mouth. Vessels washed in contaminated water, vegetables
washed or watered with water containing the spirillum, or food upon which
flies, which have previously come in contact with infectious matter, have
alighted may transmit the disease. The spirilla are quickly killed by drying,
consequently it is hardly probable that they maybe taken into the system upon
the inspired air; they are capable, however, of living upon bread, meat and
other foodstuffs for from six to eight days. The severity of the infection
depends upon the amount of the contagious matter taken into the system
and upon the resistance of the individual. It is known that the gastric juice is
decidedly inimical to the spirillum and individual immunity has been observed,
virulent cultures having been isolated from the stools of healthy persons.

In direct opposition to Koch's theory of the propagation of cholera is that
of Pettenkoffer who holds that the micro-organism of the disease develops
in the soil-water of the East during the warm months and rises thence as a
miasm into the air. He asserts that conditions favoring its development
are a low-ground water, associated with porosity, moisture and organic con-
tamination, particularly sewage.

It is not certain that one attack of the disease confers immunity.

Pathology. On gross inspection the body is usually much emaciated,
the skin over the nondependent parts is grayish in color while that over the
dependent portions of the body is livid or mottled.

Post mortem rise in temperatxire may occur and while rigor mortis is an
early manifestation contractions of the muscles of the jaws, the eyes, or of
the limbs may be observed. The subcutaneous tissue when cut is dry, owing
to the fact that the body liquids have been drained away, and the blood is
thick and dark. The peritonaeum is viscid, the intestines are congested but
not distended. The stomach may contain a turbid liquid resembling, rice-
water; its mucous membrane is congested and its vessels are distended, the
epithelium may be eroded or intact. The lining of the small intestine is usually
congested and the cavity of the bowel contains turbid serum (rice-water
material); in the later stages the hypergemia is more apparent and the solitary
and agminated follicles may be swollen; rarely they may be ulcerated. Ecchy-
moses and denudation of the mucous membrane may be observed, the latter
probably having taken place after death. Patches of false membrane may
be found in the intestine in cases of prolonged course. The comma bacillus
is found in the contents of the bowel and in its mucous membrane,



CHOLERA. 57

A condition of acute parenchymatous degeneration (cloudy swelling)
obtains in the liver and kidneys, the former may also show areas of fatty
degeneration and the latter coagulation necrosis with desquamation of the
epithelial lining of the uriniferous tubules. The spleen is not enlarged and
may be decreased in size.

The heart is dry and flaccid. The left auricle and ventricle are empty
while the right are filled with dark liquid blood. The lungs may be shrunken
and bloodless except at the bases posteriorly where they are likely to be the
seat of passive congestion.

Symptoms. The incubation period is from two to five days after which
the invasion of the disease occurs. The symptoms may be grouped in three
stages which are more or less distinct.

a. The stage of preliminary diarrhoea. This stage may be sudden in
its onset or preceded by abdominal pain, malaise, headache and emesis.
The diarrhoea is painless, the stools are frequent, fluid, yellowish or of "rice-
water " type and alkaline. They contain the comma bacillus and other
micro-organisms; there is usually no rise in temperature. This stage lasts
from a few hours to a week or more or may be absent.

h. The stage oj collapse is characterized by a profuse " rice-water " diarrhoea,
the movements being very frequent, and apparently forcibly expelled. Parox-
ysmal pain and tenesmus may be present but the patient is more often dis-
tressed with painful muscular cramps in the limbs and abdominal wall. Thirst
is marked and emesis is profuse, fluid resembling the stools being vomited
incessantly and in great quantity. The patient rapidly becomes exhausted,
and often sinks into a condition of collapse with sunken eyes, shrunken feat-
ures, palhd face, cold and clammy extremities. The surface temperature
may sink 4° or 5° F. ( 2° to 2.5° C.) below normal while the thermometer
indicates a rectal temperature of 103° to 104° F. (39.5° to 40° C). The
pulse becomes rapid, feeble and perhaps imperceptible at the wrist, the heart
sounds are markedly weakened. Respiration continues until death super-
venes in a condition of coma. At times the patient may remain conscious
until the very end. The continued depletion of the patient during this stage
results in great diminution of the secretions, particularly the urine and saliva;
the sweat glands and, in nursing women, the secretion of milk remain unaf-
fected. Microscopical examination of the stools reveals the presence of
mucus, epithelial cells, numerous bacteria, together with the comma bacillus
and at times blood cells. Chemically the dejecta contain albumin, and the
salts of the blood, particularly sodium chloride.

Cholera sicca is the term applied to this disease when vomiting and diar-
rhoea are absent.

The usual duration of the stage of collapse is from twelve to twenty-four
hours although it may last but three or four hours.



58 THE INFECTIOUS DISEASES.

c. The stage of reaction if the patient survives, sets in at the termination
of the stage of collapse and is characterized by a reappearance of the secretions,
of bodily warmth and of normal facial expression. The skin may retain its mot-
tled appearance for some days or an erythema may appear. The symptoms
gradually ameliorate, the heart action becoming stronger, the vomiting and
purging gradually diminish and the patient either may recover, there may
be a recurrence of the diarrhoea and collapse followed by death, or he
may pass into a state termed cholera-typhoid which is characterized by
cerebral symptoms, heart weakness and dry tongue. From this he may
recover or death may take place in coma which is attributed to uraemic
poisoning.

Mild cases of cholera are often seen during epidemics which are termed
cholerine. In such there are diarrhoea, vomiting and abdominal cramps,
but the collapse is not well marked. Malignant cases may also be observed
in which death takes place before the appearance of the purging and emesis
or in which the patient dies early in the disease, comatose and in a profoundly
toxjemic state.

Such complications and sequels as nephritis, diphtheritic inflammations
of the mucous membranes, and conditions due to septic poisoning, such as
parotitis, erysipelas and multiple abscesses may occur. Pleurisy, bronchitis
and pneumonia have been observed.

In the differentiation of Asiatic cholera from other conditions likely to be
confounded with it the chief points to be kept in mind are the history of
association with other cases, the presence of " rice-water " stools, the presence
of painful cramps in the extremities, the occurrence of cyanosis, collapse and
suppression of the secretions, especially the urine, and lastly the presence of
the comma bacillus in the dejecta. A preponderance of these symptoms is
not likely to occur in any disease except true cholera and, of course, the pres-
ence of the spirilla is pathognomonic.

The mortality varies in different epidemics from 30 to 80 percent. The
disease is more likely to prove fatal in the debilitated and intemperate than
in those of better power of resistance. Patients with marked and early
collapse seldom recover.

The prevention of this disease consists in the prompt isolation of all patients
afflicted with the disease and the thorough disinfection of all dejecta and
the utensils, bed and personal linen of the sufferer. The methods applicable
in enteric fever (see p. 9) will be found efficacious in this disease. During
epidemics all water and milk used for any purpose should be boiled and it is
even unwise to eat uncooked fruit or vegetables. The disease is as slightly
contagious as is enteric fever and consequently if proper precautions are
taken, those associating with patients are not likely to become infected.
The digestion should be kept in perfect order and any disturbance, partic-



CHOLERA. 59

ularly if associated with diarrhoea, promptly treated; here opium, lead acetate,
small doses of sulphiiric acid and the salts of bismuth, particularly those
which exert an antiseptic action upon the digestive tract such as the sub-
gallate, the naphtholate and tetraiodophenolphthaleinate are indicated.

The protective inoculation against cholera by means of Haffkine's virus
has proved effective in the hands of its originator and its employment produces
no evil after-effects. Other experimenters are said to have elaborated anti-
toxic sera.

Since, however, we have simpler means, namely, through disinfection,
sanitation and efi&cient quarantine, by which the disease may be prevented,
we may remain content imtil further research has succeeded in establishing
an anticholera inoculation which shall be certainly protective.

Treatment. The patient should be immediately isolated and put to bed.
During the first stage of the disease treatment should be directed at the diar-
rhoea, at the destruction of the bacilli within the intestinal tract and at the
neutralization of their toxins. Of the drugs most commonly used to check the
diarrhoea opiiim and sulphuric acid may be mentioned. It is probable that
the latter is to be preferred, while opium is to be reserved to relieve the pain;
for this pmrpose it should be given hypodermatically in the form of morphine.
A full dose, gr. i to ^ (0.016 to 0.032), may be given at first, to be followed by
smaller doses as indicated. Sulphuric acid has a destructive effect upon the
comma bacillus and may be given in the form of the dilute acid, 10 to 15 drops
(0.66 to I. o), every two or three hours. The acid may be given alone or with
the camphorated tincture of opium. Hydrochloric and nitrohydrochloric
acids are also useful.

Excellent results have been attained from the use of phenyl salicylate in
cholera; it may be given in doses of gr. v to xv (0.33 to i.o) every two or three
hovurs alone or combined with considerable doses of one of the bismuth salts,
either the naphtholate or the iodophenolphthaleinate, these last being among
the most effective intestinal antiseptics at our disposal. Calomel has also
given good results not only in controlling the vomiting but since a portion
of this drug is changed in the digestive tract into mercury bichloride it has an
antiseptic effect in addition. It may be given in dosage of from five to seven
grains (0.33 to 0.5) at the onset of the disease and continued in smaller doses —
^ to f of a grain (0.02 to 0.05) — every two or three hours during the first and
second stages of the affection.

If severe vomiting is present we may attempt its control by lavage of the
stomach and small doses of cocaine — | to ^ a grain (0.016 to 0.032). When
this symptom is very marked we should administer all medication hypo-
dermatically. In the control of the diarrhoea external appHcations are often
useful; either mild mustard pastes or turpentine stupes may be employed.
For the heart weakness the administration of alcohol and strychnine or of



6o THE INFECTIOUS DISEASES.

camphor, dissolved in aether or sterile oil, i grain (0.065) ^very six or eight
hours, is indicated.

During the second stage the abdominal cramps may be relieved by hypo-
dermatic injections of morphine and the body heat should be maintained in
this as well as in the algid stage by means of hot water bottles and, if sweating
is a prominent symptom, by the subcutaneous administration of yJto o^ ^ grain
(0.0006) of atropine sulphate which may check this distressing manifestation.

The continuous depletion of the system by the serous diarrhoea results in
marked thirst and serious diminution in the watery elements of the tissues.
The thirst may be relieved by allowing small but frequent draughts of water,
either plain water, barley water or carbonated water being permissible, and
by intestinal irrigations of hot normal sahne solution. Water may be sup-
plied to the tissues and the organism stimulated by means of hypodermato-
clysis or intravenous injection of considerable quantities of normal saHne.
As much as two quarts (2 Utres) may be given under the skin every four or
six hours. It is often wise to begin the hypodermatoclysis in the early
stages and to continue it at intervals throughout the disease. During the
algid stage the bodily heat may be kept up by immersing the patient in a warm
bath.

The patient may receive for hypodermatoclysis, instead of normal saline
solution, an artificial serum composed of one drachm (4.0) of sodium chloride
and 45 grains (3.0) of sodium carbonate to the quart (litre) of sterile water.
This should be injected at a temperature of 104° F. (40° C.) by means of a
fountain syringe or irrigating glass to the tube of which a long needle of mod-
erate calibre is attached. The solution should be put under the skin of the
buttocks, thighs or back; it is well to avoid the tissues of the neck lest oedema
of the glottis be induced. The injection treatment, also recommended, has
been followed by excellent results and consists in irrigating the large intestine,
through a soft rubber rectal tube passed as high as possible, with an infusion
of chamomile flowers, 2000 parts, gum arable, 30 parts, tannic acid, 10 parts
and laudanum, 2 parts. According to the originator of this treatment the
tannic acid not only exerts its astringent action but also inhibits the growth of
the comma bacillus and has a neutralizing effect upon its toxins. The
solution is passed in under gentle pressure, the bag containing it not being ele-
vated more than 18 inches or two feet above the patient who lies upon the left side
with the buttocks slightly raised. The fluid should be retained as long as
possible and it is said that under favorable conditions it may pass the ileo-
caecal valve and come in contact with the lining of the small intestine. The
injection may be given four times a day and in severe infections may be
administered after each movement of the bowels. If the patient is in a state
of actual or threatened collapse the solution should be hot — 105° F. (40.5° C.)
— but should there be tendency to hyperpyrexia it may be cool. Thetem-



DYSENTERY. 6l

perature of the fluid in its receptacle if it is to be given hot should be 112°
to 116° F. (44.5° to 46.5° C.) since by the time it has reached the body much
of its heat will have been lost in its slow passage through the tube. The
tendency to urinary suppression is also lessened by the hot irrigations and
may be still further combated by means of hot appUcations over the lumbar
region.

During the stage of reaction the substitution for the tannic acid mixture
of saHne solution (sodium chloride, 10 to 15 percent.) is advisable and when
the tissues seem still to be in need of water, as evidenced by thirst and relaxa-
tion of the skin, the hypodermatoclysis should be continued at increasing
intervals. Stimulants may also be necessary. When convalescence has
become established the patient should be still kept at rest and fed with the
greatest caution lest the diarrhoea reciu-. The food should be given at fre-
quent intervals but in very small amounts and must be of the most non-irri-
tating character. Peptonized milk is the first nourishment and may be
followed by other peptonized foods. Later more liberal feeding may be
permitted and tonics should be judiciously administered.

Complications should receive appropriate treatment.

Dead cholera bacilli in anticholera vaccination have been employed with
the result of apparently certain immunization and the Japanese have an
antitoxin which is said to be curative when properly administered, unless
the patient is in extremis.

DYSENTERY.

Synonym. Bloody Flux.

The term dysentery is applied to a group of infectious inflammatory intestinal
affections characterized by ulceration of the intestinal mucous membrane
and frequent dejections, associated with pain and often containing mucus
and blood. In chronic forms of dysentery constipation may alternate with
the diarrhoea.

The conditions to be included under the term dysentery may be classified
as follows: a, Catarrhal or sporadic dysentery; b, tropical or epidemic
dysentery; c, amoebic dysentery; d, diphtheritic dysentery.

.etiology. Aside from the specific causes of these different types of the
disease certain predisposing astiological factors are common to all forms.
Dysentery is especially a disease of warm climates, although its epidemic
and other varieties have been observed in northern latitudes. Season also
has a distinct influence upon the occurrence of dysentery, the disease being
most prevalent during the warm months of the summer and autumn. Damp
low-lying regions near the sea shore suffer more frequently than highland
and inland districts. Unhygienic conditions of life, unsanitary surroundings



62 THE INFECTIOUS DISEASES.

and over-crowding predispose to the incidence of the disease as is evidenced
by the epidemics which occur from time to time in army camps, jails, hospitals
and the like.

Dysentery affects all ages, both sexes and all races. Barring the proneness
of infants to dysenteric disturbances the disease is most commonly seen in
young adults. It is predisposed to by all disorders of the intestinal tract
and by errors in diet, particularly the eating of unripe or over-ripe fruit.

Catarrhal Dysentery.

Synonym. Sporadic Dysentery.

.Etiology. This form of dysenter}^ is met as a complication of the various
acute infectious diseases as well as of chronic wasting diseases such as tuber-
culosis. It is predisposed to by the ingestion of irritating and improper
food and is the type of dysentery met so frequently in children dmringthe
summer months. Here it is usually a primar}' disease and it may occur as
such in adults.

Its specific cause is in all probability the result of the presence and growth
in the intestine of the Shiga bacillus or analogous micro-organisms of which
several varieties may be present in the same case.

Pathology. The morbid changes depend upon the severity of the infec-
tion and may consist merely of an increased production of mucus, exfoliation
of the epithelial cells lining the large intestine, exudation of serum and dia-
pedesis of white blood cells. In more marked infections there is swelling of
the soUtary follicles which is foUowed by necrosis and ulceration; haemor-
rhages from the mucous membrane may occur and this structure may be
the seat of a purulent inflammation.

Symptoms. The onset of the disease may be preceded by such prodromata
as malaise, abdominal pain, nausea and moderate diarrhoea, or it maybe sudden
and marked by a chill followed by a slight or moderate rise in temperature
which seldom is higher than 103° to 104° F. (39.5° to 40° C). The t}^ical
symptoms are cramp-like pains in the abdomen accompanied by movements
from the bowels accompanied by tenesmus. At first these number not more
than five to six per day, are copious and consist of faecal matter; soon they
become much increased in number, even to 100 or more per day, are small,
mucoid and at times bloody; they are accompanied by pain and tenesmus.

Microscopic examination of the stools reveals the presence of mucus, red
blood and pus cells, epithelial cells which may have undergone partial fatty
degeneration and the bacteria of putrefaction.

After a week or ten days the stools become less frequent, contain less mucus
and blood and are greenish, due to the presence of bile.

Other symptoms manifested in this disease are a coated tongue, at first



DYSENTERY. 63

moist, later dry, loss of appetite, rarely vomiting, and marked thirst. The
patient rapidly becomes emaciated and a condition of collapse with small
weak pulse and moist clammy skin may be observed. Occasionally delirium
followed by coma and death may be met.

The usual coxirse is one week to ten days when the stools begin to approach
the normal in number and character, but at times the disease will resist treat-
ment for a long period or even become chronic. Death occurs in rare instances
from exhaustion.

The diagnosis is to be based upon the character of the stools and the intes-