THE TREATMENT OF ACUTE INFECTIOUS DISEASES THE MACMILLAN COMPANY NEW YORK BOSTON CHICAGO DALLAS ATLANTA SAN FRANCISCO MACMILLAN & CO., LIMITED LONDON BOMBAY CALCUTTA MELBOURNE THE MACMILLAN CO. OF CANADA, LTD. TORONTO THE TREATMENT OF ACUTE INFECTIOUS DISEASES BY FRANK SHERMAN MEARA, M. D., PH.D. Professor of Clinical Medicine and formerly Professor of Therapeutics in the Cornell University Medical College in New York City. Consulting Physician to Bellevue Hospital, New York; to the Mountainside Hospital, Montclair, N. J.; to the Morristown Memorial Hospital, Morristown, N. J.; to Overlook Hospital, Summit, N. J.; to Dover General Hospital, Dover, N. J.; Mount Vernon Hospital, Mount Vernon, N. Y.; Law- rence Hospital, Bronxville, N. Y.; Associate Attending Physician to St. Luke's Hospital, New York City SECOND EDITION, REVISED fork THE MACMILLAN COMPANY 1921 All rights reserved COPYBIQHT, 1916 and 1921 BY THE MACMILLAN COMPANY Set up and printed. Published January, 1916. Reprinted with corrections, August, 1916; September, 1917. Second Edition completely revised and reset Published, June, 1921. Printed in the United States of America To the memory of my father SHERMAN T. MEARA whose encouragement was my inspiration this book is dedicated 443446 PREFACE TO THE SECOND EDITION IN the revision of a book on Acute Infectious Diseases a review of the literature on the recent epidemic of influenza, as well as the camp epidemics of measles, streptococcus pneumonia, meningitis and other infectious processes treated in this book, entails a task of no inconsid- erable magnitude. It is hoped that these subjects will be found brought quite up to date. Moreover, it has seemed wise to include the more common acute infections of the respiratory tract, coryza, tonsillitis, laryngitis, and tracheo-bronchitis, and to add a chapter on acute pleurisy; furthermore, two clinical complexes recently brought to our attention, the one prob- ably incident upon the influenza epidemic, the other consequent upon military operations, encephalitis lethargica and trench fever have been added and for the sake of completeness two less commonly encountered infections that have been the object of much careful research work, rat- bite fever and Rocky Mountain spotted fever. It has been deemed advisable to retain the chapter on Grip as written. It covers a picture seen each winter as the result of an acute infection from one of several organisms but does not adequately present epidemic influenza. For this reason a new chapter has been devoted to the latter. As a result of the camp epidemics of measles, streptococcus pneumonia has been studied as never before and it has been deemed proper to consider this apart from pneumococcus pneumonia. It gives me great pleasure to acknowledge here my indebtedness to Prof. Oscar W. Bethea of Tulane University, whose great courtesy, kindly criticisms, and helpful suggestions have contributed much of value to this revision. My thanks are further due to my assistant, Dr. Connie M. Guion, without whose intelligent cooperation, the completion of my task would have been still longer delayed and to the fidelity and tireless devotion of my secretary, Mrs. Mary Nielsen. Finally I have to express my appreciation to the helpfulness of Dr. Minor B. Hill for his article on Intubation, to Dr. Alfred S. Taylor for his treatise on empyema and to Dr. William Parks, Dr. Malcolm Goodridge and Dr. Arthur W. Bingham for many helpful suggestions. The kindly letters of many friends have been a compensation for the efforts already expended on this work and a stimulus for the added labor of revision. F. S. M. PREFACE TO FIRST EDITION To the layman the word " physician" connotes a therapeutist; one whose professional end and aim it is to cure the sick. If he thinks of the physician at all as a student of the science of medicine or as a diagnostician it is only in the sense that he is busied with matters that shall lead to the prevention, cure or alleviation of disease; and yet every practitioner of medicine, seeking assistance in the exercise of his art, feels the disproportion of the much that is offered him of the cause, the course and the consequences of disease and the little that is afforded of the practical application of this knowledge to its legitimate uses, getting the sick man well. As a teacher of therapeutics I have always felt that this branch of medicine has been unduly neglected both in the college curriculum and in the text-book. With the text-book my ex- perience has been that it either speaks in generalities assuming knowl- edge on the part of the student or physician, when such an assumption should annul its very reason for being, or it catalogues and compiles endless measures and procedures without effort to exercise a judgment of their relative values. The few exceptions to this statement make themselves conspicuous. Successfully or not, it has been the attempt of the author to avoid these extremes of error. Each chapter has been made to deal with an individual disease in a thoroughly practical manner; each little detail of procedure being explained so that the reader may actually apply it. Moreover, the reason for the procedure, as based on our latest information, both with respect to physical therapy and drugs, the author has sought to give. Constant and confusing reference to the literature has been avoided, but an effort to give due credit has been made. The book, finally, must be looked on as an expression of the author's individual opinion and will be didactic rather than critical. A summary at the end of each chapter is designed to add to its use- fulness as a ready reference for the busy practitioner and as a review to the student. F. S. M. CONTENTS CHAPTER PAGE I FEBRILE CONDITIONS 1 II DIET IN ACUTE INFECTIOUS DISEASES 10 III ACUTE RHEUMATIC FEVER 30 IV ACUTE RHINITIS 71 V TONSILLITIS AND VINCENT'S ANGINA 80 VI ACUTE LARYNGITIS 94 VII ACUTE BRONCHITIS AND TRACHEITIS 101 VIII PLEURISY (PLEURITIS) 112 IX PNEUMONIA 128 X STREPTOCOCCUS PNEUMONIA 208 XI THE TREATMENT OF GRIP OR SPORADIC INFLUENZA 216 XII EPIDEMIC INFLUENZA 235 XIII ENCEPHALITIS LETHARGICA 271 XIV TYPHOID AND PARATYPHOID FEVERS 277 XV MALARIA 322 XVI DYSENTERY BACILLARY AND AMEBIC 353 XVII SCARLET FEVER 387 XVIII DIPHTHERIA 443 XIX MEASLES 487 XX RUBELLA (GERMAN MEASLES) 512 XXI VARICELLA (CHICKEN Pox) 514 XXII PERTUSSIS (WHOOPING COUGH) 520 XXIII MUMPS (PAROTITIS) 545 XXIV GLANDULAR FEVER 555 XXV CEREBRO-SPINAL MENINGITIS ; 560 XXVI POLIOMYELITIS (INFANTILE PARALYSIS) 590 XXVII SMALL Pox (VARIOLA) 608 XXVIII TYPHUS FEVER 625 XXIX PLAGUE 634 XXX DENGUE 641 XXXI ASIATIC CHOLERA 646 XXXII MALTA FEVER 656 XXXIII ROCKY MOUNTAIN SPOTTED FEVER 664 XXXIV LEPROSY 670 XXXV ANTHRAX 678 XXXVI GLANDERS OR FARCY 687 XXXVII FOOT AND MOUTH DISEASE 693 XXXVIII PSITTACOSIS 698 XXXIX RABIES 699 XL TETANUS 711 XLI INFECTIOUS JAUNDICE (WEIL'S DISEASE) 728 XLII YELLOW FEVER 735 XLIII RAT-BITE FEVER 744 XLIV TRENCH FEVER 751 XLV SEPTICAEMIA AND PY^MIA 757 XLVI ERYSIPELAS 772 INDEX. . 781 THE TREATMENT OF ACUTE INFECTIOUS DISEASES TREATMENT OF ACUTE INFECTIOUS DISEASES CHAPTER I FEBRILE CONDITIONS GENERAL PRINCIPLES IT is one of the most hopeful features of modern therapy that it is taking cognizance of the fact that the organism has been perfecting means of defense since first it became the seat of disease and that these means of defense are to be read not merely in the subtile elaboration of antitoxic bodies in the tissues and the marshalling of counter-forces in the blood elements, but also in the alteration of the functions of organs. Emesis as a symptom is primarily an effort to unburden the stomach of deleterious substances; diarrhea is protective in the same sense; cough removes secretions which are both irritants and mechanical impediments to the respiration; pain ensures rest to an affected part and so on. Inter- ference with these symptoms must be undertaken with discretion lest it become pernicious. It is the knowledge of when to let alone and when to interfere that constitutes the art of therapy. Emesis, diarrhea and cough may become a source of exhaustion; pain which has pointed the way to the trouble and hinted the need of rest be illy borne when continued and fever rise to degrees that are incompatible with its purpose and constitute hyperpyrexia. At this point, treatment steps in to modify and assist, not to disregard Nature's signals. Fever, as the physician knows it, is almost invariably the result of bacterial action, so cannot be dissociated from toxemia; but pyrexia and toxemia show but little parallelism; indeed, the worst forms of toxemia may be accompanied by no pyrexia at all, while a relatively high temperature may be seen with a minimal toxemia. Briefly, then, unless the degree of temperature is inordinately high, that is, constitutes a hyperpyrexia, the treatment of fever is not an antipyretic treatment but an antitoxemic treatment, and such fall of temperature as accom- panies our efforts is incidental to them and not the object at which we aimed. The treatment of fever involves the appreciation of certain broad principles that in the main are physiological. They are not numer- 2 TREATMENT OF ACUTE INFECTIOUS DISEASES ous, 'but they are of fundamental importance. We shall take them up seriatim. (1) rest; (2) diet, including the ingestion of water; (3) fresh air; (4) water locally applied, that is hydrotherapy ; (5) drugs ; (6) hyperpyrexia. I think it little masters what name we give the febrile process or the organism inducing it. The procedures are much the same. Rest. It is a valuable form of mental exercise for a physician to pause occasionally and review some of the fundamental facts of phys- iology that are relevant to the problem in hand. First one should recall the fact that the sum total of the body's activities are but the expression of the conversion of potential energy of the foodstuffs into these different forms of energies; that the body observes an accurate balance between the intake and output; that the law of conservation of energy obtains in the human body as well as elsewhere, and, therefore, when the intake is lessened, the expenditure should be diminished and useless forms of work should be avoided that useful purposes may be subserved. All this means that in fever rest is imperative and that, as the body cells are expending energy in the elaboration of protective substances and the processes of repair are active in inflamed tissues, muscular unrest and muscular work should be avoided. Physiologists tell us that carbon dioxide, an end product of the combustion of foodstuffs in the production of energy, may be taken as a measure of the energy of work and heat arising in the body and that the same man who during sleep eliminates 22 grams of carbon dioxide an hour will, when awake and exercising the greatest amount of muscular relaxation possible, eliminate 31 grams, and under conditions that we ordinarily term rest, such as most patients observe, eliminates 38 grams. These figures are cited to call attention to what a relative term "rest" is. Again, in febrile conditions, the vascular and other vital centres are all too often sought out and when we recall the lessened number of heart beats in recumbency and slight fall of pressure under the same circum- stances we appreciate the economy exerted in behalf of these organs by rest. Rest means something more than going to bed, though that is imperative. It means that the bed must be comfortable, so that energy shall not be wasted in the effort to maintain strained positions or avoid uncomfortable ones; it means competent nursing; it means measures directed at sleeplessness and at delirium. Mental rest is equally important, for though the loss of energy in the mental proc- esses per se is minute, strained and restless muscles are the results of anxiety and concern, as, indeed, are perverted functions in many or- FEBRILE CONDITIONS 3 gans. Leave the sick room to the sick; exclude solicitous friends, Job's comforters, mourners before the fact. Avoid the introduction of busi- ness matters or domestic concerns, and let quiet and order reign. The contrast between a well-ordered, neat, cool, sick-room, and a hot stuffy room with six to ten visitors, gas-jets in full action and Babel and Chaos regnant is one of the most striking that can be witnessed. Diet. See Chap. II, Diet in Acute Infectious Disease. Again let us appeal to physiology for facts. They are (1) That the amount of work done and the amount of heat given off by the human body each day is derived from the food taken in that day or stored in the body from previous meals and that that store is not inexhaustible. (2) That the amount of energy demanded by a man at rest each day amounts on the average to 33 calories l per kilo of body weight which in a man of average weight amounts to 2,300 calories. (3) That a sick man at rest requires as many calories of energy as a well man. (4) That fever makes certain demands in excess of those obtaining in health, because the increased temperature per se, that is, pyrexia above 102 F. increases the output some 25 per cent, on an average, thus raising our caloric requirements to 40 per kilo or about 2,800 for the man of average weight. (5) That the toxins of disease are destructive of body tissue in varying degrees, a destruction which may be overcome or minimized by a suffi- cient intake of food. (6) That the amount of protein needed each day in health is about 100 grams. (7) That in fever the requirement is about the same or may be a trifle less, 75 to 85 grams, which is enough to prevent protein loss when enough carbohydrates are added. The ap- preciation of these facts is increasingly important in the prolonged fevers, such as typhoid, certain bronchopneumonias or septic conditions. One other fact is of special importance in orientating us correctly with reference to this subject; namely, that such studies as have been undertaken to determine the efficiency of the processes of digestion and assimilation of the foodstuffs in fever show that, except at the onset, these processes are scarcely unpaired. Briefly, in the beginning of fever, do not push the food; respect the meaning of anorexia; but later increase daily to the approximation of theoretical needs. Remember that there are other foods than milk that are easily digested, including cereals, bread, butter, eggs. Water is an important item in the treatment of fever; all the water that the patient wants and his wants should be determined by offering him water at frequent intervals, as his cerebral condition may be such as to prevent him asking for the amount he needs. 1 This calorie is the large calorie and is that amount of heat that will raise one kilo of water through 1 C. 4 TREATMENT OF ACUTE INFECTIOUS DISEASES Studies of the water intake in certain infections such as pneumonia show that the amounts are sometimes extraordinary, 3,000 to 5,000 c.c. a day, and that the patients who are given a sufficiency seem to do best. Fresh Air. That the sick require fresh air would seem a thesis too simple to require emphasis, and yet many physicians make no protest against the vitiation of the sick room by a swarm of visitors and burning gas-jets and make only a half-hearted appeal for an open window. The bad effects of ill ventilation are due in part to the accumulation of carbon dioxide gas. In the country pure air contains about 3 volumes of the gas to 10,000 volumes of air. In rooms and work-shops it may rise to over 30 volumes, and in the night with the gas burning to nearly 50. We consider it niggardly in the hospital if we do not allow 1,000 cubic feet to each sick infant, but how many of our patients get 1,000 cubic feet of fresh air to themselves in the sick room? The increase of carbon dioxide is not the only evil in ill ventilation, for contamination of the air with bacteria and varied forms of dirt must ensue; while heat, moisture, or stagnation and odors add their depressing effects. But there is another quality to fresh air when taken in the open that adds materially to its value; it is the element of cold given either by the temperature of the air or by the effects of its movement. Pem- brey, in a masterly article on Respiratory Exchange in Hill's Recent Advances in Physiology and Biochemistry, says, "The success of the open-air treatment depends it would seem, not so much upon any greater purity of the air as upon free exposure; the open air increases the combus- tion and respiratory exchange improves the appetite and augments the metabolism." More than that, it is an every-day demonstration to the students in our ward that the exposure of the febrile patient to the open, cold, clear air will induce a rise of blood pressure over that obtained in a well-ventilated ward equal to or better than that obtained from our usual vasomotor stimulants, with the added advantage of being con- tinuously sustained which does not obtain with the drugs. I am convinced of the very great value of the open air treatment of fever. The pulse and respiration improve, the cerebral intoxication diminishes and the patients are almost universal in their commenda- tion of it. To reap success, however, the technique must be correct. The pa- tient's bed must be so made as to keep the body always warm, by en- closing the bed in impermeable material like rubber sheeting or paper, the use of the hot water bottle, and by sheltering from winds. The good effects, I believe, come from the action of cold on the nerves of the FEBRILE CONDITIONS 5 mucous membrane of the nose or of the face, producing reflexly an improved vascular condition. Water Locally Applied, Hydrotherapy. I am firmly convinced of the efficacy of remedial measures, operating on the various functions through the surface of the body, that branch of the healing art included under the head of physical therapy. This field has been grossly neglected for various reasons; in part because of the dominant position occupied by drug administration in the minds of most practitioners and very largely because of the time and effort entailed in the administration of these measures and the acquisition of a proper technique. Water is a very valuable instrument in combating the evil results of fever. Baruch, whose persistent advocacy of hydrotherapy con- stitutes a real service to American Medicine and has not received half the recognition it deserves, points out that the value of water lies not so much in its physical constitution as in the fact that it is an admirable material for the conveyance of heat and cold and that strictly speaking, thermotherapy is a better term than hydrotherapy in the use of water. A few facts should be borne in mind in considering hydrotherapy. (1) That we are aiming rather at the toxemia than at the pyrexia. (2) That the reaction to the use of cold water is the sine qua non of success. (3) That friction is as important as the cold in many of the procedures. The good effects of the cold water are obtained largely through the nervous system. The impulses pouring in through the countless nerves upon the centres result in & slower, stronger heart beat, and an improved vasomotor tone, which can be measured in terms of an increased blood pressure; respiration is deepened, cerebral processes improved, and metabolism enhanced. Without detailing the various procedures, one may mention as the best known, the Brand bath in typhoid fever and the chest-compress in pneumonia. Through the cold air and cold water we effect much the same results; the time of year, the facilities of the environment and the reaction of the patients determine an indication for one or the other. Drugs. Drug administration, like the other measures, is aimed not at the pyrexia but at the toxemia, and that the fever is influenced is due to a relief of the toxemia or the conditions determined by it. Cathartics occupy an important position among the drugs, because they prevent a stagnation within the bowel and the consequent absorp- tion of putrefactive products. The toxins of disease impinge upon the vital nervous centres and upon none more certainly than upon the vasomotor centre. Our great dread in 6 TREATMENT OF ACUTE INFECTIOUS DISEASES the severe intoxication, such as typhoid fever, pneumonia, diphtheria, scarlet fever, and sepsis is a circulatory failure. Circulatory Failure. The term "circulatory" is used advisedly, because upon this we can all agree, but when we try to fix this failure in the heart or in the vasomotor apparatus an abundant opportunity for difference of opinion arises. It is the belief of some clinicians that in the large majority of cases it is the vasomotor mechanism that is at fault. For this reason drugs that act either on the vasomotor centre or on the vessels seem rational. Such drugs include caffeine and I think it should be given in sufficient dosage and so administered as to guarantee its arrival at the goal de- sired. 1 give it hi the form of one of the soluble double salts, that of caffeine and sodium benzoate or caffeine and sodium salicylate, in doses of five grains every four hours, and such studies as I have made upon its effects on blood pressure show that its effects do not last even through- out this period. Next to caffeine, I use a 10 per cent, or 20 per cent, solution of camphor in olive oil or sesame oil and use more than the usual dose, giving at least five grains every four hours, hypodermically, often alternating with the caffeine, thus giving a dose every two hours. Per- sonally I have less faith in strychnine. That we can exclude the heart in all cases I do not believe and my experience leads me to believe that in all cases of circulatory failure the digitalis group is more reliable than the vaso-motors. I use digitalis in doses of one-half an ounce of the infusion (15 c.c.) three or four times a day or m. xxx (2 c.c.) of the tincture at the same intervals, and ap- preciating that it will not become operative in less than twenty- four hours, use in urgent cases as an initial dose one-half milligram (gr. 1/120) of strophanthin intramuscularly. This whole question of digitalis medication will be found fully elaborated under Pneumonia, Ghap. IX. No mention has been made so far of the antipyretics. In the early stage with bounding pulse, aconite may afford some re- lief by slowing the heart through the vagus, the coal-tar preparations may be used with relief of headache and other pains, but here again the fall of temperature is incidental. These drugs are depressants and should never be used where the circulation is impaired. Hyperpyrexia. As has been said, fever may be looked upon as of purposeful intent, as a conservative effort on the part of the organism to accomplish something useful to itself. If this be so, measures directed at the fever as such are misdirected if not pernicious, and it will be noted that the treatment of fever outlined in this chapter has been directed at the toxemia accompanying the febrile movement rather than at the FEBRILE CONDITIONS 7 latter; but as was said in the beginning, any symptoms primarily useful may in the end become harmful; one may say that Nature has overshot the mark. Excessive temperatures fall into this category as well as prolonged sustained temperatures. Hyperpyrexia threatens cell function and cell integrity as increased protein destruction shows. We see its effects best hi insolation and in certain rheumatic fevers. In these cases reduction of heat is life saving. We have no better method than the direct application of cold in the shape of cold baths or ice rubbed upon the surface of the body. The patient may be put into a bath of 90 F. and the water cooled down to 70 F. to 75 F. The body is kept immersed until the body tem- perature falls below the danger point, but it is wise to remove the patient when it falls to 102 F., as collapse may ensue on efforts to reduce it to normal. If such occurs, stimulants and heat are indicated, as in collapse from any other cause. Antipyretics of the coal-tar group are not comparable in efficiency or safety to cold water, but may be used where it is impossible to use the latter. No attempt has been made in this chapter to go into details; only generalizations have been laid down with special emphasis given to those branches of therapy commonly neglected, and for this reason serum therapy or vaccine therapy, which are specific for individual disease, have been omitted, but will be considered in their appropriate places. SUMMARY Symptoms of disease are primarily the expression of purposeful in- tent on the part of organs or tissues working under abnormal con- ditions; are conservative efforts and should be respected by the therapist. Interference with symptoms is demanded only when, having sub- served their purpose, by continuing they themselves become the source of exhaustion. Fever is a term ordinarily used to cover both pyrexia and toxemia. The treatment of fever, then, is the treatment of pyrexia and toxemia, and, except in hyperpyrexia, more especially to toxemia. The fundamental principles of the treatment of fever are: 1. Rest. 2. Diet. 3. Fresh Air. 4. Hydrotherapy. 5. Drugs. 6. Treatment of hyperpyrexia. 8 TREATMENT OF ACUTE INFECTIOUS DISEASES Rest. Lessens demand on muscular and mental energy and conserves energy for purposes of repair and production of immune bodies. Rest in practice means : Rest in bed. Comfortable bed. Well ventilated room. Good nursing. Quiet. Relief from anxiety and concern. Sleep. Diet. Determined by the realization that the body heat and the perform- ance of the functions of the muscles, organs and tissues demand a source of energy and that the only source of energy is food or the tissues themselves. Energy demands at rest are the same for a man in health or in ill- ness: about 33 calories per kilo or 2,300 calories for a man of 154 pounds. Pyrexia increases demands by some 25 per cent, on an average, i. e., about 40 calories per kilo or 2,800 to 3,000 for an adult. Toxemia by destruction of tissue makes even greater demands, es- pecially in prolonged fevers, and amounts of food equal to 50-60^70 or even more calories per kilo may be given ; the amount depending on the patient's ability to handle it and on the gain or loss of weight. Protein needs are from 65 to 85 grams. The more prolonged the fever the more urgent the observance of food requirements. Gastro-intestinal functions, secretion, motility and assimilation are affected but slightly in early days of fever or in profound intoxi- cation. Rules for Feeding. Do not urge food in early hours pr days of fever against the patient's anorexia, but when it disappears appreciate and provide for the demand for food. Water should be given freely; offered to the patient, not awaiting his request. Fresh Air. Proper ventilation of room exclusion of visitors. Open air-|-on verandah or porch observing the proper technique in bed-making. (See Pneumonia.) The value of fresh air consists mostly in its stimulating effects on vital centres, reflexly, through its effect on nerve supply to the skin of face and mucous membranes of air passages. Essential factors. Live air, moving air. FEBRILE CONDITIONS 9 Hydrotherapy. Effect same as that of air. Water is a conveyor of temperature. Cold stimulates vital centres reflexly through nerves from the skin. Essentials to success: water must be cold; friction must be applied (it is the alternating cold of water and heat of hand that affords stimulation) . Patient must react. Drugs. Cathartics to prevent or relieve stagnation and absorption of products of putrefaction. Circulatory stimulants. Vaso-motor stimulants. Caffeine in form of soluble salt (double salt of sodium salicylate or benzoate and caffeine). Dose gr. iij-v (0.20-0.30 Gm.) every 4, 3 or 2 hours. Camphor in 10 per cent, to 20 per cent, solution in oil (olive or sesame oil) in doses equal to gr. v, (0.33 Gm.) of the camphor every 4, 3 or 2 hours. Heart stimulants. For immediate action strophanthin into muscle or vein. Dose, 1/2 milligram (gr. 1/120). Follow up with or in less urgent cases begin with digitalis infusion 5ss (15 c.c.) or Tincture m. xxx (2 c.c.) three or four times a day until desired effects ensue or signs of toxicity of any kind appear. Antipyretics for pain and discomfort at the beginning, in the sthenic stage and even then with caution. Hyperpyrexia. Sudden rise of temperature to 106 F., or above, or prolonged tem- peratures of 104 F.-105F. Cold. Best as baths. Put patient in at 90 F., and lower temperature to 75 F. or 70 F. Take out when temperature of body falls to 102.5 F. Slush baths or cold sponges. Antipyretics indicated only when cold water is inaccessible. Specific treatment. (See individual diseases.) CHAPTER II DIET IN ACUTE INFECTIOUS DISEASES FEEDING the sick is both a science and an art; a science in so far as it takes cognizance of the great laws of supply and demand in a phys- iologic sense; an art in so far as it affects the application of these laws to the individual. Energy. All matter is endowed with a certain amount of energy, which manifests itself differently, under different conditions. Certain chemical substances, by virtue of the nature of the elements that com- pose them and their relationship to each other, that is, their structure, have the power to produce one or more manifestations of energy. They are said, then, to have potential energy. To give rise to the manifestations of energy, these substances must have a certain degree of instability or lability; that is, must be capable under definite conditions of undergoing changes in structure, disruptions, etc., all of which give rise to motion. The substances of which our bodies are composed and food on which they continue to exist are chemical substances of a highly labile char- acter, possessing potential energy, which in the process of catabolism or breaking down, give rise to motion, which conveyed to other bodies is manifested as work or is expressed as heat, to neglect the lesser forms of energy in the human body, such as the electrical. Energy is as indestructible as matter itself. It can be transformed from one kind to another, but it cannot be destroyed nor yet created anew. Different manifestations of energy have definite quantitative relationships to each other, as Joule's great experiments on the mechani- cal equivalent of heat showed. He demonstrated that the amount of work necessary to raise 1 Gm. of water through 1 cm. of distance was that required to raise 42.55 Gm. of water through 1 C. I have said that the conversion of the potential energy of the body or of the food into one or the other manifest forms of energy occurs under definite conditions. The definite condition in the body which gives character to its manifest energy is the "vitality" of the cell. Moore 1 calls the living cell an " energy transformer." He says: "The living cell is not a peculiarly constructed membrane obeying, 1 Recent Advances in Physiology and Biochemistry, edited by Leonard Hill, London, 1908. DIET IN ACUTE INFECTIOUS DISEASES 11 even where it seems most directly not to obey, the physical laws of diffusion and osmosis; but is an energy machine or transformer by virtue of the operation of which a form of energy appears, peculiar in its manifestations and phenomena to living matter." The kind of energy that this transformer, the living cell, produces out of the potential energy of the body and its foodstuffs is almost entirely thermokinetic, that of work and heat, and as we can express work in terms of heat, we may reduce the total activities of the body to terms of heat and express them as equal to so many "calories" or heat units. The " calorie " is a term used to express that amount of heat which is required to raise 1 c.c. or Gm. of water through 1 C. More properly, this is termed a "small calorie/' while the term "large calorie" is used for the amount required to raise 1 kilogram or 1 liter of water through 1 C., i. e., 1 large calorie equals 1,000 small calories. Calories referred to in this work are large calories. The Caloric Balance of the Human Body. As has just been said, the human body (the cells collectively) is an energy transformer; or to put it in other terms, the human body is like a steam-engine, con- suming fuel for the purpose of doing work and producing heat; but the human body differs from a steam-engine in this, that, lacking fuel, it will consume its own structuie up to the point of a complete collapse of the mechanism; so that, to maintain the integrity of the transformer or engine, it is necessary that the output by it of work and heat shall be exactly met by the fuel afforded it. To know the amount of food the human body requires, then, we must know the amount of work it does and the amount of heat it elaborates in a given time. Now Nature has given to the individual a most amazing regulator to adapt the supply to the demand on which no device of man can ever improve; that is, appetite. When one thinks that day after day and year after year, the body retains a fixed or approximate weight, under the most varying demands of work, and consequently of food, under the guidance of this monitor, one is lost in admiration; but as there are times, in the stress of disease, when this regulator fails or by the dictates of false theories, is disregarded, we need to know what the demands actually are, in order that we may guarantee that they may be met. The determination of the caloric output in man has been made pos- sible by the use of the calorimeter chamber of Pettenkofer and Voit, elaborated and perfected by Atwater and Benedict, whose work in this field has been the most extensive and accurate ever done, and whose studies of food-values have been accepted by the government as stand- 12 TREATMENT OF ACUTE INFECTIOUS DISEASES ards; and by the study of the respiratory quotient determined by the simpler apparatus of Zuntz. Work. Still another way 'to determine the caloric needs of man is to determine the heat values of the foods habitually taken by normal individuals in different callings. These analyses of the average intake and output agree wonderfully well. For men doing light or sedentary work, clerks, professional men, literary men, the requirements are between 2,400 and 2,600 calories; for those whose work is a little more arduous, as machinists, shoemakers and the like, 2,900 to 3,100 calories; for those doing hard muscular work, smiths, masons, etc., 3,300 to 3,600 calories, while those doing very hard work run up much higher, the Maine woodsmen demanding some 7,000 to 8,000 calories. Football players require nearly as much. What concerns us most is the requirement of a man at rest, for this is the condition in which we find our patients. Rest, too, is a relative term, and as used here means that degree of activity which obtains, when a patient is put to bed, which is a very different state from com- plete muscular relaxation or that prevailing in sleep. At rest the de- mands are about 2,300 calories or 33 calories per kilo of body weight, the average man weighing 70 kilos or about 150 pounds. A fact of prime importance to us as practitioners is that educed from the work of Magnus-Levy, 1 namely, that the total metabolism is the same in the sick man as in health, so far as the demands of muscular effort and heat production go; but, as we shall see, fever and toxemia increase these demands. Weight. The caloric requirement of an individual depends not only on the amount of work he does, but also on the size or bulk of his body; and while we have spoken of the requirements of a man at rest as 2,300 calories, it is meant for a man of average weight, while such wide varia- tions as a man of 200 pounds and a woman of 100 pounds are common in our every-day experience. The requirements are best thought of in units of weight, as so many calories per kilo for a man at rest 33 calories per kilo. Here, too, certain modifications have to be made, as in the excessively obese, whose fat is hardly to be considered in the same light as the more actively metabolizing tissues. Age. The figures "33 calories per kilo" obtain only for adults. In the young the growth has to be taken into consideration, which in certain periods is more intensive than in others; e. g., in the first three months of life the demands are about 110 calories per kilo; in the second three months, 100; in the last half of the first year, 90; at the end of the second 1 Quoted from Otto Cohnheim: Die Physiologie der Verdauung und Erndhrung. DIET IN ACUTE INFECTIOUS DISEASES 13 year, 75 to 80; at 10 years, 60, and at 14 years, 52. Indeed, as Cohnheim observes, the boy of 10 requires as much food as the adult who does not do muscular work, while the youth of 14 to 16 must eat 3,000 calories, about one-fourth more than his father who leads an intellectual life. Body-surface. In consideration of the fact that in all warm-blooded animals the production of heat is the most imperative function of metab- olism, and further that the dissipation of it is largely a function of the skin, there stands a relationship between these two, closer than that between metabolism and weight. In a small sphere the surface is greater, proportionally to the contents, than in a large one, for the contents in- crease as the cube of the radii, while the surfaces increase as the squares, so that in the smaller bodies the radiation is relatively greater and the heat production must be relatively more intense. So it is that we find in the infant a requirement of 100 calories against 33 in the adult, but when the surfaces are compared, it is found that reckoned in calories per square decimeter, it is about the same from 10 weeks to adult life, 13 to 14 calories per square decimeter (Pfaundler and Schlossmann). The unit of weight is, however, so much more readily obtained that we use it in preference. Metabolism experiments carried on during rest have shown that whether reckoned on the one unit or the other they are always the same for all individuals, men or women, sick or well. It must be re- membered, however, that the conditions of the experiment produce more nearly real rest than obtains in the sick-room. Differences of temperament determine very different degrees of muscular activity, while certain phases of an acute infection, like delirium, become a matter of serious import in the consideration of rest. As has been said, all this energy manifested as work and heat by the body, resides potentially in and is derived from the food. The food, then, must furnish periodically just what the body has expended in order to keep the latter intact, for if the food is deficient, ' the deficit will be made up out of the body itself, as long as it can stand the drain. Our patient at rest, then, must have 2,300 calories of food a day. Caloric Value of Foodstuffs. The foodstuffs are divided into three classes, fats, carbohydrates, and proteins. Strictly speaking, salts and water are foodstuffs, but they have no caloric value. Rubner's figures for the caloric value of foodstuffs still stand to-day, such slight modifications as have been made having but little practical significance. They are as follows: 1 Gm. of fat furnishes 9.3 calories. 1. Gm. of carbohydrate furnishes 4.1 calories. 1 Gm. of protein furnishes 4.1 calories. 14 TREATMENT OF ACUTE INFECTIOUS DISEASES With these figures and a table of the average composition of the common foods, like those of Atwater, published by the U. S. Depart- ment of Agriculture, it is no difficult task to arrange a dietary. 1 The first step, then, in arranging a diet in acute infectious diseases, is to provide, as a minimum, as many calories as are demanded by the individual when at rest hi health, 33 calories per kilo, or 2,300 in the average man. A diet must not only contain sufficient heat units, it must also be properly balanced with reference to the three foodstuffs, and of these three, the most important is protein. Protein Needs. Two facts of great importance are to be kept in mind, which differentiate protein from the other foodstuffs; first, in the adult, under normal circumstances, the daily demand for protein is fixed and does not vary with the amount of work done, as is the case with the other two foodstuffs; and second, there is no provision for a storage of an excess of protein, as is the case with fats and carbohydrates. Therefore, any excess must be catabolized and eliminated. This daily amount of protein amounts to about 100 Gm., or 16 Gm. of nitrogen. Voit's figures are 118 Gm. of protein as ingested, which, allowing for the amount found in the stools, gives about 100 Gm. net. The analysis of dietaries the world over has given a remarkable una- nimity of results, which have confirmed Voit's figures. That a man may perform hard work for months and remain in ex- cellent condition on an amount of protein far less than this, one-half and even less, has been demonstrated by Chittenden in the most elaborate and extensive set of experiments ever cariied out on this subject. Phys- iologists, however, though they must accept the possibility of this low protein need as a fact, are not yet inclined to argue from this demon- stration that such an intake would subserve the interests of the organism in the long run to the best advantage. Functions of Protein. Protein subserves three important functions. First, it furnishes substance, building material, to the body. This is spoken of as the " storage" of nitrogen. Second, it repairs the daily waste of the body, the wear and tear of the machine. Third, it furnishes heat in its combustion, that is, is a fuel. It is only in early life that the first of these functions, storage, is of prime importance. At that time it is one of the most imperative of physiologic functions. The continuance of growth, when weight may 1 An excellent table of food values expressed in units of 100 calories may be obtained from the J. A. M. A., Chicago, for 10 cents, entitled Extracts from Prac- tical Dietetics, Irving Fisher. Food V allies: Edwin Locke is an excellent hand book. DIET IN ACUTE INFECTIOUS DISEASES 15 be stationary or regressive, is a familiar phenomenon to the pediatrist, expressive of the fact that the protein is seized on with avidity even when the fuel-value of the food is insufficient for body needs. It is a curious fact that the actual amount of protein ingested in infancy is about the same month after month, but the amount devoted to storage decreases, while that used for wear and tear increases. In the first two weeks over 75 per cent, is stored; at two months 40 per cent.; at five months 23 per cent. When an individual has attained his or her growth, storage ceases, except on special occasions; these are during pregnancy and lactation, in the establishment of hypertrophy of groups of muscles, as in the training of an athlete, and during convalescence from wasting disease or after a long fast. The second function, repair of wear and tear, is the important one in adult life. This has to do with maintaining the integrity of the ma- chine as a whole and has nothing to do with the amount of muscular work, so it is a daily constant, regardless of the amount of exertion the body has been put to. It is for this purpose that the food should contain 100 Gm. of protein a day in the adult diet. The third function is incidental. Protein does furnish heat, but it is not an economical source of supply. In the infant the proper amount of protein furnishes about 7 per cent, of the calories; in the adult about 14 per cent. The reason that protein is not an economical fuel lies in that peculiar property known as its " specific dynamic action." When food is ingested, the physiologic processes sequential to it produce heat. The amount of such heat induced by fat and sugar is slight and negligible, but not so protein. The ingestion of this substance gives rise to a production of heat equal to a trifle more than 30 per cent of its caloric value. The source of this heat is a matter of dispute, but it would seem to be due to the work of the glands of secretion and to cell activities with which we are less acquainted. Lusk has intimated that in the case of protein it may be in part due to the denitrogenization of the amidobodies. This heat is lost to the body, is waste heat, under the conditions of temperature and physical regulation of heat in which man lives. He cannot utilize this heat for purposes of cell-life. This loss of heat by the specific dynamic action of protein may be expressed in this way: that to get the caloric value of 100 Gm. of protein one must ingest 140 Gm. of the food. It is this increased heat that must be dissipated that has led naturally to a limitation of meat diet in hot weather and to its general elimination from the diet of fever. The second step, then, in arranging a diet in the acute infectious diseases, is to provide enough protein to replace the wear and tear, 16 TREATMENT OF ACUTE INFECTIOUS DISEASES an amount which hardly differs from the general demand in health. It may be placed at 65 to 80 Gm. Fat and carbohydrates differ from protein in two very striking ways as articles of diet; first, when utilized by the body the oxidation is com- plete and they are eliminated as carbon dioxide or water, while the nitrogenous moiety of the protein is not completely oxidized and entails work on the part of the kidney to eliminate it, which the other food- stuffs do not require; second, an excess of fat and sugar beyond imme- diate needs is stored in the body as fat and does not demand prompt elimination like the excess of protein. The proportions of the three foodstuffs in an average dietary is protein 100 Gm., fat 50 Gm., and carbohydrates 400 to 500 Gm., giving in the neighborhood of 3,000 calories. Milk. No food in infectious diseases has been used so much as milk, and frequently to the exclusion of all others. An excellent milk will show on analysis about 4 per cent, of fat, 4.5 per cent, of sugar, and 3.5 per cent, of protein, or, to the liter, 40 Gm. of fat, 45 Gm. of sugar, and 35 Gm. of protein. Using Rubner's caloric values as given above, we see that the caloric value of a liter of milk is 700; reduced to quarts, there are about 640 calories to the quart, or 20 to the ounce a convenient figure as a mnemonic. A liter contains 35 Gm. of protein or 1 Gm. to the ounce. It will be seen presently that a low estimate of the caloric needs in fever of an average individual is 3,000. To meet this one would have to administer over a gallon of milk, which would contain over 140 Gm. of protein. These figures sufficiently demonstrate how illy adapted an exclusively milk diet is to meet the needs of an individual suffering from an acute infection. Standard Portions. When one comes to study the tables of com- position of foodstuffs, it is plain that the establishment of a dietary to respect the caloric requirements and the protein needs of a patient is a task outside the time and patience of an active practitioner. It was with an appreciation of this fact that Professor Irving Fisher, of Yale, pub- lished his tables of standard portions. It will be seen from the table representing a few of these articles selected how remarkably the ordinary servings of common articles of food, or at least multiples or simple fractions of them, amount to just 100 calories. In some of our hospitals the nurses are now instructed to bring food to the patient in these portions, so that the estimate of the daily intake can be easily made with a degree of accuracy that, though not adapted to DIET IN ACUTE INFECTIOUS DISEASES 17 research work, answers all practical purposes, and because the daily exhibition of these portions is an education to both the medical and nursing staffs. It soon becomes an easy matter to think of the ordinary articles of diet in terms of units of 100 calories. TABLE OF FOOD-VALUES IN UNITS OF 100 CALORIES i Protein in Gm. Milk, 5 oz 5. Cream, 16 per cent. (2 oz.) 1.5 Buttermilk, one and one-half glasses (9.5 oz.) 8. Koumys, one glass (7 oz.) 5. Whey, two glasses (13 oz.) 3.5 Eggs, one and one-half 10 . Whites of eggs, 6 24. Yolks of eggs, 2 4.5 Oatmeal, one and one-half serving (5.5 oz.) 4.25 Boiled rice, ordinary cereal dish (3 oz.) 2.5 Hominy, large serving (4.2 oz.) 2.5 White bread, home made, one thick slice (1.25 oz.) 3.2 One small Vienna roll (1.25 oz.) 3.2 Butter, one pat (0.5 oz.) 0.0 Sugar, three teaspoonfuls, one and one-half lumps (0.8 oz.) 0.0 Macaroni, cooked, average serving 3.0 Spaghetti " " 3.4 Tapioca " 1.1 Prunes, edible portion, three large 0.9 Lemon juice, 9 oz 0.0 Oil, one-third ounce 0.0 Codfish, two servings (5 oz.) 23 . Halibut steaks, one serving (2.8 oz.) 15. Mackerel, Spanish, one serving (2 oz.) 12 . 2 Shad, one serving (2.1 oz.) 11.2 Salmon, small serving (1.5 oz.) 7.3 Oysters, 12 12. Roast beef, ordinary serving (1.8 oz.) 10. Small sirloin steak (1.4 oz.) 7.5 Leg of lamb or mutton, ordinary serving (1.8 oz.) 10. Lamb chop, one, small (1 oz.) 6. Bacon, small serving, medium fat (0.5 oz.) 1.5 Chicken, broiler, edible portion, large serving (3.2 oz.) 19. Turkey, large serving (1.2 oz.) 7. Potato, baked, one, good size (3 oz.) 3 . 75 Potato, sweet, baked, one-half average potato (1.7 oz.) 1.5 String beans, five servings (16.66 oz.) 3.75 Spinach, two ordinary servings 6.1 oz.) 3.7 1 Adapted from Prof. Fisher's Tables. Loc. cit. 18 TREATMENT OF ACUTE INFECTIOUS DISEASES Peas, green, one serving (3 oz.) 5.7 American or Swiss cheese, 1.5 cubic inches (0.75 oz.) 6. One baked apple, 3.3 ounces 0.5 The object of our consideration is a patient suffering from an acute infectious disease: So far I have discussed only the food requirements of a man in health at rest. Such a discussion is relevant to this subject, however, because the requirements of the patient are the same plus a certain additional need determined by the infection itself. There are four factors that enter into the problem of feeding in acute infectious diseases that render it distinct. They are (1) gastro-intestinal disorders; (2) pyrexia; (3) toxemia; (4) starvation. Starvation in fever has been a tradition in medicine that has lost but little authority with the passage of time and finds wide acceptance to- day. The legitimacy of such practice I wish to examine. Disturbance of Gastro-intestinal Function. It cannot be denied that the gastro-intestinal tract is not indifferent to the effects of the infection. We are all familiar with the dry mouth, the coated tongue, the anorexia and the tympanites of many of the patients. One feels little inclined to urge food on so unwilling a receptacle and this feeling has plead potently with many practitioners to establish insufficient, often starvation dietaries. Investigation has shown that the salivary secretion is lessened, that the output of hydrochloric acid is diminished and the motility of the distal portion of the intestine is impaired. It has been claimed that the motility of the stomach, too, is prejudiced (von Leyden and Klemperer), but von Noorden maintains that that has not been the case in the patients he has studied. More important still, assimilation seems to be good, and von Leyden and Klemperer 1 found that in different patients with high fever 89 per cent, to 94 per cent, of easily digestible fat was absorbed and 91 per cent of protein. Moreover, they found no carbohydrate in the stools unless excessive amounts had been ingested or diarrhea prevailed. Taking these data and what I have seen of liberal feeding in febrile conditions, I am convinced that the ability of the alimentary tract to perform its normal functions in fevers has not been duly appreciated and the withholding of food on the supposition that this organ is crippled is unjustifiable. I do believe that in the incipiency of an acute infection these functions are more in abeyance than later, but that they quickly become compe- tent. I also believe that the state of the mouth and digestion is due in no small measure to an insufficiency of water and is greatly aggravated, 1 Von Leyden and Klemperer: Handbuch d. Erndhrungs-Therap, 1904, ii, 332. DIET IN ACUTE INFECTIOUS DISEASES 19 not by the giving of food, but by the withholding of food, which en- tails a destruction of body tissue and sets on foot abnormal metabolic processes. Fever. The term "fever" as ordinarily used, connotes the sum of two distinct factors: (1) pyrexia, and (2) toxemia. These will be dis- cussed separately, and when, under pyrexia the word "fever" is used, it is to be taken in the sense of an elevated temperature alone, i. e., pyrexia. Pyrexia. There has been an endless controversy from remote times as to the significance of fever, it being contended on the one hand that it was a deleterious factor in the disease, on the other, that it was bene- ficial and had a meaning that was -to be respected; purposeful, the teleologist would say. This is not the place to discuss at length fever and its relation to disease, but I am in agreement with the conclusions of careful students of the subject that " fever is a specific reaction against injurious materials which affect the tissues"; that it "is in its essentials a protective reac- tion," to quote from the excellent article on fever by Dr. W. G. Mac- Callum. 1 There has been a wealth of work done to prove this statement, which one will find set forth in detail in the article just referred to and in a critical review of the subject by Hermann Ludke. 2 Pyrexia below 104 F. is to be let alone; it is useful; above that figure it adds an element of harm and then antipyretic measures are indicated, but not till then. It must be remembered that many so-called antipy- retic measures, such as the cold baths, are directed not toward the temperature, but to the circulatory and nervous system, and are of the highest value when these systems are in distress. The phenomena of fever lead rapidly to the assumption that there is a great increase in heat production and a marked retardation of heat dissipation, in other words, a great accumulation of heat in the body. This is only partially so. The actual increase in the oxidative processes is relatively small, while the relation between heat production and heat dissipation is but little inter- fered with. What seems actually to take place is the regulation of these processes on a higher level, so to speak; what level, that is, at what tem- perature, depending on the effects of the toxins on the heat-regulating mechanism. This mechanism, however, under such conditions, does not display the same degree of stability as in the normal individual, but a lability that characterizes the temperature curve in infections, and, indeed, gives their individual stamp to them. 1 MacCallum, W. G.: Arch. Int. Med., 1909, ii, 569, and the Harvey Lectures, 1908-1909. * Ludke, H. : Ergebn. d. Inn. Med. u. Kinderh, iv, 493. 20 TREATMENT OF ACUTE INFECTIOUS DISEASES I have said that the increase of heat production in fever is relatively small. The figures vary; sometimes there is no increase, but on the average it amounts to about 25 per cent. This might seem considerable did we not pause to consider that in strenuous muscular exercise the increase of heat amounts to several hundred per cent. ; for example, the 8,000 calories of the Maine woodsman to the 2,300 at rest. The fact that such great increase in heat in the normal man causes no rise of temperature shows that the elevated temperature of fever requires an additional factor to that of heat production; that It is the result of the toxins as well as heat. However, as our patient is at rest, this 25 per cent, increase has to be added to the 2,300 calories allowed him, in order to make good his daily losses, so that it may be said that the require- ment of the febrile patient is 40 calories per kilo or 2,800 calories, near enough to 3,000 to make that our guide. One other effect of pyrexia I wish to mention; that is, its destructive action on protein. As Lusk says, " Infectious fevers are characterized by a toxic destruction of body protein"; but there are three factors con- cerned in the loss of nitrogen during an acute infectious process: (1) pyrexia, (2) toxins, (3) starvation. The study of non-toxic fevers, such as are induced by exposure to heat or by puncture of certain parts of the brain, show that the pyrexia can induce protein catabolism, but it seems to demand a temperature of 102 F. or over to bring about this protein loss, and experimentation has shown that a sufficient feeding can control this loss. Toxemia. It was recognized that apart from the effect of pyrexia and apart from starvation, or at least in the presence of food sufficient to meet all the theoretical considerations we have so far set forth, there still continued to be a considerable loss of protein in the acute infectious diseases. This loss came to be accepted as inevitable by the ablest investigators in the field and was attributed to the effects of the toxins and was called the "toxic destruction" of protein. Just how the toxins brought this protein loss was and is a matter of conjecture. It has been attributed by Krehl to actual cell destruction; by others to an exciting effect on metabolism by the toxins; by others to an expression of the production of antibodies and other protective substances. Certain it is that it is dissociated from the pyrexia, as such; for it is often intense when there is no rise of temperature. Taken with this destruction it has been suggested that a weakened power of regeneration exaggerates the dif- ference between catabolism and anabolism. Starvation. This does not belong to the acute infections as a rule, except as it is inflicted on the patient by an insufficient dietary. Energy must be supplied to the body each day and when the food does not do it, DIET IN ACUTE INFECTIOUS DISEASES 21 the body substance does and the protein is called on to do its share at the sacrifice of cell integrity. At the present moment one of the most intensely interesting fields of medical research is that devoted to metabolism, the building up and breaking down, anabolism and catabolism, the storage of energy and its dispersion; what one writer has called the "most fundamental char- acteristic of life, energy-traffic." The intimate processes of protoplasm yield their secrets stubbornly, but we know what they have to work on and we know what they yield back; we know the fuel and the ash, the intake and the output, and from the knowledge of these two, we deduce much that has occurred in the process of the change. Nitrogen is the basic substance on which the body structure is erected. It is ingested with the food and it is expelled in the urine, the stools and in lesser measure by the skin. In health the intake and output balance each other, and the nitrogen eliminated is divided among a number of combinations which maintain a pretty constant relationship to each other. These nitrogen combinations are spoken of as the " nitrogen partition." In disease the balance of intake and output is disturbed and the relationship of the combination undergoes a change, so that the study of the nitrogen partition in disease is a tree that bears much fruit. I have said that the nitrogen elimination is divided among three organs, the kidneys, the intestine, and the skin. As for the skin, its output is negligible except when made to functionate in an unusual manner, as in very profuse perspiration. Under such circumstances it has been known to yield as much as 0.75 to 1 Gm. of nitrogen. The stools, however, contain an appreciable amount of nitrogen. Some very curious ideas prevail even among physicians about the feces; e. g., that they represent the residue of the food; that the amount depends entirely on the amount of food ingested; that if there be no food taken there should be no feces. The stools do not represent the residue of food so long as the food is free from indigestible matter. Stools occur in fasting people and a comparison of these stools with those ordinarily passed shows that there is no difference in their composition or relation of constituents, no matter whether there be much or little food taken, and no matter whether that food be protein, carbohydrate or fat. The amount increases but little with the food and in no sense in proportion to the amount ingested. If excesses of food are eaten, a minimum residue may appear and, of course, cellulose or other indigestible substance is found. The stools are made up of the residues of the digestive juices, mucus, desquamated epithelium, bacteria, the products of bacterial action, salts 22 TREATMENT OF ACUTE INFECTIOUS DISEASES and water. Of the salts, it must be remembered that the intestine is the excretory organ for iron and calcium and for the most part of phosphorus and magnesium. The nitrogen content varies from 1 to 2 Gm., but on the whole is so constant that itlias been considered as furnishing a definite per cent, of the nitrogen ingested (15 per cent.) without prejudice to the accuracy of the metabolism study. It is to the urine that we turn, however, to derive important in- formation; for 80 per cent, to 90 per cent, of the nitrogen is excreted by the kidney as urea, uric acid, ammonia, xanthin bases, creatinin, and amidobodies. The study of the total excretion and of its individual constituents is of importance. Total Nitrogen. It has been invariably found that the amount of nitrogen excreted in fever far exceeds the amount ingested, and so much the more, the more severe the process. It is common enough to find losses of 8 Gm., 12 Gm., 16 Gm., and more of nitrogen a day; that is, in excess of the intake; and, that, too, when on a diet usually considered satisfactory. This latter figure is the amount of nitrogen demanded in Voit's standard dietary, and if it were interpreted in terms of muscle tissue would mean a loss of a pound of such tissue. Such figures will be found repeatedly in the tables of Shaffer and Coleman's studies on metabolism in typhoid fever, 1 and those of Wolf and Lambert 2 on pneumonia. The study of the total nitrogen and the determination of the " nega- tive nitrogen balance/' as it is called, tells us that there has been loss of substance to the body, but it does not tell us what tissues are suffering this loss, nor yet whether the metabolic processes are carried out in a qualitatively normal manner. Such scant information as we have along these lines is derived from the study of the parts that go to make up the total; that is, the nitrogen partition. It is the small portions that in the past excited but little interest that are now yielding us the most information. One of these portions is the substance creatinin. When Folin 3 published his classical analyses of thirty normal urines, he called attention to the fact that this substance creatinin remained practically constant, no matter what the amount of 1 Shaffer and Coleman: Arch. Int. Med., 1909, iv, 538. 2 Wolf and Lambert: Arch. Int. Med., 1910, v, 406. 3 Folin: Approximately Complete Analysis of Thirty Normal Urines; Laws Governing the Chemical Composition of Urine; a Theory of Protein Metabolism, Am. Jour. PhysioL, 1905, xiii, 45, 66, 117. DIET IN ACUTE INFECTIOUS DISEASES 23 protein ingested. On this fact he elaborated the theory that this sub- stance was an indicator of "tissue" or "endogenous" metabolism in contradistinction to "intermediate" or "exogenous" metabolism, of which urea is the chief representative. Another representative of this "constant" or "endogenous" metabolism is neutral sulphur, 1 and to a lesser extent, uric acid and ethereal sulphates. Folin showed that this substance was constant in the individual, but varied in different individuals according to body weight. He spoke of it as an "index to the amount of a certain kind of protein metabolism occurring daily in any given individual," 2 but defined that kind of "protein metabolism" no further. Shaffer, 3 however, added to our information a little further, by show- ing that not only was the output of creatinin in an individual constant from day to day, but also from hour to hour, amounting from 7 to 11 mg. of creatinin nitrogen for every kilogram of body weight per twenty-four hours; this he called the "creatinin coefficient." He, moreover, gave reason to believe that the substance was an index, not of total tissue metabolism, as Folin thought, but of one tissue metabolism, that of the muscle, as its output seemed to show a parallelism to the muscular efficiency or strength of the individual. It has nothing to do with the muscular work, but rather with the machine, the muscle itself. He suggests that it is an index of muscle tone. If one may use an analogy without too close adherence to details, one might consider the creatinin to represent the friction, the daily wear of the muscle machine, not at all the product of its work. Here was an important clue to follow up. Any substance that showed the ravages of disease in so important a tissue as muscle was worth looking after. Already studies on the substance in -pathologic conditions had assisted to suggest the above view of its significance and further work confirmed it. It was found that creatinin was diminished in conditions of muscular inefficiency, such as amyotonia congenita, myasthenia gravis, muscular dystrophy, 4 exophthalmic goitre, and in the as yet undeveloped muscles of the infant. 5 How is it affected by acute infectious fevers? *The importance attributed by Folin to neutral sulphur as an expression of "endogenous" metabolism has more lately been called into question. * See note 3 on page 22. Am. Jour. PhysioL, 1908, xxiii, 1. 4 Spriggs: The Excretion of Creatinin and Uric Acid in Some Diseases In- volving the Muscles, Quart. Jour. Med., 1907-1908, i, 63. 'Amberg and Rowntree: The Excretion of Creatinin in the Infant, Bull. Johns Hopkins Hosp., February, 1910. 24 TREATMENT OF ACUTE INFECTIOUS DISEASES There is a pretty constant agreement among the investigators that it is increased during the height of the fever and is most marked when the nitrogen loss is the greatest, but there is no numerical relationship between the two. During convalescence and even before, there is a dimi- nution in the excretion which may be attributed to muscular weakness. It must be interpreted in the sense that the febrile condition increases the wear and tear of the muscle tissue. This increase in creatinin was determined for typhoid fever, 1 for pneumonias, and for erysipelas. So much for increased wear and tear of the protein constituents of the body during the acute infectious process; but is there anything that bespeaks by its presence actual destruction of a definite tissue? There is a substance in the tissue closely allied to creatinin, which differs from it only by the presence of one molecule of water in its struc- ture (creatinin is a dehydration product of creatin), which does not appear normally in the urine, or appears only in traces. This is called creatin. Creatin is to be found in the urine only in abnormal conditions. It is found in wasting diseases, such as the cachexia of carcinoma, in starva- tion, and in fevers. It is derived from the muscle and its presence in the urine means destruction of the substance of that structure. It is very striking during the involution of the uterus after childbirth. It was found in all the studies on fevers referred to, and sometimes ran over into convalescence. Its disappearance from the urine is looked on as a good omen, and what interests us as dietitians is that when made to appear in starving animals it has disappeared under a pure carbohydrate diet. Besides the creatinin, neutral sulphur and uric acid are both increased and may be looked 'on as further expressions of increased endogenous metabolism. So far we have considered quantitative changes rather than quali- tative in the nitrogen metabolism. Qualitative changes might be taken as evidence of metabolic inefficiency. Evidence of this is to be looked for in the so-called " rest nitrogen." This "rest nitrogen" or "undetermined nitrogen" is that nitrogen which is left of the total nitrogen when the nitrogen of urea, ammonia, uric acid and creafcinin have been subtracted. If the "rest nitrogen" in- creases it may be considered as being at the expense of the urea, the most important nitrogenous substance, and so indicate a defective deamida- tion. The amido-bodies are, indeed, the most important of the sub- stances included in the "undetermined nitrogen." There are, besides 1 Klercher: "Ueber Ausscheidung von Kreatin and Kreatinin in fieberhaften Krankheiten," Ztschr. f. klin. Med., 1909, Ixviii, 22. DIET IN ACUTE INFECTIOUS DISEASES 25 leucin and tyrosin, indol, skatol, glycocoll, proteic acids and albumoses, as well as xanthin bases. Shaffer and Coleman found but little increase in the "rest nitrogen" in typhoid fever and the same was true of pneumonia investigated by Wolf and Lambert (there was absolute increase, but not in dispro- portion to total nitrogen). It may be said, then, that as a rule the urea- forming function is but little impaired, an important conclusion in considering the ability of the liver to handle the products of protein digestion. In grave cases, such as were observed in the study of typhoid metab- olism by Ewing and Wolf, the "rest nitrogen" did become high and the urea low. These authors looked on the phenomenon as indicative of inefficiency of the liver urea formation, recalling the high "rest nitrogen" found in acute yellow atrophy. Such patients probably suffer from an auto-intoxication in addition to the toxemia of the disease. All this shows that in acute infectious diseases there is a loss to the intrinsic structure of the body and that while such loss is entirely com- patible with a perfect urea-forming function and, indeed, the latter is but rarely impaired even in severe cases there are yet a certain number of grave cases in which the liver has apparently through grave changes in its structure found itself incapable of dedamiation and abnormal metabolic processes are in evidence. With this knowledge it should be the effort of the therapeutist to prevent this loss and perversion of function, or at least to mitigate them. Can the administration of food accomplish this, and, if so, how shall it be ordered? It would seem natural to conjecture that if the body was losing 10 Gm., 15 Gm., or 20 Gm., of nitrogen a day over the intake, such a loss could be made good or prevented by increasing the intake of nitrogen to that amount. The truth of the matter is that neither the amount of the loss nor any other amount, without the help of the other foodstuffs, can bring about a nitrogenous equilibrium in man. The work of Folin and Chittenden, showing the small amount of nitrogen which is really needed to establish an equilibrium, would lead us rather to use the smallest amount of protein necessary and avoid the breaking down and elimination of the superfluous nitro- gen radicles, by organs burdened with disease, and increasing the heat to the fevered organism by the "specific dynamic action" of the protein. Shaffer and Coleman were able to establish nitrogen equilibrium 26 TREATMENT OF ACUTE INFECTIOUS DISEASES in typhoid fever on from 10 Gm. to 15 Gm. of nitrogen, when sufficient carbohydrate was used. This amount will be seen to be less than the Voit standard demands, by a considerable margin. Fat and carbohydrate both spare protein; not, of course, replacing it, for they are both nitrogen-free. Fat spares the combustion of protein to furnish heat; and weight for weight furnishes, as has been shown, over twice as many calories as carbohydrates. The fat of the body is utilized in this manner as a protein-sparer. Emaciation, which bespeaks its disappearance, makes the sufficiency of food intake all the more impera- tive to prevent destruction of the body protein. Carbohydrate is a very much more efficient sparer of body protein than fat. Probably much of the demand on protein in the underfed body is for the carbohydrate moiety of its structure. Carbohydrate is im- perative to life and must be had at any cost. This the ingested carbo- hydrate furnishes, so that it both furnishes heat as does the fat, and also subserves other functions which the fat cannot do. Nitrogen equilibrium has been struck and the subjects kept at from 5 Gm. to 8 Gm. days and weeks with comfort and apparent health, when enough carbohydrate and fat are taken. The above statements hold for the protein-sparers in health. In acute infections their influence is not so marked quantitatively. Von Noorden says that in experimentally induced pyrexia the protein metab- olism is not limited to the same amount in the presence of carbohy- drates as when the temperature is normal. It would seem possible, then, by covering the caloric needs of a resting patient and adding the 25 per cent, increase induced by pyrexia, to keep a patient in nitrogenous equilibrium. In an average man this would mean, as before stated, about 3,000 calories. In practice, however, it is not true; and it was for this very reason that protein loss still continued in acute infections, when the theoretical food-needs had been liberally met, that investigators in general were convinced that this loss was due to destruction of the cell substance by the poisons of the disease "toxic destruction" and that no diet could prevent it. That this loss can be prevented and that such a fact impairs the theory of " toxic destruction," the elaborate observations of Shaffer and Coleman show. They prevented nitrogenous loss and the elimina- tion of creatin and increase of neutral sulphur, which are taken as the expression of cell destruction. They found that from sixty to ninety calories per kilo were needed to effect such a result in typhoid fever. Of this amount forty to fifty or even more calories per kilo must be furnished by carbohydrates. They point out that a loss of 10 Gm., of nitrogen or 62.50 Gm., of protein can furnish but 250 calories, and have no explana- DIET IN ACUTE INFECTIOUS DISEASES 27 tion to offer for the fact that 2,000 calories of carbohydrate are needed to prevent this loss. It has been proved, then, that in some men suffering from severe acute infectious disease, the usual protein loss can be stayed by the administration of a large quantity of foods. Vitamines. One of the most recent contributions to the subject of dietetics is the discovery of certain food elements absolutely necessary to nutrition, which are present in minute quantities and have been termed vitamines. There are two groups of vitamines the chemical nature of which has not been identified, but which take their name from the mode of extraction. They are called "fat soluble A" and "water soluble B." Their absence from foodstuffs produces nutritional dis- orders of which the best known and most carefully studied is Beri Beri and perhaps the most common marasmus. Bread made of bolted flour and cow's milk which constitute so considerable a portion of the dietary of invalidism, are deficient in vitamines. Whole wheat flour, unpolished rice, barley, yellow meal, white potatoes, peas, beans and other legumes, fruit, eggs, all contain vitamines and should enter in some proportion into the dietary. It is understood that vegetables and fruits must be fresh as the canned products are found deficient in vitamines. In this chapter I have dealt only with those laws that constitute the science of dietetics. The application of these laws to the individual; the appreciation of those factors that make every individual deviate from the type; the adjustment of theory to conditions, constitute the art of dietetics. SUMMARY The body is a mechanism for the conversion of one kind of energy (potential) into other forms of energy, for the most part heat and work (thermo-kinetic). Total energy may be expressed in terms of heat. The heat unit is called the calorie. Small calorie expresses that amount of heat required to raise 1 c.c. or gram of water through 1 C. Large calorie equals 1,000 small calories. The calories referred to in the text are large calories. The calorie requirements of a man depend on his size, his age and his activities; hence his calling or occupation. The requirements at rest (in ordinary acceptance of the term) in bed, are 33 calories per kilo of body weight or for man of 70 kilos (154 pounds) 2,300 calories. The requirements are the same for man at rest, whether he is sick or well. 28 TREATMENT OF ACUTE INFECTIOUS DISEASES Calorie requirements per kilo are much higher in the young. Calorie requirements per unit of body surface are much the same at all ages. ARRANGEMENT OF DIET IN ACUTE INFECTIOUS DISEASES 1. Provide as a minimum the calories demanded by the individual at rest; i. e., for adult man 2,300 calories. 2. Provide enough protein to replace wear and tear; i. e., for an adult 65 to 80 grams. 3. Add to calories demanded at rest the amount required by extra heat production of fever; on an average 25 per cent, rest require- ment; i. e., for adult, total of 40 calories per kilo or 2,800 to 3,000 calories. 4. Add calories, especially in form of carbohydrates, to shelter pro- teid loss. May require 60 or more calories per kilo. Amount determined by loss or gain in weight, i. e., 4,000 or more in total. Protein Needs. Voit's standard 118 grams. Actual need shown by Cbittenden to be less by nearly one-half. Functions of Protein. 1. Storage of nitrogen, in growing child, in pregnancy, in lacta- tion, in hypertrophy of muscles from exercise, and in convales- cence from disease. 2. Repair wear and tear of day. 3. Fuel protein is not an economic fuel because of high " specific dynamic action." Vitamines necessary for an accurately balanced dietary. Milk. Analysis. Fat, 4 per cent.; sugar, 4.5 per cent.; protein, 3.5 per cent. Caloric value, 700 to 1 liter. 620 to 1 quart. 20 to 1 ounce. Protein content, 35 grams to 1 liter. 32 grams to 1 quart. 1 gram to 1 ounce. Not well balanced for sole article of diet. Disturbance of gastro-intestinal function slight at beginning of fever. Fever. Ordinary use of term connotes effects of 1. pyrexia, 2. Toxemia. Pyrexia. Increases caloric demand even up to 50 per cent. Average, 25 per cent. Toxemia accelerates destruction of body protein; demands high calorie intake to prevent it. DIET IN ACUTE INFECTIOUS DISEASES 29 Starvation. Inflicted on patient by insufficient diet. Feeding. Early in fever anorexia is a conservative symptom and to be respected. After first few days gastro-intestinal functions are competent and food should be administered to meet needs. Water needs are high in fever. It should be given freely. CHAPTER III ACUTE RHEUMATIC FEVER Theories of Rheumatism. It is not my purpose to discuss the nu- merous theories advanced to account for the phenomena of acute rheu- matic fever. I will merely state that it is the consensus of opinion at the present time that the disease is an acute infection. Numerous observers have claimed to have isolated the specific organism, among the most insistent of whom are Poynton and Payne. Etiology. The classification of this "specific" organism has not as yet been fairly settled; indeed, the identity of the "specific" organisms is much in question. Some believe, moreover, that different organisms can produce the same clinical complex called Rheumatic Fever and one observer, Rosenow, maintains the transmutation of members of the streptococcus group into several forms, each inducing some differences in the clinical picture. This will be touched upon again when discussing vaccine therapy. To Poynton's view has been lent the weight of the authority of Osier's new Modern Medicine, to the pages of which he contributes the article on rheumatism, and in which the various views of the etiology of this disorder are set forth in some detail. Age. About one-half of all cases of rheumatism occur between the ages of fifteen and twenty-five years; about one-quarter in the next de- cade, that is, between twenty-five and thirty-five years. My own impression, based on considerable contact with children, is that the figures set for childhood are too low, as the disease is peculiarly insidious at this age, and deviates strikingly from the type as established in the adult. The serious complications are quite as common, even more common than in the adult. Of the cases occurring in childhood, 70 per cent, fall between the ages of ten and fifteen years. I cannot refrain from intercalating a bit of pediatric wisdom at this juncture: (1) Beware of a diagnosis of rheumatism in infancy. It is so rare that, when authentic, it warrants rushing into print, which is say- ing a good deal. The so-called rheumatic joints of infancy are almost certainly pyogenic, scorbutic, or syphilitic. (2) Scan every child's heart with care, and seek constantly in the histories for tonsillitis, stiff neck, and especially "growing pains." How many children's lives have been sacrificed to that unfortunate term no man can estimate. How readily rheumatism in children may be overlooked is shown ACUTE RHEUMATIC FEVER 31 by Langmead who, examining 2,556 English school children, found that 5.2 per cent, of them showed evidences of rheumatism and 4.49 per cent, of them in terms of heart disease. While this percentage is larger than one would, in all probability, find among our children, still among 1,000 children coming to my clinic at Bellevue Hospital just 1 per cent, showed valvular heart disease, for the most part unrecognized. Symptomatology. That the disease is rather abrupt in its onset, accompanied by fever, that sore throat is not uncommon, that drenching acid sweats may occur, and that the inflamed joints are the pathogno- monic sign, is all well known, and is reiterated here merely to emphasize the points of attacks in the application of therapy. The complications are the important events in the course of rheumatism, and will be con- sidered after rules have been laid down for the simple, uncomplicated case. Therapy. A sick man invites medical attention for two reasons: First, he wants to be cured of his disease; and second, he wants to bemade more comfortable during his illness. To treat a patient intelligently, it goes without saying that a diagnosis is imperative, but the intellectual satisfaction derived from establishing a diagnosis must not lead to a satiety that eschews further effort directed toward relief of the condition. Such a comment is justified by fact. Still another function to be sub- served by the physician is the instruction of the patient how to avoid a repetition of the attack. There are certain measures that may be di- rected toward any acute illness, others that are aimed at the particular disease in question. This order will be preserved. Rest. In the rheumatism of adults the painful condition of the joints impels rest, willy-nilly, but this by no means obtains in children. Pain, which he who suffers it looks upon as an unmixed evil, is more often a boon than a bane. If one will get in the habit of analyzing the symptoms of disease in terms of efforts on the part of Nature to accomplish a useful purpose, or as expressions of compensations, he will be amazed to see how many hints these symptoms give that they are to be utilized as allies, not combated as enemies. In rheumatism there are three emphatic reasons why rest should be insisted on: (1) Because the body cells are busied in combating an intoxication, for which then- energy should be conserved as much as possible; (2) because certain tissues are undergoing the alteration inci- dent upon inflammation, and are struggling to accomplish repair; and (3) because the spectre of cardiac involvement is never absent from the disease, and we fear that every increment of activity on the part of that organ may heighten the possibility of the dreaded disaster. 32 TREATMENT OF ACUTE INFECTIOUS DISEASES To illustrate the significance of rest, I will cite the following figures: One knows, as a fundamental physiological fact, that the energy and heat of the body are derived from the combustion of the foodstuffs, and that the carbon of these foodstuffs is in large measure eliminated from the body through the lungs as carbon dioxide; so -we can collect and estimate the amount of carbon dioxide eliminated in a unit of time, and look upon the results as expressions of the activity of the body cells during that period. This has been done repeatedly, and the same individual who during sleep eliminates 22 grams of carbon dioxide per hour will, when awake and exercising the greatest amount of muscular relaxation possible, eliminate 31 grams, and under conditions ordinarily considered those of rest, 38 grams. In this light, rest assumes a meaning, and the importance of restlessness and loss of sleep in disease is enhanced in dignity. The two important factors to be considered in estimating the amount of work done by the heart are the amount of blood expelled and the pressure, that is, resistance, to be overcome. The lessened heart rate in recumbency and the diminution, even though moderate, of blood pres- sure in this attitude will suffice to emphasize the importance of rest to this organ. Rest should be in bed. One might suppose this injunction to be super- fluous, and yet it is every one's experience not infrequently to find himself in the presence of contentious individuals who demand many reasons, when it might be supposed common sense would dictate; and one might as well write in golden letters on the tablets of his memory that he is to treat individuals, whose very individuality depends on differ- ences, not machines nor yet diseases. Bed. The bed should be of a height and width most convenient for handling the patient, who is in many instances helpless, and to whom the most gentle handling may constitute torture. A half, or at the most a three-quarter bed, with a woven wire spring, sufficiently stiff to prevent sagging, should be chosen. The standard hospital bed is an admirable example. The mattress should be soft, but resilient and firm. A good hair mattress is preferable. If the patient perspires freely, the bed should be made with thin blankets instead of sheets. The patient should wear a thin flannel nightgown, opened all the way down the front and slit along the sleeves, so that the joints may be exposed for inspection or treatment with the least disturbance, and it is well to throw a thin flannel cape about the shoulders. The nurse should be in- structed to put the clothes on this bed with a view to the comfort of the patient, rather than to preserve the symmetrical and esthetic effect so often insisted on in the hospital ward, regardless of the comfort of the ACUTE RHEUMATIC FEVER 33 patient. Often the lightest touch of the clothes is agonizing to the patient, and hoops, cradles, or other contrivances to take the weight of the clothes off the patient must be utilized. An excellent bed is one of which the so-called Gatch-bed is a type. It consists of an extra frame on which the mattress lies, broken at two places so that it can be raised and maintained by a ratchet. The break at the upper end of the bed affords an excellent bed rest that can be readily maintained at any angle, while a second break at about the bend of the knee allows the raising of the bed at this point which gives the support and prevents the body from sliding down and is a grateful change in the position of the extremities. Such a bed is particularly valuable in cardiac cases with orthopnea. Room. The best available room should be chosen, with a view to an abundance of light and air, with a southern exposure in the winter, and away from the prevailing winds at all times. The bed should be so placed that the draughts may be avoided but the air not shunned. The thera- peutics of light is not duly appreciated. The minds and bodies of many of us are as responsive to its influence as a photographic plate. Air should be admitted to the room freely. There can be no superfluity of fresh air. In summer the windows should be kept wide open. In the winter the room should be frequently aired and kept at 65 to 70 F. Personally, I do not hesitate to admit the cold clear air of a winter's day to the sick room, observing proper precautions with reference to the patient's coverings. Diet. If there is any one field within the province of medicine that promises richer yield than another for the labor expended on it, it is that of dietetics. As yet it is almost virgin, and still such results as have been obtained are of the highest significance. It has been well suggested that if the physician would give the same amount of time, work, and care to the prescription of foods that he does to drugs, enormous benefit would accrue to bis patients. In the first place, a sick man needs food, and he needs more food than is ordinarily given him. Of course, one grants that there are certain conditions that make the administration of sufficient food diffi- cult or impossible, but that does not obtain in the majority of instances. 1 As I have said, the energy and heat of the body are derived from the combustion of its foodstuffs, and as energy can be conveited into heat, the value of the foodstuffs can be expressed in heat units. Moreover, the amount of energy and heat the body gives off in a day can be meas- ured in terms of heat units; so that we can determine just how much food an individual of a given weight, under varying conditions of activity, 1 See Chapter II, Diet in Acute Infectious Diseases. 34 TREATMENT OF ACUTE INFECTIOUS DISEASES needs. The term adopted to express a heat unit is the " calorie." The amount of heat that 1 calorie represents is that required to raise 1 kilo- gram of water from to 1 C. This calorie is sometimes spoken of as the " large calorie." The "small calorie" is the amount of heat needed to raise 1 gram of water through 1 C. of heat; therefore, 1 " large calorie" equals 1,000 "small calories." Unless qualified, the term "calorie" means a "large calorie." Now, under what is ordinarily known as rest, a man gives off heat in twenty-four hours equivalent to about 33 calories per kilo of body weight; that is, a man weighing 70 kilos, or 154 pounds, will give off about 2,300 calories. This amount of heat must be replaced by his foodstuffs to keep him in equilibrium. The patient with rheumatism, however, is suffering from fever, and in fever he gives off not only what he does in health at rest, but some 20 to 30 per cent. more. If we add 25 per cent, more to our estimated calories at rest, we find the patient's needs are 2,800 to 2,900 calories. We are all aware that in febrile conditions it is customary to put a patient on a milk diet, because the different food constituents fat, carbohydrates, and proteins are so well represented in it, because its protein furnishes all the elements, amidobodies, "building stones," necessary to the construction of body protein (which is not true of all food proteins), because it is bland, and because it is easily administered. The physician's instructions frequently are a glass of milk every two hours. A glass is supposed to hold 8 ounces; more commonly, as given, it holds 6 ounces. On this schedule, ten feedings would be exceptional, and eight nearer the actual number; so the patient would get 1J^ to 2 quarts of milk a day. In a quart of milk there are 620 calories of food ; in the patient's dietary, 930 to 1,240 calories, or one-third to two-fifths of his needs as calculated. But the case is even worse than this, for, as I have shown, there are reasons why, in fever, a patient's dietetic needs are greater than those set out above. It is an easy mathematical problem to determine chat to meet the patient's caloric needs with milk would require some 5 quarts of milk, and the administration of over a gallon of milk day after day does not appeal to our common sense. Moreover, this amount of milk would contain 128 to 160 grams of protein, which is excessive. To keep within quantitative limits, qualitative changes must be made in the food. The readiest way to do this is to add to milk, cream to furnish more fat, or starch, or sugar, to furnish more carbohydrates. For example, enough milk sugar can be added to the milk to make 10 per cent, without making it disagreeably sweet; or cereals, to make ACUTE RHEUMATIC FEVER 35 gruels or milk soups. Six per cent, of sugar added to milk will give a milk equal to about 860 calories to the quart. In addition to milk, eggs, cereals, bread and butter, rice, and cereal or milk soups are permissible. An ordinary thick slice of white bread (1 1/3 ounces) furnishes 100 calories; an average pat or ball of butter (a little less than y% ounce) the same; an ordinary helping of boiled rice (4 ounces) as much more, and 1 ^ to 2 ounces of cream the same. Three even teaspoonfuls of granulated sugar affords 100 calories. There are 100 calories in a large serving of oatmeal or hominy, and one egg adds 80 calories more. This necessity for a sufficient diet obtains especially in long-continued fevers, while in the brief fevers of intense character, in which the func- tions of the digestive organs are impaired, only small amounts of food are to be urged, as the body has a surplus to meet its needs for a short time. I have introduced these figures to concentrate attention on a branch of our art that has been left too little cultivated and exercised without reason. Milk, milk soups, cereals, bread, and rice form the staple diet in rheumatism. To meat soups, which have scarcely any nutritive value, there are certain theoretical objections, but if their well-known influence in spurring a jaded appetite and stimulating what the Germans call the "appetit-saft," is taken into consideration, I think their administration in small amounts is warranted. With the decrease in the fever, eggs may be used; and in convalescence, fish, meats, and vegetables. Fluids. Water should be allowed ad libitum unless the heart is de- compensated in which case certain restrictions should be made. As more grateful drinks, dilute fruit juices are permissible, orangeade, lemonade or diluted grape-juice. See diet in Summary. Bowels. When called to attend a patient suffering from an acute infectious process, it is a good rule to assure satisfactory evacuation of the bowels. Just how much additional disturbance a neglect of this measure may induce we do not know, but we are aware of the fact that at times in an individual otherwise well, constipation may incite symp- toms akin to acute intoxication, or more commonly, depression, malaise, anorexia, and headache, and we have evidence that products of decom- position in the bowel, normally absorbed and paired, like the indol group, with sulphuric acid, can, when this function of pairing is interfered with in disease, give rise to toxic manifestations. An active saline, like magnesium sulphate or Epsom salt, sodium sul- phate or Glauber's salt, or sodium potassium tartrate or Rochelle salt, in doses of 1 ounce, or, in patients susceptible to saline purgatives, % 36 TREATMENT OF ACUTE INFECTIOUS DISEASES ounce, may be given, assisted by a soapsuds enema four to six hours later if the salts have not been sufficiently effectual. " Technique of a Soapsuds Enema. The enema is prepared by agi- tating white castile or ivory soap in warm water until a good suds is formed. The froth* must then be removed because it contains air and, if introduced into the bowel, may cause pain. From one to two quarts of soapsuds are used. This is then poured into a douche bag or fountain syringe to the tubing of which has been attached, by means of a glass connecting tube, a large catheter or rectal tube. The bed should be protected by a rubber sheet and the patient be placed in the dorsal recumbent position, the pan or douche bag be raised to a distance of not over three feet above the patient and in order to avoid getting air into the intestines the fluid should be allowed to run through the tube when it is undamped before introducing it into the bowel. " The rectal tube should be lubricated with vaseline or soap emulsion and introduced slowly into the bowel to a distance of about eight or ten inches. " One to two pints for a child or 2-4 pints for an adult should be al- lowed to run in slowly, the flow being controlled by a clamp or stop- cock attached to the tubing. When the patient begins to complain about discomfort the flow should be stopped and rectal tube should be removed slowly and gently. The patient being instructed to retain the enema for 10-15 minutes." (Pope and Maxwell.) It should be remembered that the feces represent an excretion from the bowel of mucus and other substances which represent nitrogenous metabolism, as well as a large content of bacteria, and afford a pretty constant percentage of the total nitrogenous output; that the feces are not mere food residues, and, in fact, normal feces should contain but very little food residue other than indigestible fibers of cellulose, seeds, etc. Hence it is surprising to the patient, and often to the physician, too, to discover so large results from catharsis when the patient has been on a milk diet, or even when on no diet at all. With this knowledge, then, of the formation of feces with a low or easily digestible diet, the necessity of attending to periodical evacuation is emphasized. This may best be done by enemas in most febrile diseases, but with the discomfort incident upon handling the body in rheumatism, further doses of salines may be preferred. I believe that too frequent catharsis by drugs entails an irritation that in itself may become mischievous. Sleep. Rest cannot be guaranteed unless sleep can be obtained. Of first importance is the environment. If the room is cool, well ventilated, the patient's toilet prepared for the night, the bed arranged, lights turned ACUTE RHEUMATIC FEVER 37 low and noise excluded much will have been done to secure sleep. If this is nob effectual, mild hypnotics may be tried such as bromides in doses of gr. xv-xxx (1-2 Gm.) or trional 1 gr. v to gr. xv (0.33-1 Gm.), or chloralamid gr. xx-xxx (1.33-2 Gm.) early in the evening, often the lesser dose will be found to be effectual. Adalin in gr. v (0.33 Gm.) doses is a mild hypnotic. Barbital (Veronal) and sodium barbital (Medinal) gr. v-vii ss. (0.33-0.50 Gm.) may be used, but are not favorites of mine. All too often sleeplessness is due to pain, and sleep can be obtained only by an anodyne. One may use codeine phosphate gr. 1/8 to ss (0.008- 0.030 Gm.) by mouth or hypodermically, or in severe cases morphine sulphate gr. 1/8-1/4 (0.008-0.015 Gm.) hypodermically. The doses given are for adults and must be modified for children according to Young's rule or adapted to weight. Young's rule is to divide the age of 2 the child by theage+12; e. g., for a child of 2 years = 1/7 there- 2-|- 12 fore the child's dose would be 1/7 of the adult dose. Weight Rule. Dr. Clark's rule is to divide the child's weight by 150; 50 i. e., if the child weighs 50 pounds, - - = 1/3, therefore the dose would 150 be 1/3 of the adult dose. Cowling divides the figure of the next birthday by 24; therefore if the O 1 child is 2, =-, therefore the dose of the child is 1/8 of the adult dose. Specific Treatment. It was once hoped that every disease might be met by a specific drug, and it was once believed that many diseases were cured by specific drugs; but as medicine entered on an era of more search- ing observation, and had to rest its judgment on scientific criteria, the number of specifics dwindled, until the term "specific treatment" has come to connote the treatment of one disease alone, syphilis. The Salicylates. When Dr. Maclagan, of Edinburgh, in 1874, began to use salicin, a glucoside of salicylic acid, obtained from the young bark of the willow, in rheumatism, which was quickly followed by the intro- duction of other forms of salicylic acid, the change that came over the clinical picture of this disease, that turned a bed of racking pain into a couch of relative comfort in a few hours, and a patient to whom the least touch was agonizing into one who could be handled with relative impu- nity, warranted the belief that a specific had, indeed, been discovered. It is said that we no longer see rheumatism as it was presented to the 1 Trional is the official sulphonethyl methane. For the sake of brevity trional is used throughout the book. 38 TREATMENT OF ACUTE INFECTIOUS DISEASES older practitioners, and yet the drug cannot be called specific, if we mean by that one that can eradicate the disease. That its discovery was a boon, no one who has witnessed its effects can for a moment doubt. Salicylic acid has this structure: (I) H ^ C \ (6)HC X CR(2) I II (5)HC^ X CH(3) C H (4) is the benzene ring. If we will replace the H at (2) by an-OH group, that is, make an alcohol of it, we convert it into a well-known poison, carbolic acid. H I II HC. /CH ^C X H Note what slight changes in a complex group and the introduction of what simple radicles induce potent changes in character. We have but to make another slight change, by introducing an acid radicle at (I), to convert the toxic carbolic acid (which is no acid at all, but an alcohol) into the substance in question, salicylic acid. 1 COOH ' HC^ X CH ^C X H I might add that the introduction of an acid radicle into the structure of a toxic alcohol detoxicates it. This is a general law. This substance is classed among the antipyretics and antiseptics; it is also an anodyne. Its therapeutic value is exercised in all three directions in rheumatism. Salicylic acid should not be administered as such, but in the form of a salt or ester. The effect is the same in kind in all these forms, but certain by-effects determine the use of one 1 Salicylic acid is not derived in this manner, but from ortho-oxy-benzyl al- cohol, HO.C 6 H4.CH20H. The illustration is used to draw attention to the chemical kinship of well-known drugs which are so different in their action. ACUTE RHEUMATIC FEVER 39 or the other. It should be administered in full dose. Its failure may often be attributed to insufficient dosage. Its toxicity is slight. In an adult of average weight I give as much as 20 grains (1.30 Gm.) of one or the other form of the drug every two hours for the first twenty-four hours during the waking period, or even for forty-eight hours. In severe cases even 30 grains (2 Gm.) may be given foi' the first two or three doses. As the pain subsides the dose may be cut down gradually to 15, to 10 (1.-0.60 Gm.) grains at a dose, how much and how rapidly depending on the progress of events or on signs of toxity. The dose should be well maintained at amounts of 10 grains (0.60 Gm.) every two hours until the active phases, as evidenced by fever, pain, and joint swelling, have passed. Just how this drug acts in rheumatism we do not know, but its effects are so much more prompt and satisfactory in this condition than in any other clinically akin to it, that we are tempted to believe that it has some effect on the materies morbi directly. It is my custom to keep the patients on considerable doses 5 to 10 grains (0.30- 0.60 Gm.) every two or three hours for a week or ten days after the subsidence of acute symptoms, and for four to six weeks on lesser doses of 5 or 10 grains (0.30-0.60 Gm.) three or four times a day, administering the drug much as we do quinine in malaria. If satisfactory results do not follow these doses they may be pushed to the production of toxic manifestations. Hanzlik's studies of the toxicity of the salicylates carried on at the request and under a grant from the Committee on Therapeutic Research, Council on Pharmacy and Chemistry, American Medical Association, showed that the toxic dose of Sodium Salicylate in the majority of indi- viduals of both sexes lies between 100 and 200 grains per diem (the mean toxic dose for males nearer 200, for females nearer 150). These figures are close to my customary dosage. The dosage for children should be relatively large and may be pushed to toxicity, even in cardiac disease. The tendency is to give to children too small a dose rather than too large. When men of large experience, like Lees in England, give 200- 400 and more grains a day to children under sixteen years, it will be appreciated how far short of the danger-mark, if not of efficiency, our usual dosage is. With this drug, one may administer an alkali. I prefer bicarbonate of soda of which something more than grain for grain should be given; my rule at the beginning is 2 grains of bicarbonate to one of the salicylate. It seems to lessen the irritating effect of the salicylate on the gastro- intestinal tract. The toxic symptoms, except such as constitute an idiosyncrasy are 40 TREATMENT OF ACUTE INFECTIOUS DISEASES disagreeable rather than dangerous or disagreeable long before they are dangerous, giving ample warning to watch or to stop or modify the dosage. They are: (1) buzzing, roaring hi the ears, with varying degrees of deafness, headache; (2) gastric disturbances, more rarely; (3) cardiac disturbances; (4) respiratory disturbances; (5) cerebral symptoms; (6) renal complications; (7) hemorrhages; and (8) skin involvement. This looks like a formidable array of disasters, and so do tidal waves, cataclysms, and the fall of meteors in the catalogue of everyday possi- bilities; but, like most apparitions, this list takes less substantial propor- tion when submitted to light. I will consider them in the reverse order. Skin eruptions after the use of the salicylates are rare; still a diffuse erythema, an urticaria, a hemorrhagic outbreak, and other forms may follow. It will be observed that the three forms specified have all been associated with rheumatism, and it would be difficult to determine in all cases the association of the drug with the rash. They are not dangerous in themselves, and the drug should not be intermitted on their appear- ance unless the rash is distinctly aggravated by the continuance of the drug. Retinal hemorrhages are still more uncommon, while epistaxis and other hemorrhagic manifestations have been more frequently reported, and, if severe, might enforce cessation of the drug. Albuminuria and hematuria, which have been attributed to the irritating effects of salicy- lates, may be and probably are caused by the disease itself, but with their appearance it might be wise to intermit the treatment until it is demonstrated that they do or do not play a part in the disturbance. Scott and Hanzlik have recently called attention to the appearance of albumin, leucocytes and small granular bodies resembling casts in the urine of patients taking salicylates; they note, however, that this promptly clears up after salicylates have been stopped. I do not feel that these statements should lead to the modification of our salicylate treatment of rheumatism and in a rather large experience in these cases I have never seen renal complications from this cause that were clinically recognizable or eventuated in renal disease. There can be no doubt that now and then the salicylates have induced an active delir- ium, sometimes like an acute mania. I recall a report of two such cases occurring at Bellevue Hospital, but it is very unusual. It must not be forgotten that delirium intervenes in the course of rheumatism, espe- cially, it is said, with the onset of a pericardia! involvement, and associ- ated with hyperpyrexia. Dyspnoea, characterized by slow and labored breathing (see below), has occurred, and suggests the possibility of im- purities in the drug, as, indeed, does the slow heart and threatened ACUTE RHEUMATIC FEVER , 41 collapse occasionally noted. Here, too, one must keep in mind the in- volvement of the myocardium, the lung and the pleura, in the disease. However, in either instance, so threatening a condition should indicate a withdrawal of the drug. I have recently seen four cases of bradycardia and arhythmia in rheumatism; in some of these have obtained the graphic evidence of sino- auricular block. In all cases the block disappeared with the intermission of the salicylate and in one a return was provoked by its resumption. No evidence of circulatory embarrassment was seen in these cases. Sino-auricular block has been reported in other acute infections such as influenza in which no salicylate had been administered. Auriculo- ventricular block has been repeatedly noted in rheumatism in which no salicylates had been administered and has been attributed to inter- ference of conduction impulses by the Aschoff bodies, the characteristic lesion in rheumatism, whose site of election is in and about the conduct- ing bundle of His. To sum up, I should say that the above-mentioned conditions are rare; that they may be attributable in most instances to the disease rather than to the drug, or to idiosyncrasies those peculiar reactions of the individual to drugs, food, and environment that takes him out of his class and constitutes in him an anomaly, and defies foreknowledge. I firmly believe that it is only a minority of the above-mentioned condi- tions that can be attributed to the drug itself. It stands otherwise with the first two disturbances enumerated. They are to be attributed to the drug, and their occurrence modifies our action. The ringing in the ears and a mild grade of deafness may be looked upon as a limit of tolerance with comfort rather than a menace. There is no reason to intermit the drug on this account, but if the dis- comfort is considerable, the dosage should be cut down or stopped. The gastric irritation resulting upon the administration of salicylates is the bete noir of the practitioner. It is for this reason rather than for any other that so many forms of salicylates are in use. There are certain forms of the drug from which one may anticipate more irritation than from others, but, again, the susceptibility of a particular stomach to a particular preparation cannot be predicted with any degree of assurance. I advise, as a rule, the use of the preparation that has stood best the test of time and experience. In this case it is the sodium salt of the acid, sodium salicylate. I may say at once that the acid itself is too irritating to administer internally. Order the drug alone, in simple solution. Order the dose to be taken well diluted. 42 TREATMENT OF ACUTE INFECTIOUS DISEASES For example, write thus : $ Sodii Salicylatis 15. gss. AqusB destillatse q. s. ad 60. gij M. et S. One teaspoonful in water every two hours. One will note that this calls for a 2-ounce mixture, but, if written in the metric system, that there are just as many grams in this 2-ounce, or 60 c.c., mixture as we want to give grains in one dose. Even the water has as many cubic centimeters as we want to give drops in a dose 60, that is, 1 teaspoonful. Sometimes the salt is better borne and less disagreeable to the taste if a little glycerin is used, as: 3 Sodii Salicylatis 15 . Glycerini 15 . aa 5 ss. Aquae destillatae q. s. ad 60 . 5 ij M. et S. One teaspoonful in water every two hours. If one has doubts about his patient's ability to get a good salt, he should order the salt made fresh from salicylic acid by adding sodium bicarbonate. This is a very excellent way of writing the prescription: 9 Acidi Salicylici 15 . 5 ss. Sodii Bicarbonatis q. s. q.s. Aquae destillatae q. s. ad 6Q. 5 ij M. et S. One teaspoonful in water every two hours. The druggist is to use of the soda what is needed; he adds definite proportions of the two drugs, if he follows the Pharmacopoeia, or he simply adds soda to the solution of the acid until effervescence ceases; that is, until no acid is left to liberate the carbon dioxide from the soda. In the early days of the synthesis of sodium salicylate a good many impurities existed which made such a prescription as was just cited a wise precaution, but Hilprit's study of the different synthetic sodium salicylates at the instigation of the Council of Therapeutic Research of the A. M. A. show that such impurities no longer exist and that their "investigation would seem to warrant the conclusion that the cheapest commercial synthetic sodium salicylate is the equal of the higher priced brands of the synthetic kind or costly natural product." . If, for any reason, sodium salicylate is not well borne, one may have .recourse to another form of the drug. Moreover, it has been occasion- ally noted that a patient's symptoms which did not yield to one form of salicylate, may to another, e. g., to aspirin after the failure of sodium salicylate. My own preference is for acetylsalicylic acid [aspirin], that ACUTE RHEUMATIC FEVER 43 is, salicylic acid in which the H of the OH group has been replaced by an acetic acid radicle, CH 3 CO; thus: COOH X CO.CH 3 CO II CH C X H This substance is a white powder, formed of small crystalline needles, practically insoluble in water (100 parts) and in acids, so that it passes through the stomach for the most part unchanged, and is broken up in the intestine. It is less irritating to the stomach, but that it should be devoid of all the disadvantages of the sodium salt its chemical structure forbids us to believe. I have in one instance seen a massive angioneu- rotic cedema of the face follow a single small dose, and have seen such cases reported in the literature since. However, I believe it to be a very valuable form of salicylic acid. It is best prescribed in capsules. The dose is practically the same as the sodium salt, or about 15 grains (1.0 Gm.) for a beginning dose. The Committee determined the mean toxic dose of aspirin to be a little smaller only than that of sodium salicylate, i. e., 165 grains a day for adult males, 120 for females. It is said that alkaline salts must not be given at the tune of adminis- tration because they decompose the drug in the stomach and, therefore, should be given between the doses. As Bastedo has pointed out, this is more or less a theoretical consideration and in the test-tube bicarbon- ate of soda cannot be shown to decompose the drug. He finds, indeed, that the administration of a little bicarbonate of soda in many instances lessens the irritating effects of the drug in the stomach. Another excellent preparation of the salicylic acid series is the ester, methyl salicylate, that is, salicylic acid in which the H of the acid group is replaced by methyl CH 3 ; thus: COOCH 3 HC^ X C.OH I II HC CH ^C X H Methyl salicylate is a volatile oil that constitutes well over 90 per cent, of the oil of wintergreen, the well-known gaultheria procumbens of our woods, and of the oil of birch, oleum betulse, obtained from the bark of the sweet birch, betula lenta, or is produced synthetically, and when 44 TREATMENT OF ACUTE INFECTIOUS DISEASES carefully prepared should answer the purposes of the natural oils. Of the three, the oil of wintergreen is, as a rule, preferred. It may be given in capsules, in emulsion, or in milk. I very much prefer the capsules, because in emulsion the decided taste of the drug, which may be agree- able at first, sooli palls on the patient. As for its administration in milk, the same objection obtains, and what is much more important, it violates a rule that I believe one should invariably observe never give medicine in food, for, if the medicine does disagree, its association in the mind of the patient with the food may produce a disgust for food which may be the mainstay of the case. The Committee's research placed the mean toxic dose as 120 minims of the oil of gaultheria. The drug is usually very well borne, but its decided taste, even when given in capsules (for the slight eructations it often induces is a constant reminder) is the chief drawback. Diplosal is a form of salicylate more lately come into use and as its name suggests contains two salicylic acid radicles; that is, it is a salicylo- salicylic acid or salicylic ester of salicylic acid, formed by the condensa- tion of two molecules of salicylic acid, the H of the acid radical of one molecule being replaced by the second molecule entering by its phenol group (OH) at (1); thus: COOH o.oc I ^ c \ XJ.OH H I I' HC^ X CH H It is an insoluble powder and like aspirin is little affected by acids, so is supposed to pass the stomach unchanged and like the aspirin is broken up by alkalis. It is best given in capsules and alkali should not be given with the dose but between the doses. It has the same toxic effects as other salicylates and is given in about half the dose of sodium salicylate. Hanzlik's studies showed the mean toxic dose per day was 100 grains for adult males and 83 grains for adult females. I have had but little experience with this particular form of salicylate. One will rarely have to choose outside of one of these four forms of salicylic acid in the treatment of rheumatism. If he does, the great ACUTE RHEUMATIC FEVER 45 probability is that he has not administered these forms properly, or that the patient cannot stand salicylic acid in any form, or that the series does not meet the needs of this particular case. I will mention two other well-known preparations: First, the original drug, salicin. This is a glucoside, which can be split up by acids into grape sugar and saligenin, the active principle, which is the alcohol from which salicylic acid is formed, and this formation of the acid goes on in the body after its administration. It is a white powder, bitter to the taste, rather insoluble in water (28 parts), so best administered in cap- sules. It is well borne, and by many preferred for children. The dose is the same as for the others. Second, another ester, phenylsalicylate, salol that is, salicylic acid in which the H of the acid group is replaced by phenyl C 6 H 6 ; thus: COO C/~1 N. >&M*> HC^ ^CH HC^ X CH H H It is a white powder, almost tasteless, and quite insoluble in water. It passes through the stomach for the most part unchanged, and is broken up in the intestine, two-thirds of it appearing as salicylic acid and one-third as carbolic acid. It is administered best in capsules or powders, or can be suspended in mucilage of acacia. It has no advantage over the other forms in rheumatism, and has the disadvantage of affording only two-thirds of its weight as the desired substance, while one-third is the toxic carbolic acid, which can produce its characteristic poisonous symptoms when given in large doses. The dose is about the same as for the other preparations. As I have already intimated, some patients cannot take salicylic acid in any form. We cannot, for that reason, neglect their need for relief of pain. The three drugs in most common use for such a purpose are acetanilid (antifebrin), antipyrin, and acetphenetidin (phenacetin) (officially acetphenetidinum). Of these three, the first is the most potent, also the most irritating and toxic. These drugs are not given over a long period, as the salicylates are, but as needed, to control pain. Often small doses, frequently repeated, are as efficacious as fewer large doses. Acetanilid may be given in doses of 1J/2 grains (0.1 Gm.) every half hour for four doses, or 2 to 3 grains (0.15-0.2 Gm.) every two hours. If there are heart complications, it should not be used. Phenacetin may be used in twice the dose. The dose of antipyrin lies between the two. These drugs should be promptly stopped if cyanosis appears, which is 46 TREATMENT OF ACUTE INFECTIOUS DISEASES well before cardiac or respiratory failure threaten, and, of course, as soon as pain is relieved. If the pain is severe, rather than push these coal tars to large doses, one should use morphine, in small doses, hypodermically, 1/16 to 1/8 grain (0.004-0.008 Gm.), of the sulphate. Morphine in any illness of length should be used reluctantly and in minimum dose, lest a habit be established. Two other drugs have been much used to control pain potassium iodide and colchicum. Their bad effects on the stomach are too certain, and their beneficial effects on the condition too dubious, to encourage their use. Another line of treatment, originated in England by Fuller to combat an acidity that at that time was looked upon as an etiological factor in the disease, is the "alkaline treatment." This treatment met with little favor elsewhere in Europe, but was adopted in this country to a consider- able extent, and still has some vogue. By many men it is used when the salicylates are not well borne; by others when cardiac complications threaten or exist; and by a very great many in conjunction with the salicylate treatment. Its use rests on empiricism solely. One should choose the milder alkalis sodium bicarbonate, potassium citrate, or potassium acetate; for example, 2 grains to 1 of salicylate until the urine reacts alkaline, and then in a little less dose, or enough to continue the urine alkaline. Acidosis. Miller of London has laid a great stress upon the dangers of acidoses that may obtain with the administration of salicylates which, if it were true would be a matter of serious consideration. Recent work of Hanzlik, however, does not corroborate these findings as he was unable to determine on the administration of toxic doses of salicylates that the reserve alkalinity of the blood was in any way perceptibly altered. One should be warned that the usual ferric chloride test for diaeetic acid in the urine of patients taking salicylates elicits a beautiful purple color in the urine that without control may be mistaken for the rich port-wine red of the diaeetic acid reaction. Vomiting. Miller studying vomiting in children taking salicylates found it severe in only 10 per cent, of the cases and what is of great importance that two-thirds of these had severe cardiac dilatation, and drew the conclusion that vomiting depended less on the dose than on involvement of the heart and that the more severe the heart affection the less the salicylate required to induce vomiting. Small doses of bro- mides combined with the salicylates may lessen the gastric irritation. It must be remembered that vomiting may be the symptom of cardiac involvement when no salicylates are taken and that cardiac involvement does not contra-indicate the use of salicylates, but it is well to divide the ACUTE RHEUMATIC FEVER 47 total day's dose into smaller and more frequent dosage, or use the rectal or intravenous methods. Rectal Administration of the Salicylates. Heyn of Cincinnati called attention to this mode of administration in 1912. I have used it with trivial modifications with most gratifying results over a long period of time. The essence of the procedure is to give the drug in suspension in starch paste with enough opium to lessen rectal irritation and assist in retention. Give a cleansing enema. Technique. Make a thin starch paste use it at body temperature. Take 4 to 6 ounces (not an amount too large to be retained readily) and add to it 1/2 to total daily dose, say 3i-ij (4-8 Gm.) of the sodium salicyl- ate in powder and one or two minims (0.06-0.13 c.c.) of the tincture of opium. Inject gently into the bowel and hold the buttocks together for a few moments. Repeat at 12-hour intervals. Instead of dividing the dose one may give the whole dose in one daily injection. The amount of salicylates used depends on the same consideration as when given by mouth, i. e., to the point of efficiency or toxicity. The amount of starch enough to carry the drug and not provoke a move- ment; the amount of opium the least to effect retention. Alkalis (bicarbonate of soda) should be given in same amounts by mouth as if the salicylates were so administered. Intravenous Administration. Still another method of administering salicylates, the intravenous, I recommend on the advocacy of my col- league, Conner, of New York, although I am entirely lacking in personal experience with it. Conner does not urge it in preference to the more time-honored mode of administration, but in those cases where success has not followed the latter or the stomach rejects it. I simply quote in substance and largely in words his technique as published in The Medical Record, February 21, 1914. The drug chosen is a chemically pure crystalline sodium salicylate dissolved in distilled water (preferably recently distilled) which has been freshly sterilized by boiling, to a 20 per cent, solution. Such a solution will keep well several days if protected from the light and will remain colorless. A rubber ligature is placed around the arm tight enough to obstruct the venous flow, making the veins at the bend of the elbow stand out prominently. The desired result is more effectually attained if the arm is allowed to hang down and the fist is opened and closed. The skin over the vein is then sterilized by painting with Tincture of Iodine. The best syringe to use is one made entirely of glass, holding 48 TREATMENT OF ACUTE INFECTIOUS DISEASES 10 c.c. and supplied with a, fine (small, bright, sharp) hypodermic needle. These, of course, are sterilized. The arm is extended fully and fixing the vein below by pressure with the left thumb, the operator thrusts the needle intq,the vein in the direc- tion of the venous flow, and makes certain of entrance into the vein by drawing a drop of blood into the syringe; and then injects. Pressure is made for a moment over the site of the injection to prevent leakage of blood into the subcutaneous tissue and the iodine washed off with alcohol. Fifteen, twenty, or even thirty grains are given at 12 or 8 hour intervals. No unpleasant effects were met with in Dr. Conner's experience, even after 120 grains a day. The relief from pain is striking and prompt and the stomach is not upset. The same vein can be used again and again, provided a small clean needle is used. Symptomatic Treatment. The symptoms that give character to this disease are those referable to the joints. The improvement in the local manifestations of the disorder under salicylates constitutes one of the most satisfactory evidences of their potency, and yet the resolution of these parts often lingers well behind the disappearance of the fever and the pain; and, moreover, much can be done during the height of the disturbance to ameliorate the discomfort, hasten the resolution, and prevent bad sequels. Rest. For an inflamed joint, just as for a broken bone, rest is impera- tive. Pain, which I have said is Nature's agent, impels rest, but when pain is banished or mitigated under our ministrations, the patient uses the joint too early, and often to his great detriment. The position of the limb in semiflexion is one involuntarily chosen as the most comfortable, and may be preserved during the acuteness of the attack. Various devices are used to maintain a single position. We can bolster the limb by putting pillows under the knee or on either side, or accomplish the same by the use of the Gatch bed, and find similar arrangements for the other joints. This, of course, cannot assure a high degree of immobility, and we can secure better results with splints, well padded and carefully applied. The success of these devices depends on the care and skill with which they are applied, and if simply suggested by you and left to the devices of unskilled hands in the application will be far worse than useless. Still another way to attain the desired end is by applying stiff bandages of plaster-of-Paris or starch. Again, much care must be taken in the application, as the parts cannot be daily inspected, and rough folds in the bandage, bits of dried plaster next the skin, which is moist with ACUTE RHEUMATIC FEVER 49 the excessive perspiration, can induce sores of serious import. These casts must be reapplied as the effusion in the joint disappears. In a considerable experience with rheumatism, I have very rarely had to have recourse to splints. The joints should be protected by some material that prevents chill- ing or rapid changes of temperature, such as flannel bandages. At the Presbyterian Hospital in this city (New York) a layer of cotton 1-1 1/2 inch thick, covered with gauze is wrapped around the joint like a binder and secured with safety pins. This affords, as Well, easy access to the parts. (Swift.) Heat and Cold. The patient's testimony is sufficient evidence of the comfort these measures afford, whatever opinion may be entertained with reference to their curative qualities and the rationale of their action. From the standpoint of comfort the reaction of different patients to heat or to cold differs widely. To one patient, with a painful joint, eold gives almost instant relief, while in another the pain is intensified, and finds relief from heat, and vice versa. Continuous cold exercises considerable anesthetic effect, and may be secured by the application of the ice coil, or the more readily obtained and manipulated ice bag. Ice bags of various shapes may be obtained, but the circular ice bag does well for most purposes. The ice bag must be properly filled in order to make its application efficient. The ice should be cracked in pieces not larger than the end of one's thumb, and enough to cover the bottom of the bag. Enough cold water is poured on this to enable one to force all the air out of the bag and screw the cap down to the level of the water. This pro- cedure leaves the bag supple, so that it may be wrapped around the part, which the presence of air makes impossible. Protect the part with a thin layer of vaseline or oil and a thin layer of cloth. A long-con- tinued direct application of ice to the skin may do damage to that structure. Heat is best applied by fomentations. A couple of layers of flannel are wrung out of boiling water in a wringer made of a crash towel, and applied snugly to the joint. This is repeated three or four times, at intervals of ten to fifteen minutes. The parts are then sponged with water at about 75 F., and wrapped in flannel or non-absorbent cotton. A soothing application is the cold compress. This is done by wringing two or more layers of linen or old cotton cloth or cheesecloth out out of water at about 60 F. and applying snugly to the part. This in turn is covered by dry flannel. These applications are renewed about once an hour. The effect of cold is momentary; the vessels soon dilating and conveying heat to the surface, warm the compress to the tempera- ture of the part drying it. The reaction induces a hyperemia, the value of which will be touched on at some future time. The joints should at all 50 TREATMENT OF ACUTE INFECTIOUS DISEASES times be well protected from changes in temperature. This is best done by wrapping them in layers of non-conducting material, like flannel or non-obsorbent cotton or cotton batten. The number of drugs that have been used locally are legion. I will purposely refrain from mentioning more than one or 'two that I have found helpful.' Perhaps the most common application is methyl salicylate. That it does any more than any other volatile oil, by inducing a hypermia, I doubt. That the salicyl- ates may be absorbed by the skin I have proved to my own satisfaction, but not in such amounts as to make that the object of the applica- tion. The methyl salicylate may be applied pure, or in the form of an ointment. The following is one in much use: Methylis Salicylatis -. f 5i (4) Mentholis 5i (4) M. et-adde Petrolati q. s. ad. . . , 5i (30) Tere bene simul. Sig. Apply as directed An ointment containing ichthyol has been much praised. For example: 3 Ichthyolis 5ii (8) Petrolati q. s. ad 3i (30) M. Sig. Apply as directed. Counterirritation. Counterirritation is a very old remedial measure which has survived the rise and fall of countless therapeutic efforts, and the very persistency of which, in this Nihilistic age, speaks for its reality. It is indicated rather in the subacute stages of joint inflammation than in the acute. Of the many means of inducing it, I will mention two only as worthy consideration the cautery and the fly blister. Of the two, the former is much the better, as being easier of application, easier of control, less likely to be followed by bad results locally, and entailing no danger from absorption. The cautery is flicked lightly over the part, care being taken to avoid severe blistering or deep burns. The part is then smeared with vaseline, oil, or ointment. In applying the blister (ceratum cantharadis) , it is cut about one inch square. In making the application to the knee, four such might be used, one above and one below on either side. Shave and cleanse the part. Oil the edges of the blister and apply a little vaseline to the skin adjacent to the blister, to avoid its spreading. Leave the blister in position for four to six hours, and if a blister has not formed in the skin by this time apply a warm poultice to the part, which will hasten its formation. ACUTE RHEUMATIC FEVER 51 Puncture the blister on its dependent edge, evacuating the serum but not destroying the protecting epithelium.. Dress with oil. Some of the disadvantages of the blister have just been set forth, and in the presence of a damaged kidney, as may occur in the course of rheumatism, the dan- gerous irritating effect of this drug on the parenchyma of the kidney, which it causes in the course of its excretion, must be kept in mind. Pressure. When an effusion is slow to absorb, one may hasten the result at times by applying a snug bandage of flannel or rubber, which will exert a continuous but moderate pressure. In persistent effusions, and effusions will sometimes persist after both temperature and pain have ceased, and in the acute stage with excessive and painful effusion a paracentesis is indicated. PARACENTESIS OF THE KNEE-JOINT " In synovitis the joint is considerably distended and there are four prominences about the patella, two on each side, above and below. The upper inner swelling is usually the most prominent as there is more space for the collection of fluid in this situation. In aspirating fluid from the knee-joint the object is to insert the needle so as to be sure to get the fluid and at the same time to give the least opportunity for damage to the joint cartilage. These objects are best attained in either one of the upper swellings. My personal preference is for the upper inner one. The aspirating needle should be from 8 to 10 cm. long. It should be of moderate calibre and should have a point not too long and sharp. It should have an obturator so that one may assure himself of the patency of the needle when in the joint cavity. The joint is painted with tincture of iodine over a space 5 cm. in diameter with its centre at the site of puncture. It goes without saying that the operator's hands, the needle and everything used must be scrupulously sterilized. The needle is held firmly in the operator's hand with the index finger on the shaft of the needle about 4 cm. from its point. The base of the needle rests in the palm of the hand so that it is used somewhat after the manner of a shoemaker's awl. With the thumb and index finger of the other hand the operator steadies the skin at the site of puncture. The skin at the site of puncture may be previously anaesthetized by injecting a few drops of novocaine 1 per cent. If the skin appears to be tough, as it is in a certain proportion of instances, a sharp pointed scalpel may be used to puncture the skin after the novocaine has been injected. This renders the insertion of the needle very much easier, as it is always the skin which gives most resistance. The needle is inserted in a direction upward, inward and backward through a point at the summit of the swelling. By 52 TREATMENT OF ACUTE INFECTIOUS DISEASES following this course upward, backward and inward, one gets into the joint obliquely and there is less likelihood of damaging the articular cartilage of the inner condyle of the femur. There is always plenty of effusion in this^neighborhood for aspiration and when the needle is later withdrawn the oblique entrance into the joint causes a valve effect so that there is ho leakage of the infectious material into the periarticular structures. After the needle has been inserted into the joint sufficient fluid for the purpose of examination, culture, etc., is obtained. While the needle is in the joint it is well worth while to entirely evacuate the fluid contents as this will give great relief to the patient's symptoms for a time. At the end of the procedure the needle is withdrawn in the line of its insertion, a small sterile pad is placed over the puncture hole, and the entire joint is wrapped in a bandage which causes moderate com- pression." (Personal communication from Dr. Alfred S. Taylor.) Often the effusion will not recur in the subacute cases, while the relief to the patient in the acute cases is highly gratifying. The procedure, simple as it is, should be hedged about by all the precautions of a major operation, for an infection of the joint by a pyogenic organism is a serious matter. If paracentesis be done and the opportunity affords, cultures of the aspirated fluid should be made for the identification of the organism and its use as a vaccine. Personally, I have been very rarely rewarded by culture of the joint fluid in the acute cases. Later Measures. Chronic rheumatism is spoken of by both the layman and the physician as of common occurrence. In truth, chronic rheumatism as a sequence of true acute rheumatism is a rarity. Some men believe it never occurs and for a time I was of this opinion; but recent studies in my wards have convinced me that it is an occasional happening. If it does occur care must be exercised to prevent ankylosis. Splints must be occasionally removed and plasters and bandages taken off. Gentle manipulation of the joint must be carried out; or intelligent massage, hot fomentations, hot air baths, and baking had recourse to to facilitate absorption and resolution. In these later stages it is still believed that the iodide of potassium may do good. Better in my estimation is the use of vaccines (see below). COMPLICATIONS Hyperpyrexia. The sudden onset of excessively high tempera- ture, with extreme restlessness, headache, vomiting, delirium, and later coma, suggestive of meningitis, while occurring in the course of other febrile processes, is relatively common in rheumatism. It ACUTE RHEUMATIC FEVER 53 must be treated promptly and on the same principle as a sunstroke, that is, by a rapid withdrawal of heat. This is effectually done only by the use of cold baths or packs. The patient is put into a tub at 65 F., or, if the shock is too great, the water may be warmed to 80 F., and as the water warms from the patient's body heat, the temperature is kept down by adding ice to it. The patient should be kept in the bath until the temperature falls several degrees. If a fall to about 102 F. can be attained, the patient should be removed from the bath, as the tempera- ture will often continue to fall. During the bath, ice or cold water should be applied to the head. The bath should be repeated as often as the temperature rises to between 104 F. and 105 F. If the patient becomes chilled, is cyanosed, the temperature falls well below normal, or collapse threatens, he should be removed from the bath, put in warm blankets, heat applied, and stimulants freely used. A cold pack, the wet sheet in which the patient is wrapped being continuously rubbed with pieces of ice until the desired drop is obtained, is sometimes quite as efficacious as the bath. The delirium that accompanies hyperpyrexia may be ameliorated or controlled by the measures just advised for that condition. If, how- ever, the delirium still continues one may try hyoscine hydrobromate in doses of gr. 1/200 to 1/150 (0.0003-0.00045 Gm.) provided that the heart is not involved; or better yet morphine in doses of gr. 1/8 to gr. 1/3 (0.008 to 0.02 Gm). These are adult doses. A measure which one frequently has recourse to in the treatment of delirium in acute infectious diseases with very excellent result is Lumbar Puncture; for the technique of which see Cerebro-spinal meningitis, Chap. XXII. There may be in these cases a serious meningitis with increased in- tracranial pressure or one may assume that the toxins of the disease are irritating the meninges which find relief on withdrawal of the cerebro- spinal fluid containing toxins. Cardiac Complications. The frequency of these complications, and their gravity, threatening not merely the patient's life in the pres- ent attack, but, worse yet, his future, dooming him to a life of invalid- ism and dependence, make them by far the most important features of the attack, and haunt the physician from the incipiency of the disease. A visit should never be completed without a careful examination of the heart. Changes in rate, rhythm, quality of sounds, or the appearance of adventitious sounds, should immediately put the physician on his guard. It cannot be too emphatically insisted that the mildest attack, as judged by fever, pain, joint implications, and general discomfort, may still be accompanied by grievous heart complications. Statistics vary, but from reliable sources it is gathered that peri- 54 " TREATMENT OF ACUTE INFECTIOUS DISEASES carditis occurs in 15 per cent, of the cases, and endocarditis in over 50 per cent.; in children under ten years, in as high as 75 to 80 per cent. Lees insists that in every case of rheumatism dilatation of the left ventricle can be made out. It is, he says "an inevitable manifesta- tion of the disease and one of its earliest sifanptoms" (British Med. Journ., October 12, 1912), and, certainly, the more one gives attention to alteration of cardiac sounds and outline the more convinced he is of the very high per cent, of cardiac involvement. It must be remembered that a more proper term for what actually exists in the heart is pancarditis, for the whole structure is likely to be implicated. The treatment of these conditions is the same as when occurring under other circumstances, and I will merely add that when there are signs of cardiac decompensation I am a firm believer in the use of the digitalis series in the acute cardiac disease in the same large doses as in the chronic form. The only question to be discussed at this juncture is the use of salicylates. Some authors fear the depressing effects of the drug. Others still consider that the appearance of the cardiac complica- tions indicates no change in the treatment. Personally, I have always continued the salicylates; and in the same liberal doses as in uncompli- cated cases. I have never been convinced of any bad results by so doing unless the rare occurrence of the bradycardia mentioned be called such. If salicylates have any effect on the disease organisms themselves, it would seem as if their use in the serious complications of the disease was the more urgent. Any case of rheumatism in whom a cardiac complication is evident should be kept in bed two months, even though joint manifestations and temperature promptly disappear, and as much longer as the cardiac condition and symptoms of the infection continue. While cardiac murmurs have great significance, they need not neces- sarily be present when the heart is affected; hence, the great importance of familiarity with the first and second sounds of the heart and their variation when the myocardium is involved and an appreciation of changes in cardiac outline. While the presence of murmurs should indicate heart involvement (with the exception perhaps of certain murmurs in the 2nd left intercostal space) they need not necessarily mean endocarditis or valvular change; for a goodly per cent, of them disappear and are probably attributable to hypersemia of the valves or such an affection of the myocardium as entails a relative insufficiency of the valves. The statistics of some authors (Kemp) show that nearly half of the cases with cardiac compli- cations clear up their signs before leaving the hospital and that no mean ACUTE RHEUMATIC FEVER 55 proportion of those not cleared up at the time of discharge have no per- manent damage to the valves. Aortic valve lesions show more myocardial involvement than the mitral (Brooks). If the murmur appears early in the disease, it is more likely to be the expression of valvular endocarditis than if it occurs later, at which time relative insufficiency from loss of tone may well obtain. Aortic insufficiency, double valve lesions, and pericarditis increase the gravity, but the repetitions of the cardiac involvement is what constitutes the greatest danger. When all active manifestations of the rheumatism have ceased and the patient has been kept in bed six weeks to two months beyond this, he may be allowed up in a chair and then on his feet, but always guided by the cardiac response; for a pulse rate out of all proportion to the effort made betokens a cardiac irritability that gives warning of the prematurity of the effort. In case the heart decompensates, it is to be treated as a decompen- sated heart under other circumstances. The gravity of these cardiac complications has been accentuated by the studies of Dunn 1 on over 300 cases of cardiac disease of rheumatic origin. He states that the immediate mortality of rheumatic cardiac disease is about 20 per cent, and that the final mortality of the affection followed at least ten years is 60 per cent. The mortality is seen chiefly during childhood. After young adult life is reached it falls to only 7 per cent. Most patients who weather the greater dangers of childhood and arrive at adult life get on remarkably well and this is attributed to an adaptation that takes place between the patient and his heart during the period of growth. Moreover, this author declares the earlier the cardiac lesion is acquired the more likely is the patient, if adult life is achieved, to lead an active and normal existence. After-Treatment of cardiac disease in children has been well discussed by Dunn. 1 It is largely a question of prophylaxis. With our present conviction that the tonsil is the usual portal of entry, it seems logical to remove the tonsil, if the patient has been the subject of tonsil- litis or if the tonsil shows evidence of disease. One of the most important items of the after treatment of the heart in rheumatism is the regulation of his activities. One feels that he is constantly steering between the Scylla of over-strain and the Charybdis of under-exercise. I believe Dunn is correct in concluding that the danger of the former is less than the latter. I heartily favor his plan of regulated exercise 1 American Journal of Diseases of Children, August, 1913. 56 TREATMENT OF ACUTE INFECTIOUS DISEASES beginning soon after the disappearance of symptoms. At first with passive movements against resistance, and later active exercise always within the limits of the heart's demonstrated capacity to cope with it. Overstepping the limits is shown by rapidity of heart action and dyspnea. If a child can Resume the normal activities of cnildhood without provok- ing these symptoms, he should be allowed to pursue them. Coddling merely because heart murmurs are heard really does the child great harm. Exposures to damp cold likely to provoke recurrence of rheumatism must be avoided or a removal to a climate where rheumatism is less prevalent is advisable when it is feasible to carry out this plan. Pulmonary Complications. Pneumonia and pleurisy occur in a considerable number of cases, some authors giving the figures as high as 10 per cent. I, myself, have seen it frequently in the severe rheumatism, and always with cardiac involvement. The figure 10 per cent, represents merely the incidence in the rheuumatic fever in general, but in cardiac complications and especially severe cases, they are much more frequent accompaniments. Pleurisy and pneumonia occur rarely if the heart is not affected. When the heart is the seat of endocardial changes only, the incidence is probably less than 10 per cent, but with pericarditis, which always means a severe infection, pleurisy or pneu- monia or both probably occur in half of the cases while if both pericar- dium and endocardium are involved the figures rise to a still higher point. Pericarditis, pleurisies, pneumonias, like subcutaneous nodules, are expressions of a virulent infection. The pleurisy may be an extension from a pericarditis, but this is by no means the necessary origin and probably in the majority of instances pleurisy is an expression of direct infection. Pneumonia as a complication is more frequent than pleurisy, though they often occur together as one might assume. The pleurisy is usually dry, but there may a serous exudate sufficient to tap. Both the pleurisy and the pneumonia are more likely to be on the left side. The pneumonia is very often a gradual development and the signs are often atypical; for example, a fall of temperature by crisis is not the rule, the physical signs may clear up as rapidly as they appear; the cough is not characteristic and the sputum is not rusty. My own experience has been that the physical signs are those of a lobar pneumonia with a massive pleural exudate and it has seemed to me that it does not so characteristically involve the whole lobe as a primary lobar pneumonia. Sometimes the type may be that of a broncho-pneumonia. Pulmon- ary edema may occur and at times infarctions. Bronchitis occasionally is a complication. The treatment of these conditions, the pleurisies, pneumonias, pul- monary edemas, infarctions and bronchitis is such as would be instituted ACUTE RHEUMATIC FEVER 57 under other circumstances, and does not call for an intermission of the salicylates (see Pneumonia, Chap. IX; Bronchitis, Chap. VII). Other Complications. Sore throat, if severe is to be treated as described under Scarlet Fever (see Chap. XVII and Tonsillitis Chap.V). The mouth throughout the illness should be kept scrupulously clean (see Pneumonia, Chap. IX). Other complications are numerous but rare. The skin eruptions, urticaria, erythema multiforme or nodosum, and purpuras require no special treatment. Hemorrhages from the nose, stomach, bowel, kidney may occur but rarely demand interference. Venous thrombosis is a rare complication and is treated as under other circumstances. Once in my experience an embolism of the popliteal artery occurred necessitating amputation. Anaemia is a striking feature of the disease, and indicates in convalescence the use of iron and iron-containing foods. Sweats of a severe type have long been associated in the minds of physicians with rheumatism, and may require especial consideration. They are very acid, and may cause considerable irritation. Sponging with a mild alkaline solution, as 1 per cent, sodium bicarbonate, gives relief. The skin should be kept dry with one of the numerous powders that contain talcum, or one made of equal parts of zinc oxide and starch. If the sweating is very severe, atropine may be used in doses of 1/100 to 1/50 grain. (0.0006-0.0015 Gm.) Vaccine Therapy. All the phenomena of acute rheumatic fever seen to me to demonstrate that it is an infectious process and yet, in spite of the careful work that has been done to determine the organism concerned, the positive findings are not very convincing. Nevertheless it seems wise to me to continue to make blood cultures during the febrile period and to take cultures from the crypts of the tonsils either in situ or after enucleation; from teeth; from excised subcutaneous nodules; from sinuses, ears or other obvious foci of infection. Joint fluids have been repeatedly cultured but are almost invariably negative. If these cultures are positive, most particularly those from the blood or deep Crypts of excised tonsils and obvious contamination can be excluded, I am accustomed to have vaccines made from them and by their adminis- tration give the patient at least the benefit of the doubt in this debatable question of the specificity of the organism. It must be remembered, more particularly in adults, but by no means in them exclusively, that a toxic arthritis derived from any of the foci mentioned may closely simulate rheumatic arthritis, though the heart is very rarely involved. 58 TREATMENT OF ACUTE INFECTIOUS DISEASES And in these cases vaccine therapy after the removal of the focus of infec- tion, is of real value. I am accustomed to administer these vaccines when the case has gone on to a long continued infection or is subacute in its manifestations or between the exacerbations of the rheumatism. My best results have been obtained with vaccines cultured from the deep crypts of the excised tonsils, but here of course, the enucleation of the tonsil itself is probably the more potent factor in the irnpiovement. The Dosage. The first dose should be tentative. I begin with 5,000,000-10,000,000, though some authors prefer so low a dose as 1,000,- 000. It is my custom to give the dose twice a week. The increase in dose depends upon the reaction. If there is no reaction one may increase the dose to 10,000,000, 20,000,000, 40,000,000, 75,000,000, 125,000,000, 200,000,000, and then add 100,000,000, or more, to each dose. If there is a slight local reaction one advances more cautiously; if a slight general reaction, do not increase the next dose; if a marked general reaction, wait for two or three days after it has subsided and begin again with a lesser dose. I have myself provoked an unfortunate exacerbation of symptoms with too large a beginning dose (in this case 50,000,000) . The reaction may be a reddened and tender area at the site of in- jection or a recrudescence of local lesions, e. g., in joints or a general reaction of fever, accelerated pulse and the other manifes tations of slight infection. More serious consequences can follow careless dosing. The number of injections is a matter of judgment and depends on results. I prefer eight to twelve doses and sometimes more. The technique is that of any hypodermic injection, a clean syringe and needle and a clean site of injection. The syringe should be graduated like a tuberculin syringe to hun- dredths of a c.c. When the heart is involved one should be even more careful in the dosage. Intravenous Injections of Foreign Protein (Foreign Protein Therapy), Shock Terapy. The use of non-specific vaccine or for- eign protein has been recently agitated in the treatment of acute rheu- matic arthritis as well as in other acute infectious processes, especially typhoid fever. Various proteins have been utilized, both from certain foodstuffs and bacterial bodies. All of these, regardless of their origin, when given intravenously produce a striking reaction. Indeed, favorable results from the use of such foreign proteins seem to depend on these reactions. Shortly after the injection there is a chill, accompanied by a leucopenia; in an hour or two a febrile reaction which lasts about 2-3 ACUTE RHEUMATIC FEVER 59 hours and accompanying this a sharp rise in the leucocyte count, which gradually returns to normal in 24 to 48 hours. In my ward at Bellevue, typhoid bacilli or sometimes, and especially when a gonococcus arthritis is a possibility in the case, the bodies of killed gonococci are used as the foreign protein. After the reaction, in favorable cases, there is a fall of temperature and a striking amelioration of symptoms; that is, a disap- pearance of pain and a diminution of the swelling in the joint. Cecil, reporting on 30 cases in our ward at Bellevue Hospital, found 40 per cent, were relieved of their symptoms without recourse to salicylates. In the rest it was necessary to supplement the vaccine treatment with the salicylates. Unhappily, nearly all these cases that had improved, relapsed in some measure. We can only theorize about how these beneficial results ensue, but it seems probable that these injections in some way distribute antibodies, sometimes spoken of as "a mobiliza- tion." Moreover, both the febrile reaction excited and the leucocytosis that follows are themselves useful instruments in combating the infec- tion. Our dosage has been 25,000,000 typhoid bacilli, with increasing doses to 50,000,000, 75,000,000, etc., at intervals of a day or two after the subsidence of the preceding reaction. While the results are not all that might be desired and in a case with cardiac complications should be undertaken with great care, nevertheless it is a measure that may afford prompt and lasting relief in a sufficient number to warrant its con- tinuance. CHOREA Chorea is often looked upon and treated as a separate and distinct disease, but chorea minor or Sydenham's chorea, long appreciated as mysteriously connected with rheumatism and as commonly complicated by the same kind of cardiac disease as acute rheumatism is now pretty generally looked upon as but one manifestation of rheumatism. Treatment then of chorea minor is the treatment of rheumatism except that rest is even more insisted on and more difficult to attain when both fever and pain are absent. Isolation is a very important part of the treatment. This is a guarantee of freedom from excitement. All visitors and relations are excluded and the child sees only the mother or nurse. How absolute- this shall be, how long continued depends on the progress of the case and the temperament of the patient. As avoidance of excitement as well as physical rest is the desideratum, much depends on the temperament of the mother or nurse. This does not mean that the patient is imprisoned and such isolation can be carried 60 TREATMENT OF ACUTE INFECTIOUS DISEASES on in the open air or the patient sent away to the country with the nurse and isolation effected there. In acute cases, however, the darkened quiet room is preferable. The diet should be sufficient and that of the healthy child in the milder cases arid in the acuter cases sufficient too, but chosen as in the febrile cases. These measures alone are often sufficient. They should be persisted in until effectual or for six weeks to two months have passed. Of course a time comes when the need of light and air makes us abandon the closer confinement, or the child's depression may forbid its continuance. Local Measures. Warm baths, especially before sleeping are often sedative in their effects and sometimes hot packs have a similar result. In febrile cases cool sponges may be of value. Drugs. As a rheumatic manifestation salicylates are indicated as in acute rheumatism, but there is quite a widespread belief that of the salicylates acetyl salicylic acid (aspirin) has a decided superiority over the others. The dosage should be that specified for rheumatism. Time honored, too, is the use of arsenic. It may be given in any form, but the preparation perhaps to be preferred is the liquor potassii arsenitis or Fowler's solution. The dose begins with m. ij to iij (0.13- 0.20 c.c.) increasing up to the point of tolerance. The urine is carefully watched meanwhile and with any evidence of albuminuria the drug is promptly stopped. If the stomach or bowels are affected or there is puffiness under the eyes we stop until the symptoms disappear and begin again on half the dose. Vaccines. I have had but a limited experience with the use of vaccines in chorea, but believe there is a field for them in chorea, when administered with the above precautions. I deplore the use of mixtures of organisms of unknown value and strength so widely advertised by commercial interests. Treatment of Symptoms. Restlessness may sometimes be con- trolled by the use of luminal in half grain doses (0.03 Gm.) three or four times a day. In adults slightly larger doses may be used. Three cases in my practice have shown diploplia even on these doses which quickly cleared up when the drug was omitted. When the patient is very restless and the movements severe, one may use choral, best by rectum, in doses of gr. v-xxx (0.30-2 Gm.) according to age, remembering that children bear relatively large doses. Codeine is sometimes very effective in controlling the movements. Dosage should be appropriate to age and it is to be remembered that it is very much more effective when given hypodermically. In an adult the dose ranges from 1/8 to 1 grain (0.008-0.06 Gm.) of the phosphate. ACUTE RHEUMATIC FEVER 61 For the worst forms and the maniacal type morphine sulphate in doses of gr. 1/16-1/4 (0.004-0.016 Gm.) or hyoscine hydrobromide gr. 1/200-gr. 1/100 (0.0003-0.0006 Gm.) may be necessary. At times the patients movements are so violent that measures have to be taken to restrict them lest the patient throw himself from the bed and suffer injury. In the hospital side boards have to be attached to the bed and lined with pads or pillows to prevent trauma following the violent motion. In children the same precaution should be taken with the crib. I have seen the skin on the bony parts, over the heels, malleoli, elbows, actually cornified from the constant attrition. One is likely to get sores difficult to manage. The part liable to damage should be padded. Auto-Sero-Therapy : This method has been recently advocated. Goodman describes his method as follows: Withdraw 50 c.c. of blood, centrifugalize, pipette off serum and place on ice. Do a lumbar puncture and withdraw 15-20 c.c. of fluid. Heat the serum to body temperature and slowly inject (into the subarachnoid space) taking 10-15 minutes, 15-18 c.c. of fluid. In a series of 30 cases so treated, he reported 20 cases cured and 7 improved. By cure he defines the cessation of all twitching in a week. It is assumed that some ferment or antibody present in the serum is introduced directly to the site of irritation. Convalescence from Rheumatism. The patient should be kept in bed for some time after the symptoms have subsided, one or two weeks; if the heart has been involved, longer, as detailed above. The diet should be increased to include green vegetables, later eggs, fish, and meat if they have not already been allowed. It should be simple in its character and in the manner of its preparation. It should be suffi- cient, but not excessive, nor should the patient be teased to stuff by palatable dishes. A change of environment often helps to establish convalescence, but the patient should not be hurried away too soon or exposed to discomforts in his new surroundings for the mere sake of the change. Prophylaxis. The avoidance of rheumatism, so lamentable in its consequences, must rest upon our education of the public in hygiene, through the schools and other agencies. The gospel of fresh air must be preached, clean bodies, proper clothing, avoidance of neglect, such as remaining in wet and damp clothing. More than this, parents and teachers must be made to understand the meaning of chorea, sore throats, stiff necks, and "growing pains" in children, and the results of neglect. The physician should be the teacher, as the term " doctor" implies, 62 TREATMENT OF ACUTE INFECTIOUS DISEASES both in his daily walks and in the more public capacity of lecturer, health officer, school inspector, etc. The school inspectorship is rife with the possibilities of infinite good. The upper air passages afford the portal of entry of the vast majority of rheumatic infections. Tonsils and adenoids hypertrophied to the point of obstruction, even though they have never been the seat of acute infection should be re- moved. Tonsils and adenoids that have been the seat of infection whether accompanied or followed by rheumatism or not should be removed. Tonsils and adenoids in all cases of rheumatism should be removed between the attacks. There is a difference of opinion expressed by excellent observers as to the advisability of removing tonsils during an acute attack of rheu- matic fever. That such a procedure may entail additional infection cannot be denied, nor does it seem advisable to submit a patient to the other exigencies of an operative procedure during the height of an infec- tion. Finally foreign body pneumonia is an all too frequent sequel of tonsillar enucleation even in health. But when the infection is persistent or the heart involved and other measures fail to control the infectious process it becomes a question as to whether the danger of leaving a focus of infection is not greater than the dangers entailed in its removal. Hence the difference of opinion. The most brilliant result I have ever seen in promptly controlling an acute rheumatic fever with serious cardiac involvement, lasting for 10 to 12 weeks, followed a tonsillar enucleation, which was done at a time when an acute appendical attack necessitated an operation for removal of that organ. I favor complete enucleation of the tonsil. The tissue should be care- fully preserved in a sterile container to be submitted to bacteriological investigation for the purpose of identification and preparation of vac- cines. Sinuses should be examined and any abnormality of the nose at- tended to. The teeth, especially that condition known as pyorrhea alveolaris contribute to infection, though in my experience the so-called toxic arthritis has more commonly been associated with this infection than the clinically true rheumatism. These should have dental consideration and it is a condition that puts to the test the best dental skill. Some investigators believe that bronchial infection and intestinal infection point the road to rheumatic infection and certainly these conditions demand attention. ACUTE RHEUMATIC FEVER 63 Rheumatic children, especially, when showing nervousness should not be urged at school. Moon has sensibly remarked that they should do no evening work and should rest in the middle of the day. When in these cases headache and poor sleep intervene or there is a frank exacerbation of nervousness the little patient should be taken out of school until matters improve. Damp cold has long been known to provoke rheumatism and recur- rences of rheumatism and Rosenow declares that exposure to cold after injection of rabbits with the rheumatic organism increases the percentage and degree of joint involvement. This of course accentuates the necessity of avoidance of exposure to cold and wet; the importance of promptly changing wet stockings and clothes, removal from cold damp houses and localities and the importance of warm clothing, and especially underclothing containing wool. SUMMARY Rest. Quiet. Exclusion of visitors. Mental rest. Freedom from annoyance, conversation, business cares in the adult, efforts at amusement in children. Good nursing. Bed. Hospital type preferred. Gatch bed, see text. Woven wire spring. Finn mattress. Flannel blankets. Flannel nightgown open down front or side. Room. Light and air. Avoid draughts. Temperature 65 F. to 70 F. Open air. Diet. Calories approximate 3,000 in adult and more if well taken. Protein 65 to 75 Gm. During early hours with high fever and anorexia don't push food. Milk 640 calories to 1 quart. Protein 33 Gm. Sugar 120 calories to 1 ounce. Cereals about 100 calories to large serving. Average: protein 4 Gm. Rice about 100 calories to large serving. 64 TREATMENT OF ACUTE INFECTIOUS DISEASES Oatmeal cooked 100 calories to 5.5 ounces. Protein, 4.25 Gm. Oatmeal dry 1 oz. 120 calories. Cream 16%, calories, 50 per ounce. Protein, 1 Gm. Cream 40%, calories, 120 per ounce. Protein, 1 Gm. Eggs 70-89 calories, each. Protein, 7 Gm. Eggs Yolk, 50-65 calories. Eggs, Whites 16-25 calories. Flours in general approximate 100 calories to the ounce.- Protein, 3Gm. Bread 100 calories to thick slice (1 & 1/3 ounce). Protein, 4 Gm. Butter 100 calories to pat ^scant J ounce) . 230 calories to the ounce. Milk, soups, mutton broths, chicken broths thickened with rice or cereals. Fish 6 ' I as tem P erature approaches normal. Meats after temperature has been normal a few days. Bowels. Salts Epsom, Rochelle, Glauber's gss.-j (15-30 Gm.) followed by enema of plain water or soapsuds if needed. LATEK. Enemata. Salines. Hunyadi water other mild equivalents on the market, liquor magnesii citratis, gviii-xii (240-360 c.c.), Seidlitz powders or, if obstinate, salts mentioned above and enemata to follow. " Specific " Treatment. Sodium salicylate gr. xx (1.33 Gm.) every two hours. As pain sub- sides cut gradually to gr. xv, then gr. x (1.00-0.66 Gm.) every two hours. Keep at gr. x (0.66 Gm.) until all active phases have past. After symptoms have disappeared gr. x or v (0.66-0.33 Gm.) every two or three hours for a week or ten days. Then for four to six weeks give gr. x or v (0.66 or 0.33 Gm.) three or four times a day. Continue with alkali (see below) . If satisfactory results do not ensue increase dose to production of toxic manifestations. This may be anticipated in the adult in the neighborhood of 150 to 200 grains a day, depending on the sex, weight, etc. Administer alkali; citrate of potash, acetate of potash, bicarbonate of soda, enough to render urine alkaline and keep it alkaline or neutral. Rule two grains of the alkali, preferably bicarbonate, for one of the salicylate. Toxic manifestations. (See text.) 3 SodiiSalicylatis 5ss. (15) Aqua?, q. s. ad f ii (60) M. S. Teaspoonful in water every two hours. ACUTE RHEUMATIC FEVER 65 Acidi Salicylic! ................................. 3iv (15) Sodii Bicarbonatis .............................. 5iii Q2) Aquae, q. s. ad ................................. f ii ( 60 ) M. S. Teaspoonful in water every two hours. V Acidi Acetylsalicylici ........................... gr. cl (10) Ft cap. no. xxx. S. Three (3) or four (4) every two hours. Give alkaline as above, but between the doses, to avoid incompatibil- ity, or push dose to toxic manifestations. This may be anticipated in the adult near 120 or 160 grains a day depending on sex (weight). Toxic manifestations (see text). Methyl salicylate or oil of gaultheria in m. xv-xx (1.00-1.30 c.c.) every two hours. I* Olei Gaultheriae .............................. f3v Ft. cap. no. xxx. S. Two (2) every two hours. S Olei Gaultherise .............................. f 3iv (15) Acaciae, q. s. Aquae, q. s. ad ................................ f gii (60) M. ft. emul. S. Teaspoonful every two hours. 3 Olei Gaultherise ............................... f 5iv (15) Acaciae. . . . ................................... q. s. Potassii Citratis ............................... 5i (30) Aquae, q. s. ad ................................ f giv (120) M. ft. emul. S. Teaspoonful every two hours. Give bicarbonate or other alkali gr. ii to m. i of the oil; may push to production of toxic manifestations. These may be looked for at about 120 minims (8 c.c.) a day. For toxic manifestations. (See text.) Diplosal (salicylsalicylic acid) gr. x (0.66 Gm.) every two hours. 9 Diplosal ...................................... 20.00 5v Divide in capsules no. xxx. S. One every two hours. Or push to toxic manifestations, which may be anticipated as dose approximates 80 to 100 grains a day depending on sex (weight). Administer alkali between doses. Dose about gr. iv (0.25 Gm.) per grain diplosal. Toxic manifestations. (See text.) 66 TREATMENT OF ACUTE INFECTIOUS DISEASES Rectal administration of salicylates. Use a thin starch paste at body temperature, 5iv-vj (120-180 c.c.). Add }/% daily dose of salicylate, e. g., 5i (4 Gm.). Add m. i to ii of tincture of opium if needed to retain. Inject slowly; hold buttocks together for a 'few minutes. Dose every twelve hours. or Give whole dose, e. g., 5ii (8.00 Gm.) in the same amount of starch paste once a day. Alkalis, e. g., bicarbonate of soda, is given at two-hour intervals by the mouth, the total day's dose to amount to two grains to one of the salicylates. Intravenous administration. Technique. (See text.) Use when salicylates cannot be borne for any reason as in the case of idiosyncrasies. Drugs to relieve pain. Acetanilid, gr. iss. (0.10 Gm.) every J/ hour for 4 doses; repeat at six or eight hour intervals, or gr. ii-iii (0.15-0.20 Gm.) every two hours. Give in capsules or powders. Acetphenetidin (Phenacetin), gr. iii to v (0.20-0.30 Gm.) every two hours. Give in capsules or powders. Antipyrin gr. iii-iv (0.20 Gm.) every two hours. Give in capsules or solution. For severe pain. Morphine sulphate best hypodermically, gr. 1/16-gr. to 1/8 (0.004- 0.008) adult dose. Symptomatic treatment. Joints. Rest. Semi-flexion. Pillows, cushions, sand bags. Carefully padded splints. Cold. Ice bag or ice coil. Cold compresses. Use of Gatch bed. Fomentations. Protection with non-absorbent cotton and flannel bandages. Drugs. Methyl Salicylate or oil of wintergreen. 3 Methyl Salicylatis. Menthol aa 15 per cent. Petrolati q. s. ad 30.00 gi. M. et fiat unguentum. S. Local use. ACUTE RHEUMATIC FEVER 67 Ichthyol. U Ichthyolis 25 per cent. Petrolati q. s. ad 30.00 5i M. et fiat unguentum. S. Local use, Counterirritation. Cautery. Fly-blister. Pressure. Flannel bandage. Rubber bandage. Persistent effusions. Paracentesis For Technique, see text. LATER MEASURES. Gentle manipulation. Massage. Fomentations. Baking. Vaccines. Complications. Hyperpyrexia. Cold baths. Put in tub at 65 F., or to save shock at 80 F., cooling it to 65 F., gradually. Keep temperature of water down by adding ice. Take patient out when temperature is 102 F. Repeat when patient's temperature rises to 104 F. or 105 F. Cold packs. Sheet wrung out of cold water and wrapped about patient's body and then rubbed with pieces of ice. Cardiac complications. Continue salicylates in full dose as described above. Continue in bed two months at least, after all other signs of rheu- matism have disappeared, and as much longer as the condition of the heart may seem to warrant. Allow first to sit up, then to get on feet, but always guided by evi- dences of heart's stability. Increased rate and tumultuousness of beat out of proportion to effort made, indicates continuance of rest. If heart decompensates it is to be treated like a decompensated heart under other circumstances. The acute febrile process does not centra-indicate the use of digitalis in full doses. Digitalis, full dose the equivalent of gr. ix-xii (0.60-0.80 Gm.) daily 68 TREATMENT OF ACUTE INFECTIOUS DISEASES for three or four days or until signs of accumulation or desired results ensue, then stop two or three days and resume with smaller dose gr. iii (0.20 Gm.) a day (adult dose). After treatment. Tonsilectomy. Avoidance of damp cold. Change of climate. Regulated exercise beginning soon after disappearance of symptoms. Passive first, then active within limit of demonstrated cardiac capacity. Pneumonia and pleurisy. Treat as under other circumstances. Continue salicylates in full doses. Sore throat. Careful oral toilet. (See Pneumonia, Chap. IX.) Tonsillitis, Chap. V. When severe treat as in Scarlet Fever. (See Chap. XVI.) Insomnia. Trional, gr. x-xx (0.66-1.33 Gm.) in early evening and repeat if needed two or three hours later (adult dose). Give in capsule or powder. Chloralamid, gr. xx-xxx (1.33-2. Gm.) in early evening; repeat, if needed, in two to three hours (adult dose). When pain is present use morphine hypodermically gr. 1/16 to gr. % (0.004-0.015 Gm.) (adult dose). Anaemia. Iron. Blaud's pill (Pil. ferri carbonatis), or Vallet's Mass (Massa ferri carbonatis) gr. v-x (0.33-0.66 Gm.) three times a day. In children lesser doses of same, or bitter wine of iron (Vinum ferri armarum) 5i-iii (4-12 c.c.), three times a day. Sweats. Sponging with 1 per cent, bicarbonate of soda. Talcum powder. Zinc oxide and starch equal parts. Apply locally. Atropine sulphate gr. 1/100 to 1/50 (0.0006-0.0013 Gm.). Vaccine therapy. Use only autogenous vaccines. Seek organisms by cultures. 1. from blood. 2. from joint fluid. 3. from subcutaneous nodules. 4. from depths of tonsilar crypts. 5. from sites of obvious infection as teeth, ears, sinuses. Time to use vaccines. During subacute stage or between exacerbations. ACUTE RHEUMATIC FEVER 69 Dosage. 1st dose tentative, 5,000,000-10,000,000. In cardiac case 1,000,000-5,000,000. Frequency. Twice a week. Succeeding doses. In the absence of reactions, double the doses up to 150,000,000- 200,000,000 then increase by 100,000,000 at a dose. Reaction. (See text.) If reaction is slight and local do not increase next dose. If reaction is severe and general wait until all signs of reaction have subsided for two or three days and begin with lesser dose. Number of doses. Depends on results and is a matter of judgment, 10 to 12 or perhaps more. Technique that of any hypodermic medication; cleanliness of instruments, operator and site of operation. Syringe graduated to fractions of a c.c., e. g., tuberculin syringe. In cardiac cases. Beginning dosage lower. Advance in dosage more cautiously. Foreign Protein Therapy. (See Text.) Tonsillectomy. (See Text.) Chorea. Rest in bed. Isolation. Diet. Liberal if afebrile; as in rheumatism if febrile (see above). Local measures. Warm baths especially before sleeping, or two or three times a day. Hot packs once a day. Cool sponges in febrile cases. Drugs. Salicylates in full doses as in rheumatism. Acetyl salicylic acid (Aspirin) the form preferred. Arsenic; any form. Fowler's Solution (Liq. potassium arsenitis), m. ii-iii (0.12^0.20 c.c.), as a beginning dose, increase a minim a day or a minim a dose a day up to the point of tolerance; that is, disturbance of stomach or bowels or puffiness under the eyes. Watch urine for albumin. Then stop until symptoms disappear; begin with }/% largest dose and increase again. Vaccines. As in rheumatism, but with less dose and cautious increase. Autoserotherapy. (See text.) Marked restlessness and violent movements. Chloral, gr. v-gr. xxx (0.33-2.00 Gm.) in gi-iiii (60-90 c.c.) of warm milk by rectum at night. (Children take large doses relative to their age.) 70 TREATMENT OF ACUTE INFECTIOUS DISEASES Most severe and maniacal cases. Morphine sulphate, gr. 1/16 to gr. J^ (0.004-0.015). Hyoscine hydrobromide, gr. 1/200 to gr. I/ 100 (0.0003-0.0006 Gm.). Convalescence in rheumatism. In bed one or two weeks after symptoms subside. In cardiac cases longer, as above. Diet. Made more liberal. Change of environment to be considered. Prophylaxis. Education of public. Fresh air. Cleanliness. Warm clothing. Avoidance of chilling. Inspection of upper air passages. Elimination of tonsils and adenoids. Teeth to be attended to. Avoidance of excitement and urging in school of the nervous children already infected. After treatment of the heart. See text. CHAPTER IV ACUTE RHINITIS CORYZA THIS affection, known to the laity as a "cold in the head/' is one of the most infectious diseases to which we are exposed and, as immunity seems but short-lived, these two facts contribute to make it the most common of our afflictions. What the etiological agent is, is not known. Pathogenic organisms in abundance have been recovered from the secretions of the nasal passages during an acute rhinitis, but no one of these has been proven to be the etiological agent. A strong plea has been made for a filterable virus, and such it may well prove to be; but it remains for the future to definitely settle that question. Moreover, it is possible that the rhinitis that accompanies or ushers in certain other acute infections, such as measles or influenza, may be actuated by other organisms than those responsible for a primary attack. The common cause for an infection is direct exposure to an individual suffering an attack. Some men are inclined to think that that is the only mode of infection. Others believe that many are in a carrier state, harboring the inf ecting organism as most of us do Type IV pneumococcus and afford opportunity for infection by lowering resistance as is the case with Type IV pneumococcus. Such a lowering of resistance follows exposure and chilling, such as wet feet and wet clothes, remaining in draughts when the skin is warm and moist and it has seemed to me that conditions causing intense congestion of the tissues of the nasal mucous membrane, like uncontrolled sneezing, open portals to infection. Nasal obstruction, adenoids or possibly old sinus infections, may predispose to attacks. Symptomatology The symptoms are local and in the severe forms, general. They are so familiar to every reader that an attempt to picture them is an act of supererogation. The stuffed nose, especially following nasal obstruction, the thin watery secretion that wets handker- chief after handkerchief, and excoriates the nasal openings, the dull frontal headache, and in severe cases, the conjunctival congestion, the miserable malaise, or even general aches and pains, with perhaps a slight fever, constitute the catalogue of events. The seriousness of an attack lies in the fact that it weakens the bar- 72 TREATMENT OF ACUTE INFECTIOUS DISEASES riers of resistance to other infections that invade the rest of the air passages and contiguous structures. Treatment Early or abortive. The object of this is to pro- mote hyperemia and a leucocytosis, two reactions of protective signifi- cance. To be effectual the treatment must be prompt and in the early hours of the attack. A hot bath or a hot mustard foot-bath (for technique, see index) is taken; after which the patient should go to bed. The bed must be warm and the patient should get between blankets or put on a flannel night dress or pajamas. A hot water bottle should be placed at the feet and hot drinks should be taken hot lemonade with or without a dash of whisky, (5ss.-15 c.c.) or hot weak tea or hot Imperial drink (a table- spoonful of cream of tartar in two pints of boiling water it is poorly sol- uble in cold water to which is added lemon juice or lemon peel and sugar to the taste) . All this induces sweating, diaphoresis, and for the same purpose Dover's powder (Pulv. ipecac et opii) has long been a favorite drug of many. It may be given to an adult in the full dose of gr. x (0.66 Gm.) or in any fractions of this dose at frequent intervals un- til the whole amount is taken. Great care must be taken when perspiring freely to avoid exposure; so the treatment should not be undertaken except in warm rooms and a warm and properly prepared bed. Aches and pain are best treated with acetylsalicylic acid (aspirin) in doses of gr. v-gr. x (0.33-0.66 Gm.) at 2 or 3 hour intervals or small doses of a coal-tar preparation at frequent intervals; e. g., ace- tanilid gr. i ss. (0.10 Gm.), antipyrin gr. ii (0.120 Gm.), acetphenetidin gr. iii (0.20 Gm.) at hourly intervals for 4 doses, then every 2 hours in such a prescription as follows: Acetanilidi ............................. 1 . 50 (gr. xx iiss.) Sodii Bicarbonatis ............ .......... 1 . 00 (gr. xv) Caffeinae Citratse ....................... 0.50 (gr. viiss.) M. et div. in cap. no. xv. S. One every hour for 4 doses, then every 2 hours. or: Codeinae Sulphatis 0. 125 (gr. ii) Acetphenetidini (phenacetin) 3 . 00 (gr. xlv) Acidi acetylsalicylici (aspirin) 5 . 00 (gr. Ixxv) M. et div. in cap. no. xv. S. One every 2 or 3 hours. ACUTE RHINITIS CORYZA 73 When the secretion is excessive, if the physician does not prescribe, the patient is pretty sure to take one of the multitudinous rhinitis or coryza tablets on the market, the bases of which are belladonna, cam- phor, aconite, and often quinine and small doses of opium. Local Treatment. The object of this is to promote drainage and ventilation and so afford comfort. It is effected by applications made directly to the sites involved, by sprays or by inhalations. Direct Applications. It is well to precede all applications by a cleansing spray of normal salt solution, Setter's tablets, or one of the many alkaline solutions on the market which contain solutions of both alkaline salts and certain volatile oils. Argyrol 15 per cent, to 25 per cent, applied on a cotton swab on an applicator, or used as a spray seems at present to be the choice for the purpose. In addition to this it is by some clinicians dropped in the conjunctival sacs, thus gaining access to the nasal mucous membrane by way of the lachrymal ducts. Drops of adrenalin (epinephrin) 1-1000 into either nostril, or used as a spray or applied on a pledget of cotton on an applicator and left in contact with the mucous membrane for a few seconds, astringe these structures and allow of ventilation. Cocaine has been used for the same purpose; but there are too many objections to it to permit of rec- ommendation; 1 per cent, solution of the hydrochloride is that com- monly used. Antipyrin, 3 per cent, solution, is used for the same purpose and is less objectionable than the cocaine; at times the two are combined in the strengths specified. The constringency induced by the above applications is maintained by ointments or sprays the essential ingredient of which is menthol. Ointments. As useful will be found the following: Aristol .................................... 1 .00 (gr. xv) Mentholis ................................. 0. 10 (gr. iss.) Petrolati q. s. ad .......................... 15.00 (gss.) M. S. Local use. or: Mentholis 0.20 (gr. iii) Olei Pini Pumilionis 0. 125 (m. ii) Olei Rosae 0.060 (m. i) Petrolati 30.00 (gi) M. S. Local use. Sprays. One may use 1 per cent, each of menthol, camphor and oil of eucalyptus hi Benzoinol or liquid petrolatum. 74 TREATMENT OF ACUTE INFECTIOUS DISEASES or: $ "Mentholis gr. xxx (2.0 Gm.) Camphorse gr. xx (1.30 Gm.) Eucalyp'tolis m. xx (1.30 c.c.) Olei Rosse m. iii (0.20 c.c.) Benzoinol q. s. ad gii (60.00 c.c.) M. S. Use in oil atomizer." (Coakley.) If this is found too strong the menthol may be reduced to gr. x-xv (0.66-1. Gm.) or the whole diluted with more benzoinol to an agree- able strength. Special oil atomizers must be used for all these. Inhalations. Simple steam inhalations may be found grateful, or compound tincture of benzoin, or the oil of pine, one or two teaspoonfuls on the hot water of the inhaler, or a few drops of the alcoholic saturated solution of menthol in the same manner, or such prescription as follows : I* Olei Pini Sylvestris 5ss. (2.00 c.c.) Olei Eucalypt gss. (15.00 c.c.) Mentholis gr. x (0.66 Gm.) Creosoti m. x (0. 66 c.c.) Tr. Benzoin Comp. q. s. ad gii (60.00 c.c.) M. S. 20 drops in boiling water for inhalation. For these inha- lations one may use pitchers, carafes, kettles, with stiff paper rolled for a funnel, or a croup kettle, or one of the simple and in- expensive inhalers on the market. Later, when the discharge becomes thickened, warm alkaline sprays may be used such as follows : 3 "Sodii Bicarbonatis Sodii Biboratis aa gr. xxxii (2 Gm.) Aquae dest. q. s. ad 5 iv (120 c. c.) M. S. Use as spray." (Coakley.) or one of the mild alkaline "antiseptics" of the trade. If there is still much obstruction to the nasal passages, adrenalin (epinephrin) or anti- pyrin as directed above. Such a spray as follows may prove of value : V Iodine 0.06 (gr. i) Menthol 0. 10 (gr. i ss.) Liquid petrolatum 60.00 (gii) M. S. Spray from oil atomizer with hard rubber parts. Nasal irrigations and douches are deplored as being likely to induce otitis. ACUTE RHINITIS CORYZA 75 Sore Throat. If a sore throat accompanies the coryza, the spec- ified inhalations may be used. If a tonsillitis, see Chap. V. If a cough without definite signs in chest, one may assume a tracheitis and give such a mixture as follows : 3 "Codeinae Sulphatis gr. iii (0.20 Gm.) Ammonii Chloridi 5i (4.00 Gm.) Thiocol 5ii (8.00 Gm.) M. et ft. cap. no. xxiv. S. One every 2 hours." (Bingham.) For detailed treatment, see Tracheitis, Chap. VII. Complications. As has been said the respiratory tree at large may be involved or the contiguous structures. See Bronchitis, Pneu- monia, Laryngitis, Tonsillitis (Chap. VII, IX, VI, V). Sinusitis. This is a not uncommon complication. The frontals, ethmoids, or sphenoid sinuses, or antra of Highmore may become in- volved. The methods detailed above of local applications to facilitate ventilation and drainage are of considerable prophylactic value; but clear evidences of sinus involvement requires expert attention. To those who must rely on their own management, special treatises on this subject are recommended. Antral Involvement. Efforts at drainage should first be made before having recourse to radical procedure. See details under Grip, Chap. XI. For lavage and surgical procedure consult special treatises. Otitis. This is always to be feared, especially in young children. Irrigations and douches should not be used in the nose. Instructions should be given to blow nose gently, one side at a time, to avoid forcing infection into Eustachian tubes and antra or sinuses. When antra are involved try to suck discharges back into pharynx, to expel by mouth rather than blow nose. Prophylaxis. Rooms should be kept at 68 to 70 and as in most steam heated apartments the air is deprived of its moisture an effort should be made to replace this by suitable devices. Removal of obstructions such as tonsils, adenoids, and the rest of infected tissue of Waldeyer's ring; attention to hypertrophied turbinates, deviated septa, and chronically infected sinuses and antra. Personal Hygiene. Training the vaso-motor supply of superficial vessels, so that the vessels will quickly respond to changes in en- vironment. This is done by daily cold baths, sleeping in well-ventilated rooms, windows open at all times of year, exercise in the open air, avoid- ance of overclothing, especially about the neck. 76 TREATMENT OF ACUTE INFECTIOUS DISEASES Dress lightly in house, and on going out add clothing suitable to the weather. Underclothing should be of silk or cotton mesh or if it contains wool should be very light. SUMMARY Treatment. Early or abortive. Must be begun early. Hot bath. Hot mustard foot bath. For technique see Pneumonia, Chap. IX. Patient must go to bed promptly. Bed to be made up with blankets rather than sheets or patient to wear flannel night clothes. Hot water bottle at feet. Hot drinks to be taken. Lemonade with whisky, gss. (15 c.c.). Imperial drink (one tablespoon of cream of tartar in one quart of boiling water, and sugar to taste). Dover's powder gr. x (0.66 Gm.) or in small fractions at frequent intervals until this amount is taken. Avoid exposure if this treatment is taken. Aches and pains. Acetylsalicylic acid (aspirin) gr. v-gr. x (0.33-0.66 Gm.) every two or three hours. Or coal-tar preparations, acetanilid gr. iss. (0.10 Gm.), antipyrin, gr. ii (0.120 Gm.), acetphenetidin (phenacetin) gr. iii (0.20 Gm.). Give any one of these at hourly intervals for 4 dosss and then every 2 hours. or: Acetanilidi ........................... 1 . 50 (gr. xxiiss.) Sodii Bicarbonatis .................... 1 . 00 (gr. xv) Caffeinse Citratse ..................... . 50 (gr. viiss.) M. et div. in cap. no. xv S. One every hour for four doses and then one every two hours. or: Codeinse Sulphatis ......................... 0. 125 (gr. ii) Acetphenetidini (Phenacetin) ................ 2 . 50 (gr. xl) Acidi Acetylsalicylici (Aspirin) .............. 5.0 (gr. Ixxv) M. et div. in cap. no. xv. S. One every two or three hours. For excessive secretions combinations of belladona, aconite, quinine, ACUTE RHINITIS CORYZA 77 opium, in one of the multitudinous formulas offered by pharma- ceutical houses may be tried. Local applications. Precede by cleansing sprays of normal saline or one of the alkaline solutions on the market. Argyrol 15%-25% on swab of applicator or as spray. Same may be dropped in conjunctival sacs. To relieve obstruction. Adrenalin (epinephrin). 1 :1000 dropped in either nostril or sprayed or applied by appli- cator and left in contact with mucous membrane for a few seconds. Or antipyrin, 3% solution. The effects of the above may be continued by sprays or oint- ments with menthol as the chief ingredient. 3 Aristol ..................................... 1.0 (gr. xv) Mentholis .................................. . 10 (gr. iss.) Petrolati q. s. ad .......................... 15.00 (gss.) M. S. Local use. or: 9 Mentholis .......................... ......... 0.20 (gr. iii) Olei Pini Pumilionis ........................... 0. 125 (m. ii) Olei Rosse ................................... 0.060 (m. i) Petrolati .................................... 30.00 (gi) M. S. Local use. As sprays one may use 1% each of menthol, camphor, and oil of eucalyptus in benzoinol or liquid petrolatum. or: " Mentholis ............................... gr. xxx (2 Gm.) Camphorae ............. ................. gr. xx (1.3 Gm.) Eucalytolis .............................. m. xx (1.3 c.c.) Olei Rosse ............................... m. iii (0.2 c.c.) Benzoinol q. s. ad ........................ 5ii (60 c.c.) M. S. Use in oil atomizer." (Coakley.) If this is too strong reduce the menthol to gr. x-xv (0.66-1 Gm.) or dilute with benzoinol. Inhalations. Simple steam. Compound tincture of benzoin. 78 TREATMENT OF ACUTE INFECTIOUS DISEASES Oil of pine. One or two teaspoonfuls of either on the hot water of inhaler or one or two drops of saturated alcoholic solution of menthol in the same manner. or: 3 Olei Pini Sylvestris 3ss. (2.00 c.c.) Olei Eucalyti gss. (15.00 c.c.) Mentholis gr. x (0.66 Gm.) Tr of Benzoin Co. q. s. ad. gii (60.00 c.c.) M. S. 20 drops in boiling water for inhalation. For inhalers use pitchers, kettles with stiff paper rolled, or one of the simple inhalers on the market. Later treatment. Warm alkaline sprays, e. g. $ Sodii Bicarbonatis Sodii Biboratis Sa gr. xxxii (2.0 Gm.) Aquae q. s. ad 5 iv (120 c.c.) M. S. Use as spray. (Coakley.) May use mild alkaline antiseptics of the trade. For obstruction of the nasal passages use adrenalin or antipyrin as above, or: 3 Iodine 0.06 (gr. i) Menthol 0.10 (gr. iss.) Liquid Petrolatum 60.00 (gii) M. S. Spray from oil atomizer with hard rubber parts. Do not use nasal irrigations and douches lest they induce otitis. Sore throat. Inhalations as above. See Tonsillitis (Chap. V). Cough. With no signs in the chest, probably tracheitis. 3 Codeinse Sulphatis gr. iii (0.20 Gm.) Ammonii Chloridi 3i (4.00 Gm.) Thiocol 5ii (8.00 Gm.) M. et ft. cap. no. xxiv. Or see Tracheitis, Chap. VII. Complications. Laryngitis. (See Chap. VI.) Tonsillitis. (See Chap. V.) ACUTE RHINITIS CORYZA 79 . Bronchitis. (See Chap. VII.) Pneumonia. (See Chap. IX.) Sinusitis. Local applications. Persistent cases or suspected empyema, see special treatises. Antrum Involvement. Effect drainage. See Influenza, Chap. XII. Otitis. Always suspect in young children. Routine examination of ear. Avoid douches. Blow nose gently and one side at a time. Suck discharge back into the pharynx rather than blow nose. Prophylaxis. Temperature of rooms 68 F. to 70 F. Replace moisture in air by one of the suitable devices on the market. Removal of obstructions such as tonsils, adenoids, and hypertro- phied turbinates. Treat chronically infected sinuses and antra. Personal hygiene. Train the vasomotor supply of the superficial vessels by cold baths, sleeping in well ventilated rooms, exercise in open air, avoid over- dressing in the house and on going out add clothing suitable to the weather. Underclothing should be of silk or cotton mesh or if it contains wool it should be very light. CHAPTER V TONSILLITIS AND VINCENT'S ANGINA TONSILLITIS BETWEEN the mouth and the larynx stands the wall of adenoid tissue, designed as a barrier against infection. This is distributed in a circle about the tube and is known as Waldeyer's ring. It accumulates in masses on either side known as the faucial tonsils; above, where it is commonly spoken of as the adenoid or adenoids, its structure usually showing a central and lateral lobes; and below, where it is known as the lingual tonsil. Lymphatics from the mouth drain into these structures whose function it is to check infection coming from these sites. Infec- tions which force these barriers pass to the lymphatic channels and glands beyond. Their importance to the welfare of the body is readily understood; but when from repeated infections they become the sites of chronic infection, harboring organisms ready to take advantage of any lowering of the individual's resistance they become a menace to the integrity of many remote organs and all too frequently to life. It is generally appreciated that the tonsils harbor such infection, but it is too commonly forgotten, especially in the adult, that the adenoid, and still more the lingual tonsil may be chronically infected to continue the infec- tion, after complete enucleation of the faucial tonsils. However, because the faucial tonsils are most commonly and most obviously affected we speak of this "sore throat" as Tonsillitis. The infecting organisms are in the majority of instances streptococcus hemolyticus, but the invaders may be streptococcus non-hemolyticus, (viridans) Staphylococcus aureus or micrococcus catarrhalis. The structure of the tonsil with its deep crypts, which one may think of as the prints of fingers thrust deeply into dough, favors the reception and retention of pathogenic bacteria. The tonsils become swollen and reddened and bulge out from between the pillars of the fauces, the peritonsillar tissue is also infiltrated and reddened. The sites of the plugged crypts appear as white spots, and afford the designation of follicular tonsillitis. Often the exudation from adjacent follicles coalesce. The tissue between these white areas is red and swollen. The differential diagnosis from a diphtheritic throat is often very TONSILLITIS AND VINCENT'S ANGINA 81 difficult and many times can be made only by cultures and micro- scopical examination of smears. The characteristics of a typical tonsillitis are an exudate of a yellowish color separated by a deep red mucous membrane giving a patchy appear- ance and confined to the tonsils. It may be removed without causing any bleeding. The sore throat of diphtheria, on the other hand, has a membrane of an ashen gray color. It usually starts at one point and spreads out over the tonsil and may extend onto the pillars of the fauces, the edge of the soft palate and uvula. It is firmly adherent and when removed leaves a bleeding surface. The worst form of streptococcus hemolyticus infections are called septic sore throat and are commonly seen in milk-borne epidemic mastitis in cows. The cervical glands, receiving the lymphatics draining the tonsils, become enlarged and tender and in severe infections may break down into abscesses, which may point and discharge on the surface. Bullowa insists that the gland which receives the drainage from the tonsil is situated high up in the triangle made by the sterno-cleido mastoid and the posterior belly of the digastric muscle and not the one at the angle of the lower jaw commonly called the tonsillar gland. It must be remembered that a tonsillitis may be the expression of rheumatism, a diphtheria, an early symptom of scarlet fever, a Vincent's angina, or the precursor of an infection of the respiratory tree and that syphilitic sore throat, either the primary lesion or secondary, and acute lymphatic leukaemia may lead to an error of diagnosis. Symptomatology. The onset is often abrupt and the evidences of infection severe. Chilly sensations or a chill followed by fever, head- ache, general muscular pains like a grip infection and sore throat con- stitute the symptomatology. The tonsils are swollen and red and the crypts may be plugged or a membrane be present. To be sure, many attacks are much lighter and patients may insist on keeping about. But acute tonsillitis is never a trivial affair and the involvement of remote structures, such as the kidney or the heart or joints may occur in what seems like a mild attack. Treatment. The patient should be confined to bed even in a light attack. Children and all the members of the family who are susceptible to sore throats, or infection of the air passages of any kind should be kept away from the patient. In fact, there is little common sense in allowing any person to come into contact with a patient suffering from an infectious process unless it is to act in the capacity of a nurse. Cultures and Precautionary Measures. Text-book descriptions 82 TREATMENT OF ACUTE INFECTIOUS DISEASES of the differential diagnosis between follicular tonsillitis and diphtheria lead you to wonder how a mistake could ever be made or to marvel that a differentiation can ever be achieved. Experientia docet and the man who has seen much of these two con- ditions rarely errs; but for the general run of us the knowledge that a net is always laid for the unwary and that a text-book follicular tonsillitis may be diphtheritic, plead for the culture tube in the physician's bag and the use of it as a routine in dealing with sore throats. On the other hand the throat highly suspicious of diphtheria may turn out on culture to be streptococcal in origin; for this reason, if cultures cannot be taken, or reports are likely to be delayed, or in children or adults showing prostration, let the patient have benefit of the doubt and administer antitoxin at once. (See Diphtheria, Chap. XVIII.) Diet should be light. The condition of the throat causes so much pain on swallowing that all articles of food must necessarily be fluid, or at the most semi-solid; milk, broths, cereals, custards, jellies, ice-cream, milk toast are the basis of such a dietary and one may be referred to the diet lists given in the chapters on Typhoid Fever and Pneumonia for the several items. It is amazing how much flesh is lost during the short attack of tonsillitis of three to six days and theoreti- cally a dietary should take these needs into consideration; but when swallowing is torture, knowing it to be an affection of relatively short course, one must be satisfied with what the patient can take without great discomfort. Sometimes the food is preferred hot, sometimes cold, sometimes as fluid, again with a little consistency and the frequency must be dictated by individual considerations. Drink. Water, alkaline water and such fruit juices as the in- flamed structures accept without discomfort are indicated in such quan- tities as the patient can readily take. Bowels. At the beginning of the illness it is well to move the bowels with a mild saline, such as Hunyadi water or one of its many equivalents on the market. This may be preceded, if one so chooses, by a smaU dose of calomel gr. 1/10-1/4 (0.006-0.015 Gm.) at 10 or 15 minute intervals until one grain is taken. Liquor magnesii citratis 5 viii (240 c.c.), a Seidlitz powder, or one of the more drastic salts, Epsom, Rochelle, Glauber's or Sodium Phosphate in ss, (15 Gm.) doses may be preferred. Throughout the illness the bowels may be regulated with enemata, liquid petrolatum, cascara, aloin, phenolphthalein or a mild saline water. Drugs. The salicylates have always been favorites in the treat- ment of tonsillitis; in fact perhaps, because as a local manifestation of rheumatism it seems to yield to this so-called specific and in part be- TONSILLITIS AND VINCENT'S ANGINA 83 cause of the general anodyne effects of the group. It may be given as sodium salicylate, acetylsalicylic acid (aspirin), salicin, diplosal or other form, my choice being one of the first two. The usual dose is gr. v-x (0.33-0.66 Gm.) at two-hour intervals or it may be used as in rheumatism. (For details and prescriptions see Acute Rheumatic Fever, Chap. III). A favorite prescription of mine combines small doses of tincture of aconite with salicylate Tincturse Aconiti 1.00 (m. xvi) Sodii Salicylatis 5.00 (gr. Ixxx) Aquas destillatse, q. s. ad 60.00 (gii) M. S. One teaspoonful every two hours. (Delafield.) In the early hours of the infection, the so-called sthenic period, coal- tar preparations may be used for the general aches and pains. Acetan- ilid, antipyrin, acetphenetidin (phenacetin) alone or combined with bicarbonate of soda to lessen their irritating effects on the stomach and for its antidotal action or with citrated caffeine which increases the anodyne action and is assumed to counteract the depressing action of the coal-tar drugs on the circulation, an assumption which is more than dubious. I prefer to give doses smaller than the usual text-book doses, but at frequent intervals, e. g. Acetanilidi 1 . 50 (gr. xxiiss) Sodii Bicarbonatis 1 . 00 (gr. xv) Caffeinse Citratee 0.50 (gr. viiss.) M. et div. in cap. no. xv. S. As directed. I order one of these given every 1/2 hour for four doses, then every hour for four doses, then every two hours. (Adult dose.) Fever. This is usually not so high as to need interference. The drugs above mentioned ameliorate it, though not given for that partic- ular purpose. If the fever gives the patient discomfort, it is to be met by cool or cold sponges of water; following which an alcohol rub is found gratifying. Care of the Body. A daily sponge with castile soap and warm water should be given. The nose should be freed from secretions by the use of cotton swabs on wooden tooth-picks as applicators, moistened with a saturated solution of boric acid (4 per cent.) or J^ to J^ strength DobelTs solution. The mouth should be cleansed by rinsing and gargling with the same solutions and food removed from the interstices of the 84 TREATMENT OF ACUTE INFECTIOUS DISEASES teeth and from between the gums and the cheeks and lips by the use of cotton swabs on wooden applicators. Insomnia. It cannot be too often insisted that sleep is rest and rest is repair. As a rule the milder hypnotics are sufficient ; bromides gr. xv (1 Gm.), trional gr. x-xv (0.33-1 Gm.), adalin gr. v (0.33 Gm.), chloralamid gr. xx (1.33 Gm.), or somewhat more potent prep- arations; barbital (veronal) gr. v-vii ss. (0.33-0.5 Gm.) or barbital sodium (medinal) in the same doses. If the pain in the throat is keep- ing the patient awake codeine phosphate gr. J^ (0.015 Gm.) or mor- phine sulphate gr. 1/8 (0.008 Gm.) hypodermically is indicated. Local Treatment. It not infrequently happens that an appli- cation of a strong solution of silver nitrate to the tonsils, if done in the first few hours will abort or decidedly ameliorate the process. This solution should be 25 per cent, to 50 per cent, and applied liberally with a swab. Others use a weaker solution of silver nitrate 40 to 60 grains (2.33 to 4 Gm.) to 5i (30 c.c.) and make the application three times a day. I advise the stronger solution in the first 12 hours and after that rely on hot irrigations of normal saline or boric acid 2 per cent, to 4 per cent, at 100 F. to 115 F. and if the throat is very red 115 F. to 118 F., every hour or two while awake. For efficiency much depends on technique. I refer the reader to the section on angina under Scarlet Fever, Chap. XVII where the treatment by irrigations, inhalations, sprays and gargles as well as external applications is taken up in detail. I would add as an excellent gargle, though my faith in gargles alone is small, one made up as follows: 9. Sodii Salicylatis Sodii Bicarbonatis Sodii Biboratis aa 30 (51) One teasponful in % glass of hot water to gargle. (Goodridge.) Phenol 1-100 solution used as a gargle is said to relieve pain. (Hare.) If properly applied the throat compress is of practical value where there is much pain. The technique is given by Baruch as follows: " Although this compress is probably more frequently applied than the other, it is remarkable how little its rationale is understood and how imperfectly it is applied. The usual method is to fold a handkerchief or napkin into a narrow bandage, dip it in cold water, wring it out, and wind it around the neck, securing it by pin. In a very short time the move- ments of the patient displace the bandage, which has been applied loosely to prevent choking, so that it loses its shape, allowing air to enter freely from above; more or less chilling is then produced and the TONSILLITIS AND VINCENT'S ANGINA 85 compress dries rapidly. As will be seen in the description of the thera- peutic indication of the throat compress, the object is defeated by this imperfect application, unless it is intended to treat some tracheal or laryngeal trouble. When intended for the treatment of tonsillitis, diph- theria and other pharyngeal affections, the throat compress should be applied as follows: A piece of old thin linen, of sufficient length to reach from below the ear on one side to the same point on the left, is folded into a bandage of four layers. A piece of flannel, eight by twenty-four inches, provided with a slit for each ear, is also made ready. These bandages are fitted by actual measurement to the patient's head, so that they may pass under the chin from ear to ear. The linen compress bandage is now wrung out of water at (60 F) and laid upon the middle of the dry flannel bandage. While the wet bandage is placed under the chin, the flannel bandage is unrolled from the top of the head and passed over the right side of the head (the right ear being made to protrude through the slit) and then passed under the chin to the left side, where the left ear is also allowed to protrude (the slit being made longer than actually needed, to insure perfect apposition of the bandage and prevent pressure on the ear). The entire bandage is now drawn firmly over the head and secured by pins. Two sets of bandages are required one being allowed to dry while the other is in use. " In children and restless patients, additional security is afforded by a circular turn around the head forming a bandage to which the throat compress may be pinned." Baruch. "Hydrotherapy." Adenitis. (See Scarlet Fever, Chap. XVII.) Nephritis. (See Scarlet Fever.) Convalescence. (See Scarlet Fever.) Tonsillectomy. (See Scarlet Fever.) Septic Sore Throat. The virulent forms of streptococcus hemo- lyticus infection that have received this designation are associated with such degrees of toxemia that they require special consideration. With these, too, the more serious complications are likely to ensue. Circulation. Precisely the same problem is presented here as in Scarlet Fever (unless endocarditis has intervened, for which see below). The reader is referred to the treatment of failing circulation in that disease. (Chap. XVII.) Furthermore a daily examination of the heart even well into convales- cence should be made and frequent examination of the urine and es- pecially in convalescence. This is the time, too, when the productive nephritis, secondary to a scarlet fever, the rash of which may have been overlooked is likely to develop. Toxemia. Beside the supportive treatment one has to consider 86 TREATMENT OF ACUTE INFECTIOUS DISEASES the value of the specific measures we have at hand. This question, too, is discussed under Scarlet Fever. (Chap. XVII.) We are dealing with a streptococcus hemolyticus and may have re- course to three efforts of doubtful value, but with certain theoretical justifications behind them, e. g., the administration of polyvalent strep- tococcus serum, the use of autogenous or polyvalent vaccines, and trans- fusions. Details of these procedures will be found under the chap- ters specified. Complications and Sequellse. As has been said a given case of tonsilitis may usher in a rheumatic infection and be followed by a rheumatic arthritis, endocarditis, chorea or other manifestations. On the other hand an infectious arthritis may occur and an acute malignant endocarditis or if the infecting organism is streptococcus non-hemolyt- icus (viridans) a subacute bacterial endocarditis. Nephritis. An acute exudative or an acute productive nephritis may occur, which latter may pass over to a chronic form. This is to be treated as under other circumstances. (See Scarlet Fever, Chap. XVII.) Septicaemia is not a rare result of a septic sore throat. This subject is considered in Chap. XLV. Complications due to the involvement of more contiguous structures are: Otitis media. In young children in whom this process may occur without pain, a routine examination of the ear should be made. Early incision of the drum is indicated. The treatment is fully considered under Scarlet Fever. (Chap. XVII.) Adenitis. This, too, will be found fully discussed under Scarlet Fever. Peritonsillar Abscess. The local signs and symptoms are aggra- vated. The pain is intense and may extend upward to the ear if the pus burrows in that direction. The mouth is opened with difficulty, swal- lowing is painful and feeding almost impossible so that with the toxemia and loss of food, weakness and loss of flesh are very marked. The anterior pillars of the fauces are red or purple and swollen and the soft palate often involved. There is a bulging of the tissues concerned frer quently to the midline. The uvula may be swollen and reddened. The incision is made in the most prominent portion of the swelling. The soft palate and other tissues may be treated by application of 10 per cent, cocaine hydrochloride solution, but this unhappily does not do much to lessen the pain of incision. A sharp-pointed curved bistoury may be used, the blade being protected with adhesive plaster to within a half inch of the point. The incision is made from above downward and should be nearly vertical to avoid injuring important blood vessels. It TONSILLITIS AND VINCENT'S ANGINA 87 begins at a point above the soft palate where it joins the uvula and 3/8 of an inch outside of the inner margin of the anterior pillar of the fauces. The incision should be deep to the extent of the exposed portion of the blade. Pus should follow the incision but it is possible that the failure to evacuate pus is due to an unsuccessful incision or to the fact that a pus pocket has not yet formed. A failure to make a successful incision is often due to the patient's drawing back to avoid the pain and there- fore the head should be firmly supported to prevent this. If there is much offensive pus Coakley advises syringing or sponging the cavity with 1:5000 phenol (carbolic acid) and inserts a strip of iodofonn gauze to prevent too rapid closure. If no pus follows the incision it may appear a day or two later. Relief will be afforded by a lessened congestion following incision. If pus burrows downward in the posterior pillar, an incision is made over the point of greatest bulging. Convalescence. Both physician and patient err in hastening the period of convalescence. Even after short attacks the patient plainly shows the effects for a long time. In the World War, Army surgeons studying return to fitness of patients after tonsillitis, found the period prolonged to an extent that amazed the civilian practitioner and made him realize the injustice he has regularly done his patients. Fresh air, good food a simple tonic of strychnine sulphate gi. 1/60-1/30 (0.001- 0.002 Gm.) three times a day or such a prescription as follows may be ordered: I* Tr. Nucis Vomicae ......................... ..... 20 (5v) Sodii Glycerophosphatis ........................ 20 (5v) Aq., dest. q. s. ad ........................ ... 120 (5iv) M. S. One teaspoonful three times a day. A red cell count and hemoglobin determination should be made, and if there is anemia, iron in some form is indicated. Arsenic may be combined with it. My favorite is Vallet's mass and arsenious acid, e. g. : Massae Fern Carbonatis ...................... 10 . 00 Acidi Trioxidi ............................. . . .0.045 gr.% M. Massa fiat. div. in cap. no. xxx. S. One or two, three times a day, after meals. Chronic Tonsillitis. This is not a treatise on chronic conditions, but one cannot discuss tonsillitis in any form without voicing the danger that lurks in a chronically infected tonsil. The mere cataloging of such 88 TREATMENT OF ACUTE INFECTIOUS DISEASES sequences as chronic arthritis, chronic nephritis, rheumatism or chorea, with their endocarditis, subacute bacterial endocarditis, constant infec- tion of the upper air passages with repeated colds and bronchitis as well as otitis and adenitis and the suceptibility of diseased tonsil to tuber- culous infection, is plea enough for the removal of such a danger spot. It is but a reversal of the above statement to say that the indications for removal of the tonsils are: 1. When they are causing obstruction. 2. When they are the seat of chronic infection. 3. Repeated attacks of acute tonsillitis. 4. Rheumatic fever with tonsils infected. (For discussion of time for removal see Acute Rheumatic Fever, Chap. III.) 6. Repeated infection of the upper air passages. 7. Chronic rheumatic endocarditis, as a prophylactic measure. 8. Chronic nephritis or acute nephritis if secondary to tonsilar infection. 9. Chronic cervical adenitis, tuberculous or simple. 9. The operation is a tonsillectomy; enucleation; and all diseased tissue of Waldeyer's ring, adenoid and lingual tonsil should be removed at the same time. SUMMARY Treatment. Confine patient to bed in even a light attack. Isolate from all of the family who are not acting in the capacity of nurse. Make cultures and smears from all sore throats. Administer diphtheria antitoxin to any patient who has a suspicious throat that cannot be cultured for any reason. Diet. Fluid or semi-solid. Broths, cereals, custards, jellies, ice cream, and toast form the basis of such a dietary. (See Typhoid, Chap. XIV.) Fluids. Water, alkaline waters, fruit juices in such quantities as may be taken with comfort. Bowels. At the beginning of the illness give a mild saline such as Hunyadi water. May precede the above by a small dose of calomel gr. 1/KH4 (0.006- 0.015 Gm.) at 10-15 minute intervals until a grain is taken. Liquor Magnesii Citratis, gviii (240 c.c.) or Epsom, Rochelle or Glauber's Salt, 5ss. (15 Gm.) may be preferred. TONSILLITIS AND VINCENT'S ANGINA 89 Throughout the illness regulate bowels with enemata, liquid petro- latum, cascara, aloin, phenolphthalein or a mild saline water. Drugs. Salicylates as sodium salt, acetyl salicylic acid (aspirin), salicin, diplosal. Dosage gr. v-x (0.33-0.66 Gm.) at two-hour intervals as in rheumatism (see Chap. Ill) or: Tincturae Aconiti 1 .00 (m. xvi) Sodii Salicylatis 5.00 (m. Ixxx) Aquae Destillatae q. s. ad 60.00 (gii) M. et S. One teaspoonful every two hours. (Delafield.) Or the coal-tar preparations in the sthenic period for aches and pains. Acetanilid, antipyrin, acetphenetidin (phenacetin) alone or com- bined with sodium bicarbonate and citrated caffeine. As 9 Acetanilidi 1 . 50 (gr. xviii) Sodii Bicarbonatis 1 .00 (gr. xv) Caffeinse Citratae 0.50 (gr. viiss.) M. et div. in chart, no. xv. S. One every half hour for four doses, then every hour for four doses, then every two hours for an adult. Phenacetin (acetphenetidin) double the dose of acetanilid. Antipyrin, 11/2 the dose of acetanilid, may be used in solution Fever. Cool or cold sponges followed by alcohol rub if fever gives discomfort. Care of the body. Daily sponge with castile soap and warm water. Nose freed from secretions by cotton swabs with boric acid 4 per cent. or Vi to % strength of Dobell's solution. Mouth cleansed with same solutions on cotton applicator and sordes and food particles removed from interstices, etc., with tooth picks. Insomnia. Rest imperative. Milder hypnotics usually sufficient: Bromides gr. xv (1 Gm.). Trional gr. x-xv (0.66-1 Gm.). Chloralamid gr. xx (1.33 Gm.). Or more potent preparations as barbital (veronal) gr. v-vii ss. (0.33- 0.5 Gm.) or barbital sodium (medinal) in same doses. Codeine phosphate gr. % (0.015 Gm.) or morphine sulphate gr. 1/8 (0.008 Gm.) hypodermically if the pain in the throat disturbs sleep. Local treatment. 25-50% solution of silver nitrate applied on a swab to the tonsils may abort or ameliorate the process if used in the first few hours. 90 TREATMENT OF ACUTE INFECTIOUS DISEASES Guiacol and glycerin equal parts may be used for the same purpose a*id in the same way. Silver nitrate solution containing 40 to 60 grains (2.33 to 4 Gm.) in one ounce (30 c.c.) of water may be used in place of the stronger soution and applied three times a day. I prefer the stronger solution in the first 12 hours' followed by hot (110 F.-115 F.) normal saline every hour or two while awake. For details, see Scarlet Fever, Chap. XVII, text and summary. Throat compress. (See text.) Gargles. S Sodii Salicylatis Sodii Bicarbonatis Sodii Biboratis aa. 30.00 (5i) M. et S. Dissolve one teaspoonful in three-quarters glass of hot water. Use as a gargle. (Goodridge.) Phenol solution 1 :100 used as a gargle, Hare says, will relieve pain. Adenitis, nephritis, convalescence, tonsillectomy. (See Scarlet Fever. Chap. XVII.) Pus may be removed from crypts by suction. Heart. Should be examined daily well into convalescence. (See text.) Urine. Examine frequently during the attack and in convalescence. (See text.) Septic sore throat (See text.) Circulation. (See Scarlet Fever, Chap. XVII.) Toxemia. (See text and Scarlet Fever, Chap. XVII.) Complications and sequelae. (See text.) Peritonsillar abscess. Incision. (See text.) Convalescence. Do not hasten even after a light attack. Fresh air, good food, a simple tonic such as strychnine sulphate gr. 1/60-1/30 (0.001-.002 Gm.) three times a day, or: $ Tr. Nucis Vomicse 20 (5v) Sodii. Glycerophosphatis 20 (5v) . Aq. dest. q. s. ad 120 (5iv) M. et S. One teaspoonful three times a day. " . If anemic, give iron or iron and arsenic as Vallet's mass and arsenious acid. TONSILLITIS AND VINCENT'S ANGINA 91 a Massae Ferri Crabonatis 10.00 (Siiss.) Acidi Trioxidi 0.0045 (gr. %) Massa fiat, div. in cap. no. xxx. S. One or two three times a day. Chronic tonsillitis. Enucleation of the tonsils and the complete removal of the adenoid tissue in Waldeyer's ring. VINCENT'S ANGINA This condition, which is not infrequently encountered and diag- nosed as either acute foUicular tonsillitis or diphtheria, is on the tonsil but a local expression of what may be a more widespread oral infection and in some instances an uncontrollable and fatal one, called noma or cancrum oris. It will be briefly described here. The affection is char- acterized by the formation of a necrotic membrane that most commonly is found upon the tonsils, though by no means confined to these struc- tures as it may invade the fauces, gums, cheeks and indeed any part of the mouth, pharynx and in rarer instances larynx, trachea or bronchi. It simulates closely one of two conditions and to one unfamiliar with Vincent's angina the error in diagnosis is almost invariable; when super- ficial it will be called diphtheria and when ulcerative, and it is often a deep, punched out ulcer, it will be called syphilitic. The membrane simulating diphtheria is ashy gray or has a yellowish or even greenish tinge, is easily removable and then discloses the bleeding surface of the superficial ulceration. When the ulcers are deep they are found filled with a gray pultaceous material and both forms untreated are curiously persistent. In the severe types, occurring especially after measles or in the course of certain blood diseases, notably leukaemia, the extent and swiftness of the process is appalling; soft tissue and bones, cheeks, gums, alveolar processes, melting before its advance. In the mild cases there are not many general symptoms, only a very trifling rise of temperature; the one symptom being the persistent sore throat; but in the severe type intoxication ensues with fatal results. The organisms concerned in this necrosis are easily detectable and so char- acteristic that they cannot be mistaken. There is a fusiform bacillus (bacillus fusiformis), it is double pointed, thicker in the middle and often of a beaded or barred appearance from deep staining of granules. These fusiform bacilli are always accompanied by spirilla that look like the spirochetae pallidae but have fewer twists and wider spirals. It has not yet been definitely determined whether the occurrence of these two forms constitute a symbiosis or whether they are different 92 TREATMENT OF ACUTE INFECTIOUS DISEASES stages in the development of a single organism. They are found in normal mouths where they seem to be saprophytic, but under certain conditions become pathogenic. The conditions that determine pathogenicity in these organisms, are an unhygienic mouth, neglected teeth, tne lowered resistance ac- companying or following certain diseases, as leukaemia, measles, scar- let fever, diphtheria. Treatment. Milder cases only require local treatment and the prompt manner in which a long standing and annoying condition yields to simple procedures is most satisfactory. Remove the membrane with a swab dipped in 1 per cent, co- caine hydrochloride as the ulcerations are sensitive, often exquisitely so, and apply directly to the ulcer one of the following substances: Chromic Acid, 5 per cent, solution. This is one of the best ap- plications. Repeat daily until the ulcer heals. Silver Nitrate, 10 per cent, to 25 per cent, solution applied in the same manner. Zinc Sulphate, 5 per cent, solution. I have had no experience with this application. Tincture of Iodine. This is applicable in the milder cases and on small areas. With all this, proper care of the mouth must be instituted. The dentist should be consulted and all affected teeth receive proper treat- ment. A neglect of these precautions invites relapse. As malnutrition and the lowered state induced by infectious diseases are predisposing factors, a sufficiency of a properly selected diet is of first importance in these conditions, together with fresh air and sunlight. Severe Cases. When the necrosis is deep and rapid the condi- tion is appalling and as unyielding as the milder cases are yielding. Salvarsan is indicated in these cases. The technique and dos- age is the same as in syphilis. The success that meets the use of arsenical compounds speaks for the spirochetal nature of the infecting organism. Cancrum oris is discussed under the heading of Measles, Chap. XIX, where the radical measures to stay the process are detailed. SUMMARY Mild cases. Do not require confinement to bed, nor, in the absence of constitutional manifestations, to the house. Local treatment. Remove membrane with swab dipped in 1 per cent, cocaine to relieve pain of the procedure. TONSILLITIS AND VINCENT'S ANGINA 93 Applications. Chromic acid, 5 per cent, solution to the bared ulcer daily until heal- ing is established. Silver nitrate, 10 per cent, to 25 per cent, solutions, in the same manner. Zinc sulphate, 5 per cent, solution in the same manner. Tincture of iodine: on small areas. Oral hygiene. Dental supervision. Abundant diet in cases of malnutrition and convalescence from in- fectious diseases. Fresh air and sunlight. Severe cases. Confine to bed. For choice of bed, room, care of body and maintenance of the circulation see Pneumonia, Chap. IX. Salvarsan. Technique and dosage same as in syphilis. Cancrum oris. Radical surgical procedure. (See same under Measles, Chap. XIX.) Bismuth subnitrate paste. (See Measles, Chap. XIX.) CHAPTER VI ACUTE LARYNGITIS THE larynx may be the seat of an acute inflammation, either as a pri- mary process or secondary to or a part of an infection elsewhere in or general throughout the respiratory tract. It may then be found with a tracheitis or bronchitis or an item in a "cold" or "sore throat." If patients are prone to laryngitis we suspect foci of infection in tonsils, adenoids, especially in children, and in sinuses or nasal passages. Irri- tating gases can produce a very acute inflammation. Predisposing causes are to be found in exposure to cold, damp and high winds and excessive use of the voice. Not infrequently the attacks seem to have some connection with indigestion and are prone to occur in the gouty. Symptomatology. Sore throat, more marked on swallowing, with hoarseness and cough, and in severe cases pain, are the chief symptoms. In young children from 1 to 5 years of age there is commonly in addition to the catarrhal inflammation a laryngeal spasm, due to reflex irritability, a spasmodic croup with a harsh, hollow or metallic quality to the cough, dyspnoea and inspiratory stridor. During the attack the child may look desperately ill and always sounds a note of alarm to the parent who sees it for the first time. It is always more severe at night, a remission occur- ring during the day, beginning with the early morning hours. There may be a slight temperature, especially in children, of 100 F. to 101 F. The laryngoscope discloses a redness of the mucosa and swelling and redness of the vocal cords. This is not the place to go into detail of differential diagnosis, but one must keep in mind tuberculosis of the larynx with its ulceration of cords and arytenoids; syphilis with its gummatous infiltration; edema of the glottis and, in children, diphtheria. Croup carrying on into the day should be labeled diphtheria and the practitioner is wise to take a culture in all cases of croup. In infants, with manifestations of rickets, laryn- gismus stridulus is to be thought of. The general practitioner must be as familiar with the laryngoscope as he is with the stethoscope. These instruments, with the otoscope and ophthalmoscope, are as much a part of the equipment of the general practitioner as of the specialist. The ACUTE LARYNGITIS 95 former can read headlines with them, if not fine print and from headlines we gain the essential news. Treatment. Rest; rest of the body at large and rest of the or- gan concerned. The patient should be ordered to bed; ordered because, perchance deeming it a matter of no great importance, he will not listen to language that is hortatory, but only to that expressed in the imper- ative. To rest the organ involved the patient should be instructed not to talk, and what is of equal importance the people about him should be ordered not to make him talk more than is absolutely necessary and then in a whisper. Smoking during the attack should be forbidden, an injunction illy received by the confirmed cigarette smoker. Irritating smoke or gases must be avoided, even if it necessitates removal of the patient from the environment. Bowels. A free catharsis should be administered at the begin- ning of the attack, either one of the well-known salts, Epsom (magne- sium sulphate), Rochelle (sodium and potassium-tartrate), Glauber's (sodium sulphate) or sodium phosphate in doses of 5 ss. (15 Gm.) in % glass water or full doses of one of the many saline cathartics on the market of the type of Hunyadi water; later, milder doses or enemata may be relied upon. Abortive Treatment. A hot full bath or a hot foot-bath or a hot mustard foot-bath is often taken to abort the process and in my estimation is seldom or never successful, but the patient may be rendered more comfortable by the process. If a full bath is taken the patient must get at once into a warm bed preferably between blankets or into a flannel night dress or pajamas, have a hot water bottle put at the feet and take hot drinks; weak tea, hot lemonade to which a dash of whisky may or may not do more than break the drought. The same precautions should be taken with the foot-baths, as the object is to induce a gentle perspiration, which in a cold bed and a cold room and cotton night clothes might well aggra- vate the condition. The mustard foot-bath is prepared as follows: " Mustard Baths and Foot-Baths. To prepare a mustard bath or foot- bath: Dissolve mustard in hot water in the proportion of two table- spoons of the former to a gallon of the latter. Stir well just before giving the bath. " To give a foot-bath: Fold the bed-clothes up from the foot of the bed to above the patient's knees, replacing them with a double blanket. (Be careful not to expose the patient while doing this.) Turn part of the 96 TREATMENT OF ACUTE INFECTIOUS DISEASES doubled blanket over the feet and back under the legs. Flex the knees and place the foot tub, half filled with water 115 F., lengthwise on the bed, between the folds of the blanket. Lift the feet with one hand and, with the other, draw the tub under them. Put them into the water slowly, that they may become gradually accustomed to the high temperature. Fold the blanket around the tub and knees, and bring down the bed-clothes. In about ten minutes add hot water, being careful not to pour it in near the feet. The bath lasts about twenty minutes. Take out the feet in the same manner as you put them in, drying them well, and place a hot-water bag against them." Maxwell and Pope, Practical Nursing. In the early dry stage the cough is irritating and painful and sedative measures are indicated : Inhalations. The inhalation of plain steam is gratifying or one may add compound tincture of benzoin, oil of pine or oil of eucalyptus, 5i-5ii (4-8 c.c.) on the surface of the water. One may use one of the many inhalers on the market, some of which are very inexpensive, or devise one from a kettle, pitcher or carafe to which a cone is affixed, made of a roll of stiff paper by which the steam is led to the face of the patient, lying on his side. In children a croup kettle, one of the best of which is that devised by Holt, is the safest and most convenient. The child may be put into a tent made by a sheet thrown over the head of the bed, to the post of which laths may be attached to give elevation or over a clothes horse placed about the head of the bed or even over an open umbrella. Chil- dren must not be kept for long periods in these confined spaces, the damp, warm air of which becomes depressing. In the early stages the drug which seems to afford the most relief is ipecac. A good prescription is as follows : (Adult dose) J% Vini Ipecac 10.00 (Siiss.) Potassii Acetatis 10. 00 (Siiss.) Aquae q. s. ad 120.00 (giv.) M. et S. 5ii (2 teaspoonfuls) every three hours. A favorite prescription of the late Dr. Francis Delafield was tartar emetic and ipecac each gr. 1/100 (0.0006 Gm.) every half hour. Cough. If the cough is excessive one may have recourse to codeine in doses of gr. 1/8-Ji (0.008-0.015 Gm.) of the phosphate, or heroine in doses of gr. 1/16-gr. 1/12 (0.004-0.005 Gm.) of the hydro- chloride. It is only the exceptional case, that not yielding to the above measures and losing sleep, requires morphine sulphate in gr. 1/8 (0.008 ACUTE LARYNGITIS 97 Gm.) doses hypodermically. A local application of equal parts of spirits of turpentine, spirits of camphor and olive oil, well mixed and sprinkled liberally on a square of flannel, laid upon the chest and pinned to the night clothes may be found to ameliorate the cough. Local Treatment. Cold compresses to the larynx are often effectual. They should be applied as described by Baruch in his Hy- drotherapy. 11 The Wet Compress, Technique. Two or more folds of old linen, thin or thick as may be required, and of the necessary size and shape to conform to the part which is to be treated, are formed into a compress. Cotton cloth is objectionable because it does not receive or hold moisture so well. If, however, linen is not available, the oldest and most worn cotton cloth should be selected. The compress is wrung out of water of the required temperature (60-75 F.) and is covered with flannel or with a dry piece of linen of the same shape, but an inch or two wider and of sufficient length to secure the wet cloth snugly when pinned. It is a sine ua qnon of the cold wet compress that air be excluded from it, be- cause the vaporization of water contained in it by warmth of the skin renders the latter extremely sensitive to chilling, which is the usual result of the imperfectly applied compress. The compress is renewed every hour as a rule, but this depends on each individual case. Before removal a fresh compress should be laid in readiness. A cardinal rule to guide in the renewal of the compress, applicable in all cases, is that the latter should be warm before removal. If it has not been warmed by an hour's apposition with the skin, it must either remain or be removed without renewal." Ice Collar. A special ice bag made to apply as a collar may be used. For technique in filling the bag and its application, see Pneumonia, Chapter IX. Fomentations. Application of fomentation. Cut two or three thicknesses of flannel, sufficiently large to surround the neck. This flannel is placed in a crash towel, boiling water poured upon it, the ends of the towel twisted in opposite directions to squeeze the water from the flannel. The skin is smeared with vaseline or sweet oil and the flannels applied with dry flannels outside, all of which are kept in place by a binder. These are replaced as fast as they become cool. Care must be taken that not enough hot water is left in them to drip down upon the skin and burn. Sprays. Perhaps the best spray is one containing menthol gr. ii in 5i of liquid petrolatum (albolene). 98 TREATMENT OF ACUTE INFECTIOUS DISEASES Ac. Carbolic! (Phenol) ....................... gr. iii 0.20 Menthol ........ ............................ gr. v 0.33 Benzoinol ............................ , ____ 3i 30.00 M. et ?. Spray the throat while taking a deep breath. In children steam or medicated inhalations as above are indicated. Hot fomentations, using the technique given above, and small doses of ipecac and tartar emetic aa gr. 1/100 (0.0006 Gm.) at 4 to 6 hour intervals and, if there is spasm, antipyrin gr. i (0.060 Gm.) and sodium bromide gr. iii (0.20 Gm.) to a dram of water 4 c.c.) may be given at four-hour intervals. The spasmodic croup is interrupted by the use of emetics, the safest and best is syrup of ipicac in teaspoonful doses at 15 minute intervals until vomiting occurs. There is rarely occasion for alarm, unless the croup is diphtheritic. Complications. The one of alarming significance is edema of the larynx, more commonly occurring after the inhalation of irritating gases. The measures for relief must be prompt. They are: Scarification. "When the dyspnea is severe no time should be lost in scarifying the edematous tissue. This should be done by first spraying the back of the throat freely with a 20 per cent, solution of cocaine, and instructing the patient to swallow any excess of the fluid, so that some of the solution may bathe the edematous tissue in the arye- piglottic folds. A cotton-wound laryngeal applicator should be dipped in a 20 per cent, solution of cocaine and the swollen region of the larynx brushed with the solution, the tongue being protruded and the laryngeal mirror employed in order to paint accurately the swollen areas. Some- times the edema will be markedly diminished owing to the constringent action that this drug has upon the mucous membrane. It is not safe to rely upon this entirely, for in an hour or so, when the effects of the co- caine have passed off, the edema usually reappears in a more aggravated form. Five minutes after the cocainization the parts should be well illuminated with a laryngeal mirror and a curved, concealed laryngeal knife should be introduced, the knife being concealed during the intro- duction, and only pushed forward to scarify the tissues when it has reached the areas of greatest swelling. Hemorrhage and transudation of serum follow, the swelling diminishes, and respiration becomes easier. If this procedure does not diminish the edema and cyanosis deepens, then tracheotomy should be promptly performed." Coakley, Diseases of the Nose and Throat. ACUTE LARYNGITIS 99 Intubation. (For technique see section under Diphtheria (Chan XVIII.) Tracheotomy. If this operation is to be performed, a text- book on surgery should be consulted. SUMMARY Treatment. Rest of the body at large and of the organ concerned is imperative. If speaking is necessary, do so in a whisper. Smoking is forbidden. Irritating smoke or gases must be avoided. Bowels. An initial catharsis with a saline, e. g., Epsom, Rochelle or Glauber's salt in doses gss. (15 Gm.) in % glass water. Later, enemata or milder salines. Abortive treatment. Hot full bath or hot foot-bath or hot mustard foot-bath may abort the process. Technique see text. Follow by going to bed at once between hot blankets or in warm flannel night clothes with hot water bag at feet. Take hot drinks such as lemonade containing whisky. Inhalations. Plain steam or add compound tincture of benzoin, oil of pine or oil of eucalytus 5i~ii (4-8 c.c.) to the water in an inhaler or in a kettle, pitcher, carafe, etc., to which is attached a cone of stiff paper by which steam is led to the patient's face. For children the Holt Croup Kettle is best, or use a tent. (See text.) Ipecac, best drug in early stages. Vini Ipecac .............................. 10.00 (Siiss.) Potassii Acetatis ......................... 10.00 (Siiss.) Aquae q. s. ad ............................ 120.00 (Siv.) M.etS. Two teaspoonfuls every three hours for an adult. OrDel- afield's favorite prescription of tartar emetic and ipecac, each gr. 1/100 (0.0006 Gm.) given every half hour. Cough. If excessive, give codeine phosphate gr. 1/8-1/4 (0.008-0.015 Gm.) or heroine hydrochloride gr. 1/16-1/12 (0.004-0.005 Gm.). For loss of sleep due to cough not yielding to above, morphine sul- phate gr. 1/8 (0.008 Gm.) hypodermically. Local application of oil of turpentine, spirits of camphor and olive oil equal parts on a warm flannel laid on the chest and pinned to the night clothes. 100 TREATMENT OF ACUTE INFECTIOUS DISEASES Local treatment. Cold compresses to the larynx. (See text.) Ice collar. (See text.) Hot fomentations. (See text.) Sprays. Menthol gr. ii (0.120 Gm.) in 5 i (30 c.c.) of liquid petrolatum (albo- lene) or 8 Ac. Carbolici gr. iii Menthol gr. v Benzoinol 5 i M. et S. Spray the throat while taking a deep breath." (Coakley.) For children. Inhalations as given above. Ipecac and tartar emetic of each gr.l/100(0.0006 Gm.) every 4-6 hours. If there is spasm give antipyrin gr. i (0.060 Gm.) and sodium bromide gr. iii (0.20 Gm.) to a dram (4 c.c.) of water every 4r-6 hours. Complications. Edema of the larynx. Scarification. (See text.) Intubation. (See Diptheria, Chap. XVIII.) Tracheotomy. Consult special surgery text-book. CHAPTER VII ACUTE BRONCHITIS AND TRACHEITIS THESE conditions will be considered together as the processes are identical and the terms are merely referable to regional distribution. The pathology consists of a catarrhal inflammation of the whole bron- chial tree with a thick mucoid exudation, becoming thinner as the process advances toward resolution or becoming muco-purulent. It is usually confined to the larger and medium sized tubes; but in children and the elderly is prone to involve the smaller bronchi, when it is spoken of as a capillary bronchitis, and is, indeed, a broncho-pneumonia, though the areas of consolidation may be too small to give it the physical signs. Not infrequently the process is limited to the trachea (tracheitis) and the larger tubes; commonly the infection begins as a coryza and spreads downward, involving the larynx in its progress. The bronchial involvement is always bilateral though in exceptional instances physical signs may be confined to one side and to a limited region. When these signs are so limited it is not justifiable to make a diagnosis of bronchitis until broncho-pneumonia and tuberculosis are excluded. If localized bronchitis occurs at the bases, the diagnosis should be broncho-pneumonia, if in the upper lobe, tuberculosis and more particularly at the apices; but broncho-pneumonia and a so-called grip pneumonia, a partial consolidation of the lobar type, may affect one upper lobe to simulate closely a tuberculosis. The infecting organisms may be the influenza bacillus, pneumococcus, streptococcus, micrococcus catarrhalis and more rarely others. The inhalation of irritating gases may be the direct cause, as was witnessed on so large a scale amid the barbarities of the late war. Among the predisposing causes are exposures to wet and cold, causing chilling, to which fatigue contributes, hence its frequency in Spring and Autumn with their sudden changes, overheating of rooms, overdressing, close confinement; causing sluggish vaso-motor response when exposed to cold. In children, adenoids and hypertrophied tonsils predispose to infection. (Holt.) The immediate cause in the vast majority of instances is direct expo- sure to infection from others suffering from coryza and bronchitis, especially in crowded conveyances and places of amusement. Bronchitis, too, is a common and early accompaniment of several 102 TREATMENT OF ACUTE INFECTIOUS DISEASES r ifcfectt Hemorrhage. Early stages, oozing, no treatment. Serious latter part of second and third week. Mild. Cut down food. Enjoin rest. Moderately severe. Ice bag to abdomen. Calcium lactate, gr. x (0.60 Gm.) three times a day. Horse serum, 10-20 c.c. To avoid anaphylaxis in use of serum. (See text.) Human serum, 10-20 c.c. Thro mboplastin. 20 c.c. in water gviii several times a day by mouth. Severe with symptoms of hemorrhage. (See text.) Morphine sulphate hypodermically or intramuscularly, gr. % (0.015 Gm.). Exsanguination. Elevate foot of bed. Heat to extremities. Physiological salt solution (3i-Oi) (4 Gm.-500 c.c.) hot in the bowel. Hypodermoclysis of same, or Ringer's solution. Infusion of same into vein. Best of all, transfusion. (See text.) Perforation. (For symptoms, see text.) Surgical intervention. Nervous system. Headache. Ice bag. Sleeplessness. Less marked with the Brand bath and sufficient diet. Bromides. Bromide of potash, gr. xv-xxx (1-2 Gm.). or Potassii Bromidi. Aimnonii Bromidi. Sodii Bromidi ............................ aa 5.00 (gr. Ixxx) Aquae destillatae ................... q. s. ad 60.00 (gii) M. et S. 3i in water. Repeat in two hours if needed. TYPHOID FEVER 317 TrionaJ gr. xv-xx (1-1 .30 Cm.) . In a little warm water or in whiskey, brandy dr wine or in powder; wash down with water. Repeat in two hours if needed. Chloralamid gr. xx-xxx (1.30-2 Gm.). In cold water (not hot), in wine, whiskey, or brandy, or in powder and wash down with water. Repeat if needed in two or three hours. If marked or prolonged. Morphine sulphate, gr. 1/16-1/4 (0.005-0.015 Gm.). D elirium Restraint. Cold baths. Tepid baths with cold water to head. Ice bag to head. Morphine hypodermically, gr. 1/8-1/4 (0.008-0.015 Gm.). Lumbar puncture. Draw off 20 c.c. or even more. (For technique, see Cerebro-Spinal Meningitis, Chap. XXV.) Stupor. Cold baths. Tepid baths. Ice bag to head. Lumbar puncture. Circulatory disturbances. (For symptoms, see text.) Prevention. Sufficient diet. Cold baths. Fresh air. Failing circulation. Digitalis. Infusion 5ss. (15 c.c.) three times a day, or tincture m. xxx (2 c.c.) three times a day for three or four days, or longer until improvement in the circulation is seen or accumula- tion is evidenced. (See text.) In urgent circulatory distress. Strophanthin (Boehringer's) (0.0005-0.00075 Gm.) (gr. 1/120-1/90) intramuscularly or intravenously, and then follow with digitalis as above, or crystalline strophanthin (ouabain) 1/2 to 3/4 the above dose. When either therapeutic or toxic effect is severe, stop using for three or more days, and repeat if needed. Another method (less satisfactory). Digitalis infusion 3i~ii or tincture m. x three times a day may be given without interruption unless the stomach is irritated. If satisfactory results do not ensue, or for any reason (idiosyncrasy) digitalis cannot be taken, 318 TREATMENT OF ACUTE INFECTIOUS DISEASES Vasomotor stimulants. Caffeine sodium salicylate or caffeine sodium benzoate, gr. v (0.35 Gm.) into muscle every four, three or two hours. Camphor in oil 10 per cent, or 20 per cent., gr. v (0.35 Gm.) every four, three or two hours, or alternate at every two-hour intervals the caffeine and the camphor in gr. v (0.35 Gm.) doses. Strychnine sulphate (less valuable), gr. 1/60-1/30 (0.001-0.002 Gm.) every three or four hours. Given hypodermically. Threatened collapse. Adrenalin (Epinephrin) m. xv (1 c.c.), into a muscle or m. iii-iv (0.20 c.c.) into a vein. Follow by caffeine or camphor in gr. v (0.35 Gm.) doses into muscle and by strophanthin 1/2 mg. (gr. 1/120) into muscle or vein. Urinary tract. Bacilluria. Urotropin as a routine. Begin as temperature approaches normal and continue for a month after, gr. v-x (0.30-0.60 Gm.) three times a day for three con- secutive days each week. If urine is alkaline, add benzoate of sodium or ammonium, gr. x (0.60 Gm.) to each dose of urotropin. If this does not clear it up use Bladder injections of silver nitrate 1-5,000 solution daily, or saturated boric acid solution daily. Vaccine therapy. Intravenous: initial dose 25 to 50 million diluted to 1 c.c. (For inter- vals and reactions, see text.) Complications. Phlebitis. Rest fixation relative or absolute. Enclose in non-absorbent cotton. Wet dressings Aluminium acetate. Poultices. (See Pneumonia, Chap. IX.) Meningismus. Tapping. Meningitis. (See Cerebro-Spinal Meningitis, Chap. XXV.) Convalescence. (See diet in Summary.) After temperature is normal, seven-ten days. Prop up in bed: three to four days more. Sit up in chair, a little longer each day, after a week get on feet. If temperature rises, consider bowels; too much meat too early. TYPHOID FEVER 319 Get out in sun and air. Watch bowels. Mild cathartics such as cascara, aloin. Treat anaemia. Blaud's pill (Pil. ferri carb.) gr. v (0.35 Gm.) three times a day. For weakness. Strychnine sulphate, gr. 1/60-1/30 (0.001-0.002 Gm.) three times a day, or tincture of nux vomica m. x-xv (0.60-1 c.c.) three times a day. Do not return to work, or admit business matters too soon. Long vacation of three to six months. Prophylaxis. Protection of community. Supervision of water supply. Boards of Health and Sanitary Commis- Filtration plants. Policing water sheds. Supervision of milk supply; inspection of health of workers. Inspection of drains. Inspection of oyster beds. Inspection of green vegetables. Sewage disposal. Notification of cases. Schools. Exhibitions. The patient. Isolation. Disinfection of all discharges and clothes and utensils. (See above.) Preventing access of flies by screens. Care on part of attendants. Treatment of "carriers." Prophylactic; urotropin as above. Inspection of urine and stools of convalescents for the organisms. Vaccines for all "carriers," beginning 25,000,000, work up to 1,000,000,000, four to seven day intervals, in six to nine doses. May try for feces "carriers," Bacillus Bulgaricus by mouth; or by rectum in small amount of sugar solution, 2 per cent. Gall-bladder "carriers." X-ray cure has been reported. Drainage of gall-bladder has been necessary and has cured. Diagnosis established by Einhorn tube. Sodium bicarbonate, 2 grams three times a day. (See text.) Preventive inoculation, for typhoid. 1st dose. 500,000,000. After 7 to 10 days. 2nd dose. 1,000,000,000. After 7 to 10 days. 3rd dose. 1,000,000,000. 320 TREATMENT OF ACUTE INFECTIOUS DISEASES Preventive inoculation for paratyphoid. First dose 500 million of Para A 375 " " " B After 7 to 10 days second dose. ., These are often combined in the proportion of 1 billion to typhoid and 750 million each of paratyphoid A and B per c.c. First dose, one half c.c. and the second and third, 1 c.c. at 7-10 day intervals. PARATYPHOID FEVER Until bacteriological research determined the identity of the paratyphoid organism the clinical entity was submerged in the picture of typhoid fever. In the vast majority of cases this infection of low mortality, not more than 1 per cent., was considered as a light typhoid of short duration and it is doubtful if it ever would have been distinguished on clinical grounds alone, for its symptomatology is almost identical with that of typhoid; a prolonged fever, slow pulse, rose spots, enlarged spleen, hemorrhages, leucopenia, tympanites. No symptom is distinctive. The fever is as a rule less high and less prolonged, the hemorrhages are less profuse, perforations are very rare; but what is all this but the picture of a light typhoid? The complications are the same, such as meningitis, thrombophlebitis, cholecystitis and pyelitis, but the latter and pyelonephritis and cystitis are stubborn in their persistency and the discharge of bacteria long continued. Pulmonary complications including a considerable percentage of pneumonias, often with pleurisy and sometimes with empyema, are not uncommon. The bacillus paratyphosus may be recovered from the sputum.. Such cases are often looked upon as purely pulmonary; the paratyphoid infection being overlooked. Gastro-intestinal symptoms, too, are likely to be more marked and, indeed, this infection may present the picture of acute gastro-enteritis and even of cholera. Relapses are rare. The organisms concerned are two types of bacilli called bacillus paratyphosus A and bacillus paratyphosus B. The former produces acid on suitable media and the latter alkali. Paratyphoid B is a far more common agent than A hi the production of the disease. Para- typhosus B has so many points in common with the bacillus enteritidis of Gartner that the differentiation depends largely on agglutinating properties. Infection is conveyed by the feces and urine, through contaminated food and the careless handling of infected excretions. Paratyphoid B at least seems also to be transmitted through infected meat. TYPHOID FEVER 321 The diagnosis lies in the determination of the bacillus in blood, stool or urine cultures and in agglutination reactions (Widal). It is the only way to distinguish between typhoid fever and paratyphoid fever and the agglutination and cultural characteristics of bacillus A & B alone distinguish the one infection from the other. The pathology shows the same implication of the lymphoid tissues in most cases as in typhoid, the same ulcerations, but perhaps more superficial. Treatment is in all respects like that in typhoid fever. Under that heading, too, will be found a discussion of prophylactic vaccination in paratyphoid. CHAPTER XV MALARIA FROM the barks of the various species of cinchona is derived an al- kaloid, called quinine, and this quinine is more truly a specific than any other drug in the whole pharmacopeia. The treatment of malaria resolves itself pretty much into the skillful use of quinine. The r61e of the mosquito, the anopheles, the varieties of the lowly order of animal life, the sporozoan protozoa (the plasmodium vivax, or tertian parasite, the plasmodium malarise or quartan parasite and the plasmodium falciparum or estivo-autumnal or malignant parasite), the stereotyped manifestations of chill, fever and sweat and the inter- mittent or remittent temperature in malarial infection are familiar to us all. It is only within the last three or four years that, thanks to the labors of Bass, the cultivation of the malarial organisms has become possible and undoubtedly much light of therapeutical value will be shed on the problem by him and those who are using his methods. While we are interested in the differentiation of the manifestations of the disease, into the tertian, quartan or estivo-autumnal forms, as based on the variety of the invading organism, the degrees of severity, after all, depend not a little on where the infection occurs as well as on what organism is present. In the Northern States we have to treat relatively mild cases; in the South much more severe and some pernicious types; and in the tropics many pernicious cases. The lighter cases, such as predominate in the North, are due to the benign tertian parasite, plasmodium vivax, and much more rarely the quartan plasmodium malariae, causing intermittent fevers, while the tropical fevers are more commonly due to the malignant tertian, estivo-autumnal organism, p. falciparum, causing a remittent type of fever. However, here in the North one rarely sees the pernicious types of infection, algid, comatose, though estivo-autumnal forms are frequently met with. Considering first the milder cases as seen here in the North, some of them are so slight that the patient may object to going to bed. The ordinary attack, however, compels the patient to seek rest. In any case our results are better when the patient does go to bed and is made to observe rest. MALARIA 323 Rest. The difference between the appearance of the shaking, fevered or sweating patient of one day and the apparently well individual of the next, is one of the most striking contrasts of medicine. During the period of intermission, the patient feels so well that he will often rebel against remaining in bed and greets his physician sitting up and dressed on the occasion of his next visit. In the milder cases, no strenuous objection to this performance need be voiced; but, if the paroxysm has been severe, the patient should be assured that his remaining at rest facilitates success in aborting the second. In the remittent estivo-autumnal forms it should, of course, be insisted upon. Each individual paroxysm means an intoxication, and as the result of this and the marked pyrexia accompanying it, tissue destruction has been entailed which makes all the more imperative the economy in the body's energies accomplished by rest of the tissues attacked by the organism. The one tissue in which a gross lesion occurs, is the red blood-cell and its destruction induces a degree of anemia. Now, in untreated cases or badly treated cases, emaciation and anemia of a marked grade ensue and the necessity for rest is as urgent as in other infections of long continuance. With prompt treatment this does not obtain, and after an anticipated paroxysm fails to appear the patient may be allowed to get up. Bed. On account of the brevity of the attack, when well treated one may be less insistent on the nicety of details with reference to the bed than in the infectious diseases of longer continuance, if it entails extra expense in the procuring; but in severe cases, in pernicious types with continued fever, we economize the strength both of the patient and attendant and enhance the success of our treatment if an iron half-bed with woven wire-springs and firm mattress, which is best illustrated by the hospital bed, is used. Room. If the patient is still in a malarious district his room should be so chosen that the chances of further infection are lessened. By selecting one in the upper part of the house, since the invasion by the mosquito is less likely, and making doubly sure by the use of screens or mosquito netting, this object is accomplished. This, too, affords a certain protection to attendants. In other respects the room should be chosen in severe cases accord- ing to the same criteria that obtain in other acute infections, with a view to size, ventilation, light, access to the open air by veranda and nearness of bath room, simplicity of furnishings and remoteness from disturbing elements of the household. Diet. The suddenness of the attack, the anorexia, nausea and vomiting contraindicate any effort at nourishment during the paroxysm. 324 TREATMENT OF ACUTE INFECTIOUS DISEASES During the afebrile periods of the intermittent type of fever, semi-solid or solid food of a simple character may be taken, but at any meal occur- ring within six hours of the anticipated recurrence of the paroxysm the food should -be fluid or semi-solid, as milk, eggs, cereals or toast. This is in consequence of the vomiting that may ensue. It is interesting to note that Bass and Johns in their studies on the culture of the plasmodium observed that the blood seemed to form a better culture medium immediately after a full meal and this they say corresponds with the clinical fact that the parasites will often disappear from the blood and the paroxysms cease if the patient is put to bed and given a purgative and put on a light diet. If the fever is of the remittent type, the same precautions should be observed at the periods of paroxysm, but in the intervals the diet, while it should be somewhat restricted in the choice of food, should nevertheless contain sufficient nutritive value in terms of calories and protein. Care of the Bowels. Calomel should be given either in one dose of gr. iii-v (0.20-0.33 Gm.) or in divided doses of gr. % (0.015 Gm.) every }/ hour for six or eight doses, and this may be followed in 3 to 4 hours by a saline. The best time to give the cathartic is between the paroxysms. It should, however, precede the quinine when possible. SYMPTOMATIC TREATMENT DURING THE PAROXYSM The phenomena of the paroxysm, chill, fever, and sweating have been looked upon as the expression of the action of a toxin released by the plasmodia at the time of sporulation, but Wade Brown from his recent studies concludes that they are all in part at least due to the toxic action of the malarial pigment, that is, hematin, derived from the destroyed red blood cells. The three stages of the paroxysm are each provided with their own particular form of discomfort for the patient and demand pretty constant attention and ministration to mitigate their evils. Chill. Beginning with chilly sensations, followed by shiverings and then shakings, with the skin covered with "goose-flesh," pale, cyanotic, the face pinched and the teeth chattering, the patient can only complain of the cold and beg for warmth. One does everything possible to afford this, by putting hot-water bottles to the feet, wrapping flannel about the extremities, heap- ing on blanket after blanket and giving hot drinks, hot water, weak tea, hot weak milk, into which a dash of ginger may be stirred, hot lemonade, a little hot whiskey or brandy. MALARIA 325 The discomforts may be mitigated by the use of codeine phosphate in half grain (0.033 Gm.) doses by mouth or spirits of chloroform in one dram doses. Vomiting. One other feature of this stage often requires inter- ference namely, vomiting. If there is much useless retching, a draught of warm water may help to effect an evacuation of the stomach; then simple measures to stop further vomiting may be pursued, as sipping of efferves- cent drinks such as ginger ale or Seltzer water or putting a mus- tard paste on the epigastrium. Bromides in 10 or 15 grains (0.66-1 Gm.) with spirits of chloroform in teaspoonful doses may be of value given by mouth. If the retching cannot otherwise be overcome, administer mor- phine hypodermically, in doses of gr. 1/12 or gr. 1/8 (0.005-0.008 Gm.) of the sulphate. Collapse. In the old and feeble, symptoms of collapse may threaten during the chill. These are to be met by hot drinks of coffee, brandy or whiskey, or a teaspoonful of aromatic spirits of ammonia in water; or a little strong water of ammonia may be inhaled from a towel or handkerchief held a little way from the nose. This stage lasts from a quarter of an hour in light cases to two hours in very severe ones; and then come occasional flushings of heat and gradually there is established the febrile stage. Fever. In a few minutes the patient is "burning up with fever," complaining as bitterly of the heat as he was of the cold shortly before. The face is flushed, the whole skin red, the pulse bounding. The hot-water bottles are removed, blanket after blanket comes off, until only a sheet remains; bits of cracked ice are sucked, cold water or cold lemonade is sipped, cool sponge baths given or sponges of water containing alcohol. A light rub with the hand, using 25 per cent, alcohol in water, affords much comfort. Headache is the feature of this stage as vomiting is that of the chill, though occurring also in the first stage. This is relieved by cold cloths, wrung out of ice water and applied to the brow. The cold sponging mentioned lessens the intensity of the headache. If, however, it is intense and not lessened by the measures advised and, especially, if delirium accompanies it, one may try codeine phosphate in 1/4 or 1/2 grains doses (0.015-0.030 Gm.) or the morphine sulphate in small doses hypodermically, gr. 1/24 to gr. 1/12 (0.003-0.005 Gm.) may be given. Coal tars should not be used. This stage lasts usually from four to six hours and then as the fever 326 TREATMENT OF ACUTE INFECTIOUS DISEASES declines, perspiration appears on the face and forehead and the third stage of sweating is ushered in. Sweat. Soon the whole body is covered with a drenching sweat and, except "for the discomfort of the sweating, the patient grows rapidly better. Relief is afforded the patient in this stage by rubbing the body with dry towels and changing the linen. He may be allowed drinks of water or lemonade freely. If symptoms of collapse intervene, as but rarely occurs, hot drinks and stimulation as advised during the cold stage should be given. Sleep usually follows this stage. Blood examination shows a moderate leucocytosis during the attack and leucopenia with large mononuclear increase between the attacks. Parasites may be found at any time during the afebrile period. Such are the events and their treatment in the milder cases of tertian and quartan fevers of this latitude. Of the estivo-autumnal fevers of the North, it may be said that they are more severe than the other types, but very rarely pernicious. The nervous symptoms and the aching pains of the limbs and back are more striking and the paroxysm is much longer, usually over twenty- four hours and often permitting but a few hours of intermission or remission. The chills are not as frank; the rise of temperature less abrupt, delirium or apathy more pronounced and the patient more prostrated. Parasites are found a few hours after the onset of the paroxysm and may be very difficult or impossible to demonstrate later. Such cases often resemble typhoid fever. Herpes labialis is common, especially in the benign tertian. The spleen enlarges and is one of the most pathognomonic features of the infection. Specific Treatment. As I have said quinine is looked upon as more truly a specific than any other drug in use, and yet its specificity is due to effects not confined to the plasmodium malariae alone, but common to all protoplasm. In general it 13 a protoplasmic poison. At first and in slight doses, this action on protoplasm is expressed by an enhancement of function, that is, stimulation; but this in turn, in sufficient dosage, is followed by depression of function, paralysis of same and death. That this action varies in degree in different stages of cell-growth and cell-activity is also true and upon this fact depends its usefulness as a drug. Now, the protoplasm of the malarial organism seems peculiarly susceptible to it, but by no means equally so at all stages of its develop- ment. It is so much more susceptible to quinine than the body-cells, MALARIA 327 that amounts that will kill the plasmodium have no deleterious effects on the latter. It is during the stage when development and nutrition are most active, that is, in the young stage of the parasite, that quinine is most operative. This fact has a practical bearing on the administration of the drug. Bass and Johns believe that the quinine does not directly kill the para- sites but produces a permeability of the red blood cells to the blood serum which contains an element destructive to the plasmodium. Time of Administration. Many rules are given by numbers of physicians with reference to the time of administration, and by some of them with an insistence on exactness that would seem to attribute more of the success to this item in technique than to the drug itself. Facts about the absorption and excretion of quinine are as follows: Within thirty minutes evidences of it are found in the urine. In six hours half of it is eliminated, but after that the elimination is more tardy and traces of it can still be found in the urine after seventy-two hours. Sporulation the setting free of the young parasites in the blood- stream occurs at the time of the chill. We should theoretically get the best results by a large dose given three or four hours before the antic- ipated chill, at a time when the maximum amount of quinine would be in the circulation to act upon the organisms during their egress from the red blood-cells. We may, then, a few hours before the paroxysm give our maximum dose. It goes without saying that this will in no way abort the coming chill, as the organisms responsible for that are protected in the red blood-cells; but it will destroy their offspring and abort the chill for which they would be responsible forty-eight or seventy- two hours later. Bethea is accustomed to give the full day's dose at this time, dividing it into six parts and administering the doses at one- hour intervals beginning five hours before the anticipated chill. Again, as others advise, the quinine may be administered during the decline of the fever. The fever we believe to be coincident with the setting free of the parasite in the blood. The young organisms very quickly attach themselves to the red cells which they seek to pene- trate. If quinine is given at this time, its rapid absorption, as just expressed, brings it into contact with them and effects their destruction. Still others advise dividing the daily dose, administering a portion, three times a day, every four hours or every six hours. As we have seen, only half the dose ingested is excreted in six hours, so this procedure keeps the blood cinchonized continuously. This method has advantages where the time of the paroxysm is more difficult to determine, as in the remittent or continuous forms, in quotidian infection and in the perni- 328 TREATMENT OF ACUTE INFECTIOUS DISEASES cious types, and particularly if there is a constant migration of plas- modia from cell to cell, as Mary Rowley Lawson contends. So one may administer the dose (1) a few hours before an expected paroxysm; "(2) at the decline of the fever of a paroxysm; or (3) divide the dose throughout the twenty-four hours. The object is to have enough quinine in the blood to kill the organism when it is free. Preparations. There are numerous salts of this alkaloid, repre- senting varying weights of the alkaloid and varying solubility. Most of the salts are sparingly soluble; a few freely. Of these the sul- phate which contains about 75 per cent of the alkaloid (74.31 per cent.) is the most commonly used when the drug is administered by the mouth. The more soluble acid hydrochloride or bisulphate, or quinine and urea hydrochloride is used for hypodermic purposes. The sulphate is practically insoluble in water (1 in 800), and is usually administered in capsules or wafers. Pills and tablets are likely to be hard or tough and in this way the drug escapes absorption. The 2 grain (0.15 Gm.) quinine capsule is the favorite unit. There is no ques- tion that this drug were better given in solution and, indeed, where the condition of the stomach leads to a suspicion of its impairment and hydrochloric acid may not be secreted, the solution should be used. The drug is freely soluble in any dilute acid, hydrochloric, sulphuric, phosphoric or tartaric. A minim per grain is enough. The objection to this method is the intensely bitter taste. Effort may be made to dis- guise it. One way is to dissolve the dose in a few grains of citric acid gr. x (0.60 Gm.) in a little lemon juice, add to it water in which a pinch of bicarbonate of soda has been dissolved and take while effervescing. The hydrobromide, soluble 1:40 or the bisulphate, soluble in 8 1/2 parts of water and the dihydrochloride soluble in less than equal parts of water (1 to 0.6), may be used instead of the sulphate. Bethea favors the hydrobromide because of its ready solubility, large quinine content, and possible antidotal effects of the bromide to cin- chonism. Dosage. I am convinced that our dosage for malaria in tem- perate zones has been too low and accounts for the frequent relapses. Regardless of the form of infection I advise gr. xxx (2 Gm.) of quinine a day until the paroxysms cease and at least gr. xx (1.30 Gm.) a day for ten days to two weeks, and then gr. xv (1 Gm.) on two successive days of each week for two months after. This amount may be divided into two or three doses a day. Bass, beginning with the same large doses, 10 grains (0.66 Gm.) three times a day, for three days, then gives 10 grains for each night for eight MALARIA 329 weeks without intermission. This is the fruit of an exceptional clinical experience. Stitt gives the treatment adopted in the Canal Zone where tropical conditions mean severe infections, as follows: 15 grains of quinine three times a day (45 grains a day) for a week or until the tem- perature has been normal five or six days; then 10 grains three times a day for ten or 12 days. Vedder recommends grains xxx daily until symp- toms have disappeared and plasmodia are no longer found; then grains xv daily for two weeks; then grains x daily for two months at least. Not all tropical workers, e. g., Manson and Koch, give so large doses as this. Moreover, there seems to be a great variety of opinion about the toxicity of the drug which it is not becoming one whose experience has been confined to the treatment of malaria in the temperate zone to pass upon. Using such doses as I have mentioned in the first para- graph under Dosage, I have never seen toxic results except in rare cases of idiosyncrasy that will be discussed later. If large doses are not well borne by the stomach, the 24 hour intake may be divided into smaller, but more frequent doses and must be administered by night as well as day to keep the blood properly cin- chonized. Bethea favors more frequent administration he gives 3 grs. every two hours during the day and every three hours during the sleeping period. After the period of intensive treatment he gives four grains three times a day for about eight weeks. I believe Wellman is right when he advises a repetition of the treat- ment thirty or forty days after the initial dose. If a case relapses it means either that the drug was not absorbed or the dose was insuffi- cient. It is better with such a relapsing case to use the drug in solution. Quinine Immunity or " Fastness." It should be emphatically stated that perhaps as much or more damage can be done by too small doses as by very large ones: for not only is the "cure" as estimated by disappearance of symptoms delayed ; but when small doses are given at the beginning of the treatment the organisms gain a resistance or im- munity to quinine or as it is sometimes put, become " quinine fast" and thus are able to resist large doses later and so perpetuate the initial attack or prepare the way to relapses. Quinine in Children. Children require large doses proportion- ately; Wellman gives one grain for each year of a child's age three times a day. This rule to be followed to ten years. Bass gives the following dosage: to infants under one year 1/2 gr. (0.03 Gm.) ; at one year 1 grain (0.06 Gm.) ; 2 years 2 grains (0.012 Gm.) ; 3-4 years 3 grains (0.2 Gm.) ; 5-7 years 4 grains (0.25 Gm.) each night in 5i (4 c.c.) of aromatic syrup of Yerba Santa. Older children may take it 330 TREATMENT OF ACUTE INFECTIOUS DISEASES in capsules as does the adult. The doses are for 8-10 years 6 grains (0.4 Gm.); 11-14 years 8 grains (0.5 Gm.). Over this age adult dose. These doses are kept up for eight weeks. Holt believes in much larger doses. He'-feives an infant of one year 8 to 12 grains, and says children of five to ten years require nearly as much as an adult. I should favor the large doses. They can be given to infants and small children suspended in syrup of Yerba Santa, as Tannate, in chocolate lozenges or this prescription for a child of 6 years: . Quininse Sulphatis. gr. xxx (2 Gm.) Ft. cht. no. xviii S. Six (6) powders in chocolate syrup each day as directed. Or it may be given by rectum in solution or in starch paste when one should use two or three times the dose by the mouth. Oral adminis- tration is preferable. Pernicious Infections. As I have said, the pernicious type of the disease is rarely seen in the North; in the South and in the tropics, however, it is much more common. It is caused exclusively by the estivo-autumnal form of the parasite. One of the best criteria, aside from the severity of the symptoms, for a pernicious infection, is that set by some of the tropical workers; namely, the percentage of infected cells and the number of doubly in- fected cells. When 5 per cent, of the red cells are infected the case trespasses upon the dangerous. The fever is usually irregularly remittent or constant. The dose recommended is larger than those usually given in temperate climes. While Rogers recommends gr. x (0.66 Gm.) three times a day, James urges gr. xlv (3 Gm.) a day, in doses of gr. xv (1 Gm.) three times a day for at least ten days and Wellman gives gr. xx-xxx (1.30-2 Gm.) for an initial dose, followed by gr. x-xx (0.60-1.30 Gm.) every four hours, until the attack clears up (one to four days), then about gr. xx a day. The profound intoxications are seen more commonly in those who have had repeated attacks or in neglected cases, and in those in whom resistance has been lowered from one cause or another. Profound depression of all the vital centres is seen, and a particular imposition of the poison on one or the other organ gives a stamp to the picture and affords abundant cause for error in diagnosis. Thus we have a comatose form in which sudden loss of consciousness resembles apoplexy; apathetic conditions with icterus, like yellow fever; diarrheas that resemble cholera or dysentery; and not infrequently an MALARIA 331 attack characterized by profound prostration, collapse, excessive sweat- ing, sometimes subnormal temperature, the algid form. In these cases quinine must be used hypodermically or intravenously according to the urgency. Hypodermic Use. Of the two methods, subcutaneous and intra- muscular, the choice should be decidedly for the latter. The rate of absorption is more rapid and the danger of necrosis less. There is now an almost universal condemnation of the subcutaneous route. The best salt for hypodermic use is the dihydrochloride, which dis- solves in less than its own weight in water. Make up a solution as follows : Quinine dihydrochloride 5.0 Gm. Distilled sterile water 10 . c.c. One may take m. xv (1 c.c.) of the solution given above and dilute to Siiss. (10 c.c.); better 5ss. (15 c.c.) or better yet 5i (30 c.c.) and slowly inject under the skin where the subcutaneous tissue is loose or into the muscle. The amount needed in the twenty-four hours is some 24 grains, given in divided doses in this way. In worst cases up to gr. xlv (3 Gm.). In these severe but less urgent forms, if given by the mouth, the amount should run up to the full doses of Wellman given above. This method, necessary in this class of cases is not free from disa- greeable results and in exceptional circumstances real danger. As commonly used, the solutions are too concentrated, the result being that a precipitate from the serum is caused by the quinine and the tissues may undergo necrosis. The more dilute the solution the safer the procedure becomes; it should never be more than 10 per cent. Moreover, too concentrated solutions will not be absorbed. One should take every precaution to be assured of a sterile needle, syringe and skin, should paint the latter with iodine and inject into the gluteal region or muscles of the back and go down deep into the muscle. There is likely to be some pain and induration but this probability is greatly lessened by the high dilutions. However, abscesses not infrequently occur in spite of all pre- cautions. Another preparation of quinine which is excellent for hypodermic use and freely soluble is the quinine and urea hydrochloride to be used in the same dose. Hypodermoclysis. The same preparation in a gr. xv (1 Gm.) dose is used in 2 to 3 pints (1,000-1,500 c.c.) of salt solution (5i-0i 332 TREATMENT OF ACUTE INFECTIOUS DISEASES (4 Gm.-500 c.c.). In diarrheal forms and in collapse this should be an especially valuable method. Intravenous Use. In severe forms of pernicious malaria, by far the best practice is to put the drug into ttte vein. This may be done in physiological salt solution. For example: Quinine Hydrochloride 0.50 Gm. (gr. viiss.) Sodium Chloride . 25 Gm. (gr. iii.) Sterilized, distilled water 30.00 c.c. (gi.) or twice this dilution. In most urgent cases two and four times the dose gr. xv-xxx (1-2 Gm.). Bass thinks a 10 grain dose is sufficient and much larger doses dan- gerous. His method of dropping two 5-grain tablets of quinine dihy- drochloride into the barrel of a 20 c.c. syringe, drawing up physiological salt solution to dissolve them and then filling to 20 c.c. and injecting, is simple and convenient. Others use a salvarsan apparatus for the pur- pose. There seems to be much controversy among authorities as to proper dilutions; some urging the value and safety of 10 per cent, solutions, others pleading for high dilutions 1 to 250; critics find danger in one or the other. Dilutions of 1 to 30 to 1 to 60 seem fairly free from objections. 1 The dose should be repeated at intervals of a few hours, 2 or 3 up to 6, until the patient is so far improved as to make oral administrations effectual. This usually occurs in 24 hours. The necessity for frequent intravenous dosage is emphasized by the rapid elimination of quinine so administered, it being only a matter of a few hours. Inject all at once into the basillic vein made prominent by a ligature as above. (For technique see Rheumatism, Chap. IX.) Other veins if more accessible may be chosen. A word more about quinine before we proceed with our subject. This drug is an antipyretic and used as such under certain circumstances. Its antipyretic action is apparently due to the depression of function of protoplasm, of which mention has been made. Some effect, too, upon ferment action can be determined. The result is a lessened output of heat from the tissues, through direct action and not through the inter- mediation of the heat regulating nervous mechanism. It must be re- membered, however, that in malaria the control of temperature is to be attributed entirely to the destruction of the plasmodium and not at all to this pharmacological action. 1 Some of the pharmaceutical houses now put up in ampoules quinine in solu- tion ready for immediate use. MALARIA 333 Cinchonism. Of more importance to us are those toxic symp- toms that may occur when inordinate doses of the drug are given, and so can be avoided ; and which occur after very small doses in certain people, whose reaction to the drug constitutes an abnormality which we call an idiosyncrasy, and cannot be avoided. Idiosyncrasy is one of those philological accomplishments, sent as an advance agent to occupy a territory until knowledge shall advance. It is the shadow rather than the substance of a thing, but like many other shadows in affairs temporal it is allowed to usurp and continue to rule as the real thing. It is derived from two Greek words, ttw, own, and (See Bacillary Dysentery above.) Diarrhea. Sub-acute and chronic stages with ulceration. Silver nitrate. (See Bacillary Dysentery above.) Solutions of quinine by the bowel, 1-2000 up to 1-1000. Diet in chronic cases. (See Bacillary Dysentery above and Typhoid Fever, Chap. XIV.) Carriers. Colon irrigations of silver nitrate, 1-2000 up to 1-300, increasing rapidly if the bowel shows toleration. Irrigations with quinine solution, 1-1000 up to 1-500. Oil of Chenopodium. Dose m. xvi (1 c.c.) every three hours. Precede by magnesium sulphate and follow by castor oil. Surgery. In most intractible cases appendicostomy followed by irrigations of normal saline solution or 1 per cent, bicarbonate of soda or boracic acid solutions to cleanse bowel and then followed by 1- 10000 permanganate of potash solution, or protargol, 1-500 or silver nitrate 1-5000 to 1-2000, quinine solutions aos above. Prophylaxis. Boiling of drinking water. Cooking of all foods. Disinfection of excreta. Cleanliness of hands. Keeping flies from stools by screening. War of extermination on the fly. Detection and treatment of the carriers. (See text.) CHAPTER XVII SCARLET FEVER THE causative agent in scarlet fever remains unknown up to the present time, but the close association of the streptococcus pyogenes with this disease and its certain etiological relationship to many of the most serious manifestations, concomitant or sequential, of the disease, makes it of great importance from the standpoint of therapy. The infection probably enters the body through the nose and mouth and is conveyed by the secretions from these organs in the act of cough- ing, sneezing, talking, spitting or by objects contaminated with these secretions, such as eating utensils, handkerchiefs and towels. The period of greatest infection is probably at the tune of the early rash. There are in all probability chronic carriers and especially convalescents with chronic ear discharge, discharging gland or persistent catarrhal symptoms of nose, throat and bronchi. The period of incubation is an important one, because it meas- ures the time during which a child exposed to scarlet fever may become a source of infection to other children and the time during which contact with other children should be avoided. Unfortunately, there is no precise agreement as to this period or, perhaps, the period itself varies considerably, resulting in statements by various observers that range from one day to three weeks. Excellent authority may be quoted for two to four days and ten to fourteen days. My inclination is to anticipate the shorter period; but, considering it from the standpoint of possible danger to others, to set the limit of isola- tion of the exposed at three weeks. This may be an excessive, caution as some of our best State Depart- ments of Health set the period at eight days. The onset is usually abrupt, beginning with vomiting in the vast majority of the cases, a sore throat, a considerable rise of temperature, and in twelve to twenty-four hours an erythematous eruption. Unfortunately for the clinician, the diagnosis is often made diffi- cult by deviations from the type. The eruption may be delayed for three, four or five days or be atypical or evanescent. The sudden onset with vomiting, sore throat and a rise of temperature, should always make one suspect scarlet fever. The bright injection of the throat, 388 TREATMENT OF ACUTE INFECTIOUS DISEASES and an increasing leucocytosis and polynucleosis enhance the prob- ability. McCollom lays great stress on the hypertrophied papillae at the tip and edge of the tongue, like small grains of cayenne pep- per scattered upon it. If the eruption has been evanescent, overlooked or doubtful, the papillae growing daily more distinct, the increasing eosinophilia as the temperature disappears and the leucocytosis de- creases, the evidences of desquamation or the late onset of nephritis finally fixes the diagnosis and determines certain precautions for the patient and those who might be infected by him. Distribution of the Family. The diagnosis once made or with good reason suspected, immediate measures must be taken to protect other members of the family, who have not had scarlet fever. The ages of the individual members of a family determine differ- ent precautions. With reference to the adults, two facts are to be kept in mind; first, that recurrence is so rare that those who have had it have little to fear for themselves, but may convey the disease to others; hence, adult members of the family should come in contact with the patient as little as possible and those who may come in contact with children outside should keep remote from the patient, or, if the contact with other children is intimate, should remove from the house during the course of the disease. Teachers should remove from contact with the patient and notify the Public Health authorities. They should not return to their work until they receive the consent of these authorities. No person, who has come into contact with scarlet fever, should handle food supplies for eight days. Second, that susceptibility decreases with years; McCollom's figures show that of 5,000 cases less than 5 per cent, occurred after twenty-four. The adult, then, who has not had the disease, runs a risk which should be avoided if possible, but a risk that is so slight that it yields to pressing exigencies. The other children in the family should be removed to another house and there kept from contact with other children until the longest period of incubation, which we may take as long as three weeks, has passed, although very excellent authority is content with eight days. (Osborne, Epidemiologist of Mass. State Board of Health.) Their return home will depend on the patient's length of illness and upon the complications, which, themselves, may lengthen the period of infectivity, e. g., discharging ears. They should not be allowed to go to school until this incubation period has passed or, if there is communication between them and the patient through other members of the household, they should not return to SCARLET FEVER 339 school until the patient is recovered and the danger of their own infec- tion is passed. When it is not possible to remove the other children, every contact with the patient, direct or indirect, must be avoided to the best of the ability of those concerned. It has been claimed that isolation can be effected more certainly in scarlet fever than in measles, but it must be remembered that the susceptibility to the former infection is not so great as is the case in the latter; hence, dependence on such isolation cannot be offered as a reason for keeping other children at home, if it be possible to remove them. It must be remembered, too, that a light case in one patient in no way assures that the infection will prove light in the others; an assumption to which parents are peculiarly prone. All contacts, adults and children, should have their throats and skins inspected and temperatures taken two or three times a day at least dur- ing the first week, to determine the early symptoms of the disease. If this inspection is made by the physician in attendance on the case it should be done on his arrival and before he has seen the patient to lessen the possibility of becoming himself the conveyor of the infection. THERAPY Room. To begin right is to win half the battle and an unwill- ingness to inconvenience the rest of the family must not stand in the way of the patient's needs. That room in the house which will meet the demands of the physician, nurse and patient best must be given up to him. The demands of the patient are space, ventilation, light, cleanliness; those of the nurse are economy of effort in managing the room; access to a bath-room devoted to the patient; nearness of her own room; those of the physician, ease of ingress and egress with minimum danger to the family. This ideal can be attained in commodious quarters, but only ap- proximated elsewhere. The room must be large enough with enough windows to avoid being stuffy and afford good ventilation, without exposure to draughts. A top floor room is excellent or one with approach to a balcony or one at the side of the house affording a special entrance. Moreover, sunlight as well as air must have access to the room. Both cleanliness and economy of effort are afforded by stripping the room of furniture, carpet, hangings, pictures, etc. The floor may be bare or covered with carpet lining and over this unbleached muslin. An open fire-place has its advantages for the sick room. 390 TREATMENT OF ACUTE INFECTIOUS DISEASES Isolation is made more complete by sealing doors leading to other rooms or hallways, except that in use. This sealing may be done with strips of paper laid along the cracks and reenforced to several thicknesses. Gum tragacanth makes an,, excellent paste, is easily re- moved and does not stain or injure paint. . The admission to all rooms used by the patient, i. e., the sick room, the bath-room, the nurse's room, should be protected by sheets. If the first entrance is to the bath-room and then to the sick room, both entrances may well be protected. An arrangement that has advantages is two sheets to the door entering the sick room; one on the inside and one on the outside of the entrance or portal. The one attached to the top and right side, the other to the top and left The floor and woodwork should be rubbed down with damp cloths or cloths saturated with 1 to 1,000 bichloride of mercury from time to time and the cloths burned. If the floor is covered, then the same strength bichloride may be sprinkled on the covering from time to time. It is customary to saturate the inner sheet with 1 to 20 carbolic or with bichloride solution, but the heavy odor of the carbolic and the amount of toxic material that must be introduced into the room to keep the sheets wet through all the weeks of illness makes it objectionable. It would seem better to replace the sheets from time to time, destroy- ing the old, if made of cheap material or sterilizing them if of good material. The Nurse. In a disease necessitating so close confinement and demanding so close attention, there should be both a day and a night nurse. If this be not feasible, a member of the family should lend assistance, but then should be as completely isolated from the rest of the family as the nurse. When nursing devolves on the mother or other member of the family their isolation from the rest of the family is a duty that must be emphasized by the physician and, all the more, because it is iso difficult to make the necessity understood and observed. In the presence of the patient the nurse should wear a gown and a cap that covers the hair completely and in the care of a bad throat and in the handling of secretions, rubber gloves. An occasional antiseptic spray to the throat is a wise precaution. The nurse should not come in contact with other members of the family or with people outside the sick room unless the occasion be imperative and then she should subject herself to the same kind of disinfection as on leaving the case. The nurse should not sleep or eat in the sick room, but should have a room adjacent to the sick room devoted to herself. Taking air or exercise, the nurse should choose that time of day and SCARLET FEVER 391 those localities that minimize the possibility of contact with susceptible individuals. Clothes should be changed and hair washed. The Physician. In an outer room the physician should leave his overcoat or, better yet, his coat and vest, and entering the bath- room or some small ante-room where his accouterments for the sick room are left, don a gown reaching the floor, and tight at wrists and neck. In addition he should have a cap to cover the hair, and a pair of rubber gloves if he is to examine the throat, as he ought to do. Wearing rubber shoes and turning up the trousers are precau- tions worth observing. All instruments used in routine examination, including the stethoscope, should be left in the sick room or bath-room and disinfected before using again. While an honest and conscientious examination of the patient should be made, undue loitering and prolonged examinations only add to the peril of some other patient. On leaving the patient, the physician leaves the gown, cap, shoes and gloves in the bath-room or ante-room, and washes his face and hands thoroughly with soap and water. This is more important than the antiseptic to follow, in the efficacy of which the physician's faith is often of too childlike simplicity. Following the soap and water, alcohol, preferably 50%, furnishes an excellent antiseptic, or bichloride in the strength of 1 to 1000 or carbolic or lysol in the strength of 1 per cent.; but to both the carbolic and lysol the objection of the clinging and disagreeable odor attaches, while they are less efficacious than those mentioned. When a gown may not be obtained, a sheet may be arranged about the person in such a way as to effect the same purpose as a gown. In the absence of any such protection or in a visit to a suspected case, the overcoat and street gloves may be worn. Full duty to the public who trust the physician is done only when he changes his clothes and better yet takes a full bath before seeing other children. Unfortunately, this is a rule rarely followed; hence, only the most rigid precautions on occasions of visits to the scarlet-fever patient can minimize the danger entailed by such a failure of proper ob- servances. He should plan to see the case only early or late or allow some interval between this visit and the next on a child, spent in the open air. He should not take obstetrical cases or do surgery. Precautions in the Sick Room. Articles in common use about the patient, when of such a nature as to permit it, should be kept in an antiseptic solution. The thermometer must be left with the patient. No effort at disinfection will justify its use among other patients. It may be kept in carbolic, 2 per cent, or stronger up to saturation, 1 in 392 TREATMENT OF ACUTE INFECTIOUS DISEASES 20. The tongue depressor should be of wood or glass. If of wood, to be destroyed by burning after each usage; if of glass, kept in carbolic like the thermometer. Syringe nozzles whether of hard rubber or glass (and they should not be of glass when used to irrigate the throats of young children, lest they be bitten and broken), are to be treated in the same manner. Dishes, knives, fork, spoons used by the patient or nurse should be boiled for at least a half hour. A small gas stove in the bath- room or adjoining room facilitates the procedure. If the utensils are removed from the sick room to be boiled, they should first be soaked in 1-20 phenol (carbolic) for 20 minutes to 1/2 hour. Urinals, bed-pans and sputum cups should be disinfected with phenol (carbolic) one in twenty and the same strength carbolic should stand in them when not in use. Bed-linen should be soaked overnight in phenol (carbolic), 1-50 to 1-20, and then boiled for a half hour before being sent to the wash. Discharges from the mouth, nose and ears are better caught on pieces of gauze or cloth that can be burned at once. Cats, dogs and birds should be excluded. Only a few books or toys and such only as may be destroyed later are permissible. Temperature of the Room. Thorough ventilation with avoid- ance of draughts upon the patient is the desideratum; 65 F. to 70 F. are the figures usually given and are useful to prevent overheating in the colder months, but in the winter, cold itself is not dangerous but helpful, providing the patient's body is properly protected and the temperature brought up to 70 F. before the body is exposed for any purpose. Bed. See Pneumonia, Chap. IX. The weight of clothing is determined by the comfort of the patient and the temperature of the room. Patient. The patient must be put to bed; an injunction, which while unnecessary in. severe cases, meets with opposition in the mild ones. An explanation of the consequences, in terms of kidney compli- cations, especially, will persuade the parents. A tepid sponge bath is given each day, which, given on a blanket, exposing one part after another, in a warm room, entails no danger. Nightgown. This should be of flannel and if this is too irritating to the skin, a thin cotton or silk undervest may be worn under it. Diet. No person in contact with the patient should prepare the food for the family nor should the nurse come into contact with the general food supply of the family. The diet in scarlet fever is determined by the same fundamental princi- SCARLET FEVER 393 pies as obtains in the arrangement of a dietary in other acute infections, except so far as the frequency of nephritis may modify it: (See Diet in Acute Infectious Disease, Chap. II) i. e., in the first few days of the infection, when anorexia is marked or the angina entails much suffering from the act of deglutition, the feeding should not be pushed beyond the patient's inclination; but after that period has passed, the theoretical needs of the body must be taken into consideration. The frequency and severity of the nephritis which comes late in the course of scarlet fever determines greater precautions in scarlet fever than in any other of the acute infections. Many authors write as if any article of food other than milk might precipitate an attack of nephritis. I think we are convinced to-day that the nephritis is due to the toxins of the disease or to other infectious organisms or their toxins accompanying the disease, such as the strep- tococcus, whose action would not be modified favorably by an insuffi- ciency in quantity or quality of food. That a constant examination of the urine for the first, least evidence of nephritis should be made, ought to be emphasized and when such evidence appears, then the kidney should be given the greatest degree of rest compatible with the imper- ative needs of the rest of the organism, like any other damaged organ. The consensus of opinion is that milk has proved itself, empirically, to be the best single article of food in scarlet fever; but that it should be the only article of food in scarlet fever or that it has proven to be specific as a preventative of nephritis is doubtful. The three great functions of the kidney are the elimination of water, of salts and of nitrogen. It is desirable to heap no excess of the one or the other upon the kidney. They are nicely proportioned in milk; for example, 2 quarts of milk furnishes about the average water intake for twenty-four hours. In these 2 quarts of milk are about 70 grams of proteid, or 11 grams of nitrogen. While this amount of proteid is below the average proteid intake of a man in health, it is enough to maintain him in health, as Chittenden's experiments showed and in disease a "luxus consumption " should be avoided as putting a burden on the kidney. In these 2 quarts of milk are about 3 grams of salt. This amount is way below the average salt intake, but in health we use salt largely as a condiment and so small amounts as here given more than meet the actual physiological needs. Moreover, sodium chloride is illy excreted when the tubules of the kidney become impaired. Two quarts of milk, however, furnish but 1,280 calories of food; less than 50 per cent, of the demands of a man of average weight in fever. If sufficient milk were given to meet the caloric needs of 3,000 calories, twice as much proteid and twice as much water as is required 394 TREATMENT OF ACUTE INFECTIOUS DISEASES would be administered. To meet the caloric needs, either the milk must be fortified or other articles added. The milk may be fortified by adding to each glass milk-sugar or cream or both. One ounce of cream, 16 per cent., 50 calories, 7 ounces -of milk, 140 calories and 1/2 ounce of milk-sugar, 60 calories, makes 250 calories to each glass of 8 ounces or 2,000 calories to the 2 quarts. Additional sugar may be introduced in such drinks as lemonade or orangeade. Other milk preparations, cereal gruels, well-cooked cereals (oatmeal has been objected to an account of a high purin content), bread and butter, milk toast are suitable for the dietary. Among the cereals and flours are to be mentioned arrowroot, rice, barley, cornstarch, flour, farina, imperial granum; all of which can be made into gruels; or they may be used without the milk in the shape of jellies of barley flour, tapioca, sago or thoroughly cooked farina, rice, cornmeal. Vanilla ice-cream or lemon ice may be allowed from time to time. The basis of the dietary, then, is milk; modifications of milk, such as koumys, buttermilk, matzoon, zoolak, cereal gruels, cereals, bread and butter and milk toast being added when the milk disagrees or when the appetite lags from the monotony of the diet. After the period when a nephritis is likely to ensue, more articles may be added to the diet; eggs, custard, potatoes*, other vegetables, oysters, fish and finally meat. Meat soups should be avoided at all stages, because they contain largely, almost exclusively, nitrogenous extractives which have little or no nutritional value, but must be excreted by the kidneys. CALORIC VALUES Milk 20 Calories per ounce Cream, gravity .' , 50 Calories per ounce Koumys 14 Calories per ounce Buttermilk 10 Calories per ounce Whey 7.5 Calories per ounce Sugar 120 Calories per ounce Bread 100 Calories per slice (about 12 slices to a 1-pound loaf) Barley (meal or flour) 1640 Calories to the pound Wheat flour 1625 Calories to the pound Farina 1685 Calories to the pound Baked custard . 183 Calories to 2 heaping table- spoonfuls Tapioca 1650 Calories per pound Rice 1630 Calories to the pound Cornmeal 1655 Calories to the pound Butter 119 Calories per ball (% ounce) SCARLET FEVER 395 Oysters 88 Calories per dozen Fish 100-150 Calories per % pound Eggs 70-80 Calories per egg Potatoes (white) About 100 Calories for medium size (4 to 5 ounces) The caloric requirements in short acute infections may be disregarded. The caloric requirements in prolonged infections are some 25 per cent, more than in health and often much more is taken with benefit. We try to meet the theoretical requirements, while not disregarding the patient's appetite and wishes too violently, but if the patient will take more than these requirements willingly and handles it well we should give it to him. Water. Water or lemonade or orangeade or the juice of grape fruit or grapes may be given freely. Imperial drink, a tablespoonful of cream of tartar (acid potassium tartrate) to 3 pints of boiling water (to get it in solution) to which sugar and lemon peel is added to suit the flavor, is a grateful drink and a good diuretic. The amount of fluid to be taken should be well above the 2 quarts taken in health. Drink should be offered every hour and the patient allowed to take such quantities as he will. It must not be left to the patient to ask, as he is often too sick to do so. Skin. The patient should have a sponge bath once or twice a day both for comfort and cleanliness. It should be done in a warm room, between blankets and as a precaution against chilling, which in a fever seems to me over- exaggerated, one part of the body at a time is exposed for the bath. Itching and burning of the skin is often an annoying feature of the exanthem. This may be allayed by sponging with a solution of soda bicarbonate, a teaspoonful in 3 pints of water, or a bran bath, a handful of bran in a muslin or cheesecloth bag immersed in a gallon of water until it becomes slightly milky in appearance, or the skin can be kept well dusted with a rice or talcum powder. Calamine lotion, 5i (4 Gm.) calamine to 1 pint (500 c.c.) of lime water. For extreme itching 1 per cent, to 2 per cent, phenol in olive oil. When exfoliation begins cocoa-butter, or vaseline may be ap- plied; if 1 per cent, to 2 per cent, phenol be added to the latter it allays the itching and burning. Cold cream (ointment of rose water) affords an excellent application. Soaking in warm water helps to get off the peeling skin; picking, rubbing and scraping the skin to expedite the desquamation is not justifiable, for it wounds the skin and opens antra of infection. 396 TREATMENT OF ACUTE INFECTIOUS DISEASES The care of the mouth, throat and nose is of supreme impor- tance, because the throat is often the seat of streptococcus or other pyogenic invasion, which, neglected, may permit of the spread of the infection by direct extension, into the ears-; air passages, nose and acces- sory sinuses, while by way of the blood stream and lymphatics, the glands, joints, kidneys and heart may be attacked. All procedures must be thoroughly and conscientiously carried out, but with extreme gentleness, because of the pain produced by careless- ness, but much more because the wounded surface invites the entrance of infection. For the same reason, mild applications are indicated. Physiological salt solution Si to Oi (4 Gm. to 500 c.c.), boric acid solution, 2 per cent, to 4 per cent., or half strength Dobell's Solution (a weak solution of bicarbonate of soda and borax, aa 5ii to Oi (8 Gm.- 500 c.c.) with about 1/3 of 1 per cent, phenol (carbolic acid) seem to me to be the safest substances to use whether in the shape of simple mouth wash, spray or irrigation. Any of the mild alkaline solutions, so-called antiseptic solutions, marketed under various names offer an agreeable substitute. After taking food the mouth should be rinsed with one of these solu- tions, the teeth cleansed with a cotton swab on a wooden tooth pick wet in the solution and the dead spaces between lips and teeth and teeth and cheeks searched for particles of food or collections of secretions by the same means. The sicker the patient the more painstaking should be this search. For sordes on lips or teeth and for the thick coat upon the tongue, half strength solution of hydrogen dioxide (official) should be ap- plied before the milder solutions. Much of the coat may be removed from the tongue by gently scraping the tongue after this treatment with the edge of a whalebone, but there must be no violence. When the mouth is very dry equal parts of 2 per cent, boric acid solution and albolene (liquid petrolatum) with a little lemon juice added is efficacious and pleasing. If the breath is fetid, the mouth foul and stomatitis in evidence one may make an application of the following solution: 3 Phenol (watery solution 1 in 20) Glycerin aa 3i (4 c.c.) Boric Acid (saturated watery sol.) gviii (240 c.c.) M. This is followed by the milder solution. The same solutions may be used for the nose; dried secretions being previously moistened and softened by application of sweet oil or vaseline. SCARLET FEVER 397 Application should be made with cotton on a tooth pick and very gently. Sprays may also be used. Irrigations are to be avoided unless special indications arise, as the solution may make its way with infectious material into the Eustachian tube and set up middle ear disease. For the throat gargles are of little use. The spray is much better and irrigations of hot saline solution 3i to Oi (4 Gm. 500 c.c.) are safer here and very grateful. The milder solutions are to be used unless the angina is severe. The genitals should be carefully inspected and kept clean by the use of the same solutions. Bowels. When first seen a free catharsis should be induced, one or two watery stools. One may begin with calomel in gr. 1/4 (0.015 Gm.) doses every 1/4 hour for four or five doses and follow with salts. Calomel is easily taken and well borne by children in these doses and if there is nausea the calomel acts as an antiemetic. In the child this dose may be followed by milk of magnesia gss. (15 c.c.) or liq. magnesii citratis 5vi to viii (180 c.c.-240 c.c.) or Rochelle salt 5ii (8 Gm.). In the adult the doses of salt are doubled or Epsom salt or Glauber's salt may be given in doses of 5ss. (15 Gm.). If nausea continues, cracked ice, or bicarbonate of soda in doses of gr. x-xv (0.60-1 Gm.), may be used, or small doses of bismuth gr. xv (1 Gm.) or of cerium oxalate gr. v (0.30 Gm.) are of value. An excellent prescription calls for a combination, 3 Bismuth Subnitratis gr. xv (1.00 Gm.) Sodii Bicarbonatis gr. x (0.60 Gm.) Cerii Oxalatis gr. v (0.30 Gm.) M. This may be given stirred in a little water and repeated at two-hour intervals if needed. The bowels should be kept open by the use of enemata every other day or by mild cathartics, such as liq. magnesii citratis, Hunyadi water or cascara. TREATMENT OF SYMPTOMS Fever. It is well to bear in mind that the symptoms of dis- ease are often of conservative significance, of purposeful intent, subserv- ing some definite function in combating the agents of disease or the results of their invasion, and that interference is indicated only when this purpose has failed and when pyrexia, too, is adding a burden, not to be endured. 398 TREATMENT OF ACUTE INFECTIOUS DISEASES Fever, so far as we can read its signs, points rather to the establish- ment of a condition in an acute infection which enhances the efforts and efficacy of the various modes of reaction against the causative agent and its products. If we accept this view there Is no reason to attack temper- ature under all circumstances and, as often, with measures themselves harmful. But we have to learn that this useful temperature may, under conditions, become in itself a danger. These conditions are excessive temperature or long sustained temperature and that the term, hyper- pyrexia is a relative one; for a febrile reaction of 105 F. would scarcely be considered as hyperpyrexia if of short duration; it becomes a decided hyperpyrexia if sustained for days. Another fact to be borne in mind is that the fever is loaded with the onus of the toxic effects of the materies morbi upon the nervous system and upon the cardio-vascular and respira- tory apparatus. The measures that empiricism has directed against fever are successful because they combat the effects of toxemia upon the organs mentioned. A moderate degree of fever, then, 104 F. or below is to be let alone, unless accompanied by other evidences of toxemia, but. when above this and sustained, efforts are to be made to reduce it. (For niore- detailed discussion of fever see Chap. I.) The one measure that outranks any other as an antipyretic both in its efficacy and safety is the application of cold through water as the conveying agent. For infants sponging is best; for children the pack and sponging; for early and middle adult life the pack or bath. Neither the eruption nor the fear of kidney complications should contraindicate the measure. We are discussing here hyperpyrexia as such and the object of any procedure is extraction of heat. It is well with children to begin with water relatively warm, 95 F. to 90 F. and increase the degree of cold, to 80 F., 75 F. and 70 F. or colder, the degree of cold and the length of the bath depending on the result in terms of reduced temperature and the reaction of the patient. The patient is to be carefully watched. When the temperature falls to 102 F. or thereabouts, the bath should be interrupted. If the patient becomes thoroughly chilled or shows any evidences of collapse, the procedure should stop, the patient be wrapped in a dry blanket, heat placed at the extremities and hot drinks given. When high temperature is accompanied by collapse and clammy extremities, heat should be applied to the extremities and cold in the shape of compresses or sponges to the trunk. Angina. Strictly speaking angina is a complication of scarlet SCARLET FEVER 399 fever, but a complication so frequent that it may well be considered as characteristic. We are considering here not the erythematous angina, which has just been touched upon in considering the care of the mouth, but the membranous or gangrenous angina. A membranous angina may occur in every degree of severity, from a small patch here and there to a spread- ing membrane, covering tonsils, palate, pharyngeal wall and invading the nose and Eustachian tubes. The gangrenous type may be secondary to the membranous or occur as primarily such. The invasion of the nose and the sinuses, the middle ear, the ac- companying adenitis, the possible pneumonia, the ensuing nephritis, the severity of the toxemia and the fact that not only the streptococcus but the Klebs-Loffler bacillus may be concerned in the formation of the membrane make the condition not infrequently a most serious menace to life, demanding the most conscientious and scrupulous con- sideration. In the first place let it be emphasized that the presence of membrane should mean diphtheria until excluded and while in the majority of cases the diphtheria bacillus is not present the percentage in which it is, especially in hospital practice which represents patients drawn from the poorer and congested districts, is alarmingly large. One should never trust to clinical descriptions for differentiation, but take a culture in each instance. If such facilities are not at hand, the patient should be given the benefit of the doubt and a sufficient dose of antitoxin, 10,000 units. If the case is a very severe one and un- checked by cultural data, the antitoxin should be used as in a case of diphtheria. When the culture is taken, wait upon the report and, if positive, treat as a diphtheria. If there is any laryngeal involvement, it is almost sure to be diphtheritic and the antitoxin should be used at once, not awaiting the return on the culture. Give 10,000 units and repeat in eight hours if no improvement or in four or six if getting worse. Whether the membrane is due to streptococcus alone or to both it and the diphtheria bacillus, the procedure is the same, in other respects than in the administration of the serum. Two facts are to be kept in mind. 1. That cleanliness of the parts is the desideratum and that the mildest solutions and the mildest manipulations must be used. 2. That the local condition can be ag- gravated and its spread and invasion of other structures be facilitated by injury to the parts, either through the irritating or corrosive effects of the applications or the mechanical injury done in the application; and that it is extremely doubtful if any of the so-called antiseptics 400 TREATMENT OF ACUTE INFECTIOUS DISEASES have any effect to kill appreciable amounts of the infecting organ* isms. The modes of application are irrigations, gargles, sprays, inhalation of vapor and topical application with a swab. The most reliable of all these modes of application is the irriga- tion and the most useful substance hot physiological salt solution, one teaspoonful of common salt, sodium chloride, to the pint of water. The patient's head is supported by pillow or rest unless too sick, then the head may be turned to one side, a towel tied about the neck, a pus-basin or other receptacle held beneath the chin and the stream of saline directed from a fountain syringe or irrigator held a few inches above the head, but not high enough to exert force, through a hard rubber nozzle, or through a rubber tube, such as a catheter, against the affected parts, the tongue being gently depressed with a wooden or glass tongue depressor. If very young children are so treated, the nozzle may be placed between the molar teeth and the stream directed to the tonsils and pharynx. The excess runs out into the basin. The amount used should be 1 pint to 2 quarts, according to the demands and the effects on the patient. The temperature should be as hot as can be comfortably borne. One must determine this empiri- cally, beginning with a temperature of 110 F. to 115 F. in the adult and 100 F. in the young child. The frequency every two to three hours in the day and every four hours at night. Not only does this clear the throat of secretions and wash away loose membrane, but it relieves the pain in no small measure and induces a moderate degree of hyperaemia, which may itself be a factor in resolu- tion. Half saturated boric acid solution, 2 per cent., or Dobell's solution diluted from two to four tunes may be used as the irrigating fluid. If there is much tenacious mucus in the throat, an abundant spray or preliminary irrigation with a solution of sodium bicarbonate gr. xx (1.30 Gm.) to the ounce or one containing Sodii Bicarbonatis Sodii Biboratis aa gr. xxx 2 Gm. Aquae dest. q. s. ad 5 iv 120 c.c. M. (L. Browne in Coakley on Diseases of the Nose and Throat.) may be used to rid the throat of this material before the saline irrigation is given. If there is a considerable deposit of membrane or in any case, appli- cations, preferably by spray or very gently with the swab, of full strength SCARLET FEVER 401 of peroxide of hydrogen may be used. It may be better borne in full strength on the swab than in the spray and the latter diluted one to two or three times. In a bad throat, then, one may get rid of the tenacious mucus by the alkaline spray, then touch the exudate with the peroxide of hydrogen and finally use the hot saline irrigation. If the process is fatiguing, or causes discomfort, it must be simplified as much as is consistent with results. Sprays of saline, boric acid solution or Dobell's as above may be given between the irrigations as often as they prove grateful to the patient. Inhalations of hot vapors are sometimes appreciated by the patient. It may be merely steam or steam medicated with compound tincture of benzoin, 3i to the pint of hot water or oil of eucalpytus. These may be used in a croup kettle or one of the simple devices on the market or a common kettle with a cone at the nozzle to direct the steam or a pitcher of hot water with a cone over it. Gargles are in no sense a substitute for irrigation or spray, first, because they do not reach the affected part thoroughly and, second, because the act of gargling is in itself often very painful. If the patient, however, finds relief by such a measure there is no contraindication. One uses the same substances as in the spray or irrigation. Cracked ice, held in the mouth and sucked, often gives great com- fort. Cold applied to the neck in the shape or compresses or coils or ice- bags may afford great relief. They must be properly applied and not allowed to annoy. If heat is the more grateful, it may be applied in the shape of hot cloths. In gangrenous cases one may use an irrigation of potassium per- manganate 1 to 2,000 before using the saline irrigation. Sprays of adrenalin (epinephrin) of varying strengths have been advised to diminish congestion and afford relief. I have been disap- pointed in their results. Alcohol diluted six or eight times used as a gargle is said to be of value. Touching small gangrenous patches with tincture of iodine has been mentioned as helpful. Application of Lbffler's solution once or twice a day is a method long pursued. (Loffler's Solution. Menthol 10; solve in toluol ad 36 c.c., alcohol absolut. 60 c.c., Liq. ferri chlor. 4 c.c.) I purposely refrain from mentioning many escharotics that have been advised, as I believe their use is fraught with danger. 402 TREATMENT OF ACUTE INFECTIOUS DISEASES Nose. Here again cleanliness is the purpose of the measures used and here even more gentleness than in the care of the throat must be exercised. The best solution is, as in the throat, physiological salt solution or 2 per cent, boric acid solution , or a Dobell's solution diluted two to four times. Irrigation, so valuable a measure in the care of the throat, is to be deprecated as a routine in the nose, because of the ease with which the irrigation fluid runs into the Eustachian tube, carrying with it infection to set up otitis media and its sequelae. The spray is the best vehicle here and, about the anterior nares, most gentle swabbing. When membrane is present a solution of hydrogen dioxide diluted three or four times may be applied or sprayed before the cleansing spray. If the condition of the nasal passages is such as to make imperative other measures than the spray, e. g., in young children with profuse persistent discharge, the irrigation may be adopted with extreme pre- cautions. One uses the same cleansing solutions mentioned, directs the patient to keep the mouth open during the whole procedure, which lessens the danger of forcing fluid into the tubes, begins on the side the more obstructed to avoid damming back, holds the irrigator at the least height to just make the fluid pass through, and uses a glass nasal tip or a soft rubber catheter with multiple holes cut in it. Once in four to six hours is often enough. So good an authority as McCollom advises in membranous rhinitis insufflations of calomel. A muco-purulent, sero-purulent or serous rhinitis occurs in 10 per cent, to 20 per cent, of the cases. The turbinates are cedematous, the discharges acrid and excoriating. In the majority of the cases it developes in convalescence, when otherwise the patient is considered cured. Its secretions are highly infectious and responsible for many return cases. The measures of cleanliness mentioned above are used, but recent work with vaccine therapy gives encouraging results. The staphylococcus aureus is present in the vast majority of the cases. From cultures of it and other organisms present an autogenous vaccine may be made, or in the absence of these facilities the stock staphylococcus vaccine or bacterin may be used. The initial dose is 50,000,000 to 100,000,000, according to age and condition. The doses may be given twice a week or every fifth or sixth day. Usually three injections suffice for a cure. Slight febrile reactions may be anticipated. No doubt the sinuses are often involved and a persistent temperature in the absence of obvious cause, such as the ear, should make one think of SCARLET FEVER 403 the maxillary, ethmoid and even the frontal and sphenoidal sinuses, in spite of the late development of these sinuses in the child. Cardio-Vascular Apparatus. There has been much discussion about the relative parts played by the heart and vaso-motor mechanism in circulatory failure. I interpret the results of such discussions and experiments as follows: that while the myocardium may be the seat of parenchymatous or interstitial change, such lesions are relatively rare and as the cause of death extremely rare. That circulatory failure may be considered as practically always due to vaso-motor failure and that the result of experimentation points to the vaso-motor center as the particular part of the apparatus at fault. In one group of cases the heart sounds may be clear and strong to the end, bespeaking competency on the part of that organ, when the vaso- motor center has been so impaired as to make the cardiac effort futile. Pallor, cold extremities, a small, empty rapid pulse with a low blood pressure bespeak the condition. In another group, the first sound of the heart may be muffled or almost disappear, or may be split; the pulmo- nary second sound may be split and accentuated; there may develop a systolic murmur at the apex and the heart may show a tachycardia, bradycardia or arythmia. Yet these signs may not mean and, in the great majority of cases do not mean, any intrinsic change in the heart structure or its functional capacity, but may be explained by that same loss of tone that obtains in the vascular system, and the murmur be one or relative insufficiency of the auriculo-ventricular valves, from relaxa- tion of the rings. In hearts in which loss of tone occurs, the unsupported thin conus arteriosus feels the effect most markedly and its contact with the chest wall immediately overlying at the second left intercostal space gives occasion to the murmur. Very slight dilatation may sometimes be made out and in the area of the conus denote its dilatation. The apparent impairment of cardiac action is due to loss of normal resistance ahead in the dilated peripheral vessels. Theoretically, then, our attention should be directed to the vaso- motor system in particular. It is our misfortune that we have no drug that can do for the vaso- motor system what digitalis does for the heart. The drugs credited with effects upon the vaso-motors are caffeine, camphor, strychnine and adrenalin. . None of these are as reliable as we could wish, all are evanescent in their effects, necessitating frequent dosage and to each is denied by many competent men the effect credited to it, if we except adrenalin. 404 TREATMENT OF ACUTE INFECTIOUS DISEASES Digitalis. But let us suppose that there is no improvement in the circulatory condition in response to these measures. Shall we use digitalis? I should say decidedly yes. It may be objected first, that if the heart is not impaired it is questionable whether digitalis can enhance its functions; but even though the chances of its impairment are statis- tically small, there is still the possibility that it is to some degree and may be helped by digitalis; second, that its effect on blood pressure through its action on the vaso-motor apparatus in man is in doubt, but still that it has such an action in animal experimentation is accepted, and the benefit of the doubt should be given in serious cases; third, that its effect on the heart is lessened in fever, e. g., the inhibitory action of the vagus enhanced by the drug may be set aside in fever, because under the influ- ence of the toxins, the inhibitory action is said to be lost in part or whole. I question the accuracy of this statement; for I have repeatedly slowed the heart in fever by sufficient doses of digitalis; moreover, we now have electrocardiographic evidence ef the pharmacological effect of the drug on the heart in acute infectious diseases. In the presence of so much doubt our anticipations must be tempered, but it seems to me that any drug which under other circumstances has so decided an effect to improve a faltering circulation, should not be left untried because of theoretical considerations. Whatever the cause may be of circulatory collapse in acute infectious disease and however digitalis may operate in this condition it is my con- viction strengthened by a considerable experience that this drug and its pharmacological equivalent strophanthin are the only reliable agents applicable to the condition. The action of digitalis is slow, however administered, and if we are accepting it as an agent to be used, it must be begun before the condition has become dire. I feel that it may well be begun when frank evidences of failing circulation set in as an adjuvant to the vaso-motor stimulants mentioned. The dose in an adult should be 5ss. (15 c.c.) of the infusion three times a day or four times a day; that is, the equivalent of 10 1/2 to 14 grains (0.66 to 1 Gm.) a day. Any official preparation may be used in equiva- lent doses. It must always be prepared fresh from a fresh green leaf. Such doses may be kept up for 12 to 15 doses. For very rapid effects, strophanthin may be used in doses of gr. 1/120 (0.0005 Gm.) into muscle or vein, with the anticipation of a digitalis effect beginning within the hour. Such doses should not be repeated except with caution, in less than twelve hours. Digitalis may be begun at once in the above doses, as its effects will be delayed for some thirty- six hours. SCARLET FEVER 405 For the child of five years give about one-quarter this dose of digitalis or strophanthin. A more elaborate discussion of and more detailed instructions for the use of digitalis in any acute infectious disease will be found under pneumonia (Chap. IX). Caffeine may be used if digitalis fails. I am a little loath to use it when large doses of digitalis have been given, as I think there is an incompatability between the drugs, at least in some individuals, including rapid heart, dyspnoea and alarming evidences of circulatory insufficiency. I advise then that small doses be administered tentatively at first to assure oneself that no such incompatibility exists. Its ac- tion is complicated and not constant in effect. I quote the authority of Meyer and Gottlieb's Experimental Pharmacology as an explanation for both these statements. Its action, they say, is a combination of the following factors: "1. Stimulation of the vaso-motor centers: Con- striction of the arterioles and as a consequence under certain circum- stances a rise of blood pressure. 2. Effects upon the heart in a multi- fold manner: (a) Stimulation of the cardiac inhibitory vagus centers; Slowing of the pulse, (b) Stimulation of the peripheral accelerating cardiac ganglia: Quickening of the pulse rate; according to the circum- stances and to individual factors the one or the other action predomi- nates, (c) A change of the heart muscle, whose diastolic capacity de- creases and whose systolic energy increases: as a consequence, there is usually a diminution of output per beat and lessening of blood pressure, (d) Dilatation of the coronary vessels. "If the vascular contraction dominates, the result will be a rise of blood pressure above the norm; but if the vaso-constrictor centers are but little excitable or paralysed through some pharmacological agent, like alcohol, then caffeine will bring a fall in the blood pressure as a rule." In man, in moderate doses, a slowing of the pulse ensues with a dimin- ished output per unit of time. It is only the effect on the vaso-motor centers that dominate the blood pressure that justifies its use. This effect is brought about through the splanchnic vessels. Many other territories, such as the renal vessels and coronaries are dilated. (Soil- man.) Caffeine is best given in the form of one of the soluble double salts of sodium benzoate and caffeine or sodium salicylate and caffeine. It should be given hypodermically or for more rapid action, intramus- cularly, in doses of gr. iii to gr. v (0.2 to 0.33 Gm.) ; this is equal to about half the amount of pure caffeine. In a child of five years gr. ss.-i (0.030- 0.060 Gm.); at ten years gr. i-ii (0.060-0.120 Gm). It should be re- peated at two-hour intervals in urgent cases, for the effect rarely lasts 406 TREATMENT OF ACUTE INFECTIOUS DISEASES beyond this period. One may anticipate an effect within five minutes, arriving at a maximum within the half hour and amounting to 10 to 20 mm. Hg. It may last two hours, but in my observations often a much less time. Camphor. This is less reliable than caffeine, but is my second choice. It should be given in doses of gr. iii to gr. v (O t 20-0.30 Gm.) in the adult and gr. ss. to i (0.030-0.060 Gm.) in a child of five years, and gr. i to ii (0.060-0.120 Gm.) at ten years. It is best given in a solution of 10 to 20 per cent, in olive or sesame oil, or in 10 per cent of ether hypodermically or intramuscularly and should be repeated every two hours in urgent cases. One should never use camphor put up in par- affin (mineral oil) as extensive necrosis of tissues have followed upon its administration. The results when they are positive are in my observa- tions very like those of caffeine, a rise of pressure in a few minutes, reaching a maximum within the half hour to 10 to 20 mm. Hg. and lasting from forty-five minutes to over an hour. One may alternate these drugs, each every four hours, thus one or the other every two hours. Strychnine is the third choice. It should be given as sulphate in doses of gr. 1/60 to gr. 1/30 (0.001-0.002 Gm.) every three hours in the adult and in doses of gr. 1/200 to gr. 1/150 (0.0003-0.00045 Gm.) at five years and double this dose at ten years. Personally, I place but little reliance on this drug. Adrenalin (Epinephrin) is not appropriate for continued dose. Its effects are prompt and evanescent. It has value in sudden collapse and acts on the vessels themselves, when the center cannot respond to stimulation. Its effects vary with the mode of administration. In my studies I have seen no effects when given by mouth or rectum. The effect is uncertain under the skin; it may be decided and prompt or much delayed and slight or fail. It is more certain when given into the muscle and most certain by the vein. The dose by the skin is m. x (0.65 c.c.) of 1:1000 solution; by the muscle slightly less; as an initial dose m. vii or viii (0.5 c.c.). By the vein m. ii or iii (0.120-0.2 c.c.). This is the dose for an adult. For the child of five years one-quarter the dose, at ten years or twelve years one-half. There is danger in the careless handling of this drug and more es- pecially in the presence of a weak heart. I have seen in an adult, mori- bund, a dose of m. vii (0.5 c.c.) into the vein shoot a pressure of 60 to 70 mm. to 230 mm. faster than it could be taken. Such strains on the heart may cause a failure on the part of that organ. Alcohol I believe to be a depressant and condemn. Cold in the shape of packs or cold air with proper precautions SCARLET FEVER 407 of bed making have excellent results on the circulation. See Open Air Treatment. (Pneumonia, Chap. IX.) Nervous Symptoms. These depend upon the severity of the attack. In moderate grades of the infection there may be some stupor, but in the more severe, delirium of the active type or a low muttering delirium. There is nothing better for the cerebral manifestations of the tox- emia than cold water as described under the treatment of hyperpy- rexia, in the shape of packs, sponges or baths. An ice-cap applied to the head has a sedative effect. If there is much restlessness bromides may be used, gr. iii (0.20 Gm.) to gr. v (0.30 Gm.) three or four times a day in children, gr. xv to gr. xx (1-1.30 Gm.) in adults. Sodium, or potassium salts may be used or equal parts of sodium, potassium and ammonium. Small doses of acetphenetidin (phenacetin) , gr. i to gr. ii (0.060-0.120 Gm.) at four-hour intervals may be given to children, but the temptation to use drugs instead of such measures as hydrotherapy must be com- bated. Sleeplessness. For milder grades the effects of the baths are often sufficient. Instead of the cold bath, sponging with warm water may prove more sedative. The small doses of bromides or acetphenetidin (phenacetin) advised may prove effectual. In adults, trional, gr. x to gr. xv (0.60-1 Gm.) to be repeated in two or three hours, if necessary, or chloralamid, gr. xx to gr. xxx (1.30-2 Gm.) to be repeated in the same tune if not effectual. For wild delirium, sacrificing sleep and rest and imperiling the patient by the exhausion provoked morphine sulphate must be given, in the smallest dose effectual. In the adult gr. 1/8 (0.008 Gm.) hypoder- mically to be repeated in two or three hours if needed, in the child of six, gr. 1/48 to gr. 1/24 (0.0015-0.003 Gm.) SERUM AND VACCINE THERAPY The achievements of modern medicine in serum and vaccine ther- apy naturally turn our minds to these fields in the consideration of so dire a malady as scarlet fever. As yet neither of these methods have yielded satisfactory results in this disease. This will be readily under- stood when we consider that the causative agent of scarlet fever is not yet known and that streptococcic infections during the acute stage are but little amenable to vaccines. With regard to vaccines we may quote the statement of Weaver in Musser and Kelly's Practical Treatment that after a considerable experience with vaccines he concludes that 408 TREATMENT OF ACUTE INFECTIOUS DISEASES their use early in scarlet fever does not stay the usual complications but that they are useful in the treatment of the subacute and chronic stages of some of the streptococcus complications of the disease. Immune Human Serum, however, gives a more hopeful out- look; it is derived from patients recently convalescent from the disease and is presumed to contain antibodies against the scarlet fever virus and streptococci that have been associated with it. While statistics so far accumulated are inadequate from which to draw definite conclusions the workers have been competent and care- ful observers and their convictions are worthy of serious consideration. The serum is obtained by withdrawing blood from patients in con- valescence during the fourth week. Patients who have been septic are excluded and care taken to determine each donor free from tubercu- losis. The serum is tested for syphilis, and its sterility determined. Serum from several patients is pooled, as the antibody content of individuals vary and we have no way of determining that content; this is stored in an ice box. The modes of administration are by the vein as practiced by Reiss and Jungman in amounts to 40 to 100 c.c., following the technique given under pneumonia, Chap. IX. Emphasis must be laid on the increased efficacy of early administration. Weaver, more recently, following the same details of preparation, preferred the intramuscular route, giving an average dose of 60 c.c. into the muscles of the outer side of the thigh. He divided the dose between the sides. Usually one dose sufficed, but in a few a second was given. Personally I should prefer the intravenous route if the vein can be readily entered; but if the results are as satisfactory as they are re- ported to be by the intramuscular route, one can readily appreciate how this method would come into more general usage. Zingher made use of the whole blood withdrawn in the second and third weeks of convalescence instead of the serum. He withdrew blood from the veins at the bend of the elbow, citrated at once with 1 c.c. of 10 per cent, sodium citrate to each 30 c.c. of blood and introduced this fresh blood in doses of 70 to 240 c.c. distributed among several large muscle masses. This blood even kept in the ice box deteriorates after one to two months. All of these investigators seem equally enthusiastic. The best results, of course, are in those who are toxic, not septic. There is a prompt fall of temperature. In the toxic cases this fall is likely to be permanent, in the septic cases to be followed by a secondary rise. The fall begins about 2-4 hours after the injection and reaches its maximum in 12 to 24 hours. Accompanying this are amelioration of the general condition, lessening of cyanosis, diminution or disappearance of delirium and change in the appearance of the patient. Even septic cases show SCARLET FEVER 499 improvement if the serum is used early and the recurring temperature is usually less high and the course seems to be shortened, but if adminis- tered late, in septic cases, no good results ensue. Normal Human Blood. Zingher, however, says that even in the late septic cases, with extensive throat exudate, higher septic tem- perature, poor circulation, dusky skin, often with running ears and en- larged cervical glands the use of fresh normal citrated blood is followed by a definite beneficial effect in some desperately ill patients. His doses are 4 oz. up to 4 years and 6 to 8 oz. in older children and adults, which may be repeated at intervals of 4 to 5 days if needed. This is given into the muscles. The general practitioner, unless he has ready access to a scarlet fever service will probably still delay the use of serum to the late case of which he despairs. He should keep this method in mind in all cases that appear severe at the onset. A polyvalent streptococcus serum, in the production of which some thirty types of streptococci obtained from scarlet fever cases have been used has been tried in the Annaskinderspital in Vienna since 1902 with gratifying results. This is known as the Moser serum. The statistics in this hospital are quoted as 8 per cent, against 13 per cent, in the other hospitals of the city. Such results would seem ex- tremely satisfactory, for the gain must logically be attributed to the successful combating of the streptococcus toxemia. The Moser serum has never been obtainable in this country, which is regrettable consider- ing the long and satisfactory usage in so reliable a service. In this country a polyvalent serum from different sources has been used, e. g., that of the New York Board of Health. Personally, I am inclined to use the polyvalent serum from such reliable sources, because, in the absence of any known harm, I feel, in desperate cases, the patient should be given the benefit of the doubt. The quantity used depends on the make and is specified in each in- stance. Otitis. So frequent a complication is otitis in scarlet fever that the possibility of its onset should not be forgotten from the day the case is taken in hand. The frequency varies in different epidemics and has decided relation to the severity of the throat symptoms. In large bodies of statistics the incidence of the complication has been set at figures varying from 10 per cent, to 33 per cent., while in cases that may be termed severe the percentage runs to 50 per cent, and 75 per cent. It should be laid down as a cardinal rule that the ears should be examined daily with the otoscope. Few simple procedures repay the effort expended on them comparable to otoscopy. The small size of 410 TREATMENT OF ACUTE INFECTIOUS DISEASES the auditory canal in the little patients and the difficulty of determining landmarks discourage many practitioners in making the effort. Of very great assistance are the magnifying otoscopes with electric light attach- ment, easily portable with a small batteryv These instruments bring out the field with remarkable distinctness. This examination becomes the more imperative when one appreciates that the condition may occur without pain and the first premonition of its existence be determined by a discharge. Before this discharge appears, however, opportunity for a spread into adjacent structures has been given and the rupture of the drum may sacrifice the integrity of that structure beyond repair. Again, patients who are very ill or who are delirious may not voice the pain and discomfort they feel and thus give no clue to the condition. As a prophylactic measure I would reiterate the warning given in considering the care of the nasal passages, that irrigation may induce the otitis and if the state of the nasal passages seem to demand the use of an irrigation, it must be done with extreme care and with the patient's mouth open. With appearance of bulging of the drum, congestion and reddening of the drum, a loss of lustre and macerated appearance of the drum, an incision is indicated. To the general practitioner a detailed description of the drum appearances that do or do not indicate paracentesis is often confusing. It seems to me that a decided deviation from the normal in the appearance of the drum and especially if accompanied by pain in the ear and a rise of temperature ought, in a disease in which the sequelae of otitis are so serious, to demand immediate interference. Technique. The external auditory canal should be cleansed first with cotton on an applicator with 1 to 1,000 bichloride. A curved bistory or a paracentesis knife is used. The incision should begin pos- teriorly and below at the end of the malleus, sweep upward along the edge of the drum to Shrapnell's membrane, through it and out along the upper and posterior wall. Do not use wicks and drains or pack the canal tight with cotton. Irrigations should be instituted every 2 hours by day and every 4 hours by night with 1 to 5,000 bichloride of mercury or with boric acid solution, 2 per cent, to 4 per cent. A pint should be used, from an irri- gator or fountain syringe held 2 to 2 1/2 feet above the level of the ear As the ear improves, the frequency may be decreased to every 4 or 6 or 8 hours. In irrigating a child's ear the ear should be drawn down and back; in an adult up and back. With a skilled hand the pain is but momentary though intense; a i SCARLET FEVER 411 whiff of chloroform or ether may be given or ethyl chloride and the inci- sion done during the primary stages of anaesthesia. For the pain of earache, dry heat is the best application. This may be afforded in the shape of a hot salt-bag, a hot water bottle or hot plate. Irrigations and instillation are 'to be deprecated, because the maceration ensuing blinds the landmarks and makes both the examina- tion and incision more difficult. If, however, the pain is not relieved in this manner, one may try a device advised by Yeo. Heat a large sized wine-glass with hot water; pour this out and then into the hot glass place a pledget of cotton, pouring on this 10 to 20 drops of chloroform and then apply the whole closely over the ear, or phenol (carbolic) in glycerin 5 per cent. gtt. ii-iii. If irrigations must be used, use first simple hot water, then 4 per cent, cocaine hydrochloride. The natural course of the discharge in older children and adults is one to two weeks, but much longer in young children. In these, however, it usually ceases within twelve weeks. After the drum is incised, a cessation of discharge with a rise of tem- perature, pain over the mastoid or swelling there denotes an implication of that structure; but swelling may be absent, pain or tenderness slight and the discharge profuse and yet the mastoid involved. A rise of tem- perature, not otherwise accounted for, should lead to strong suspicions of the mastoid and surgical advice and interference sought. Involve- ment of the sinus, of the meninges and the brain are all possibilities that keep us awake to the slightest signs of the same with a view to expert opinion and surgical intervention. It must be remembered that these discharges are highly infectious and should be treated with 1 to 20 carbolic or 1 to 1,000 bichloride and what can be burned should so be disposed of. Vaccines. The very fact that these discharges are so infectious; that they detain the patient in the hospital so long; that in the end a small per cent, must be released on the supposition that the discharges are no longer infectious, only to demonstrate that the supposition is not always correct makes any treatment that has theoretical promise wel- come. Good evidence is forthcoming that the recently developed vaccine therapy is fulfilling this theoretical promise to some degree. This is not the place to cite the literature at length on the subject, but an extremely instructive consideration of this subject will be found in an article in the Journal of the A.M. A., April 11, 1911, by Weston and Kolmer, entitled "The Treatment of Suppurative Otitis Media (Scarlatinal) by Bacterial Vaccines (Bacterines)." Their conclusions were "that the best time, all 412 TREATMENT OF ACUTE INFECTIOUS DISEASES things considered, for commencing vaccine treatment in cases of otitis media, is from the eighth to the sixteenth day of the discharge," thus agreeing with nearly all observers, that the subacute stage is that in which the most favorable results ensue. "That continued high fever, nephritis, toxemia and various intercurrent affections are contra-indica- tions to the administration of vaccines." "That under yaccine treat- ment, three times as many patients are cured within thirty days and permitted to go home as under the usual treatment. This means that the average residence of the patient in the hospital has been considerably reduced." The organisms most commonly met are staphylococcus aureus and albus, bacillus pseudodiphtherise, streptococcus pyogenes and bacillus pyocyaneus. The vaccine should be autogenous and one finds that recultures do not always show the same organism or show additional organisms. The staphylococcus is often found early, a week later the bacillus pseudodiph- therise often intrudes and as a still later comer, as in many suppurative conditions, appears the bacillus pyocyaneus; hence, the value of recul- tures and fresh vaccines. The initial dose depends on the organism, being small with the streptococcus, 5,000,000 to 10,000,000, larger with the staphylococcus, 20,000,000 to 50,000,000, and a little more with the others mentioned. The doses should be administered twice a week or every 5 or 6 days. The increase depends on the reaction. The reaction is (1) general, a slight fever. (2) Local; an increase in the discharge. (3) With some organisms, such as the streptococcus, a local redness at the site of injection. It is desired to increase the dose so that little or no reaction occurs. The ear should not be syringed or medicated during the treatment, as, in the lighting up of the process, as a part of the reaction, a spread into adjacent structures is facilitated by the syringing. The most cases are cured within five or six doses; a few may require a dozen and a very few more. Adenitis. A certain amount of involvement of the lymphatic glands always occurs and especially of the cervical glands. When the angina is severe the adenitis may be very marked. Usually, however, this inflammation of the gland that occurs at the height of the fever subsides without suppurating. Curiously enough the serious involvement of the glands is a late manifestation, occurring during des- quamation, most commonly in the third or fourth week or even later, and, indeed, may occur in the same glands which, enlarged during the period of maximum intoxication, had resolved. Those at the angle of the lower jaw are particularly affected. It is this adenitis that so fre- SCARLET FEVER 413 quently goes on to suppuration. Whenever a temperature occurs during convalescence this is the one territory the involvement of which must be kept in mind. Cold. The best application to be made at once is cold in the shape of ice in the ice-bag or bladder-skins. There should be a layer of flannel between the ice and the skin. Direct contact or too long contact may damage the skin. While remaining skeptical about the value of drugs locally applied, my choice is for ichthyol, painted on pure or in the shape of a 25 per cent, ointment. There is a difference of opinion about the value of hot applications, such as poultices. My own feeling is that it is useless and looks away from good surgical practice. At the very first sign of suppuration, incise. The glands may not suppurate, but become gangrenous, the tissue overlying breaking down; or there may be a great deal of periadenitis and cellulitis with brawny induration. There is a difference of opinion about the advisability of incision in these cases. Such brawny masses will often resolve, but if the toxemia is increasing and the process spreading, free incision into the tissue should be made. Arthritis. An arthritis, a so-called scarlatinal rheumatism, occurs in about 4 per cent, of the cases, coming on as a rule in the second week of the attack. In the majority of cases it may be classed as a toxic arthritis; in rare instances it is a septic process. It resembles the gonococcal type of arthritis rather than that of true rheumatism, affecting the small joints of the fingers and wrists, as well as the large ones. There is as a rule only slight swelling and redness; rarely an effusion of serum, very rarely pus. It lasts as a rule only three or four days, exceptionally a week. It may be treated on the same principles as the arthritis of rheumatism (see Rheumatic Fever, Chap. Ill), namely, rest to the joint, by splints or other devices, pillows, folded blankets, local applications of ice, or a snug bandage if there is effusion; if not, methyl salicylate painted on and the joint wrapped in a thick layer of cotton batten and the inter- nal administration of sodium salicylate or other form of salicylate, such as acetyl salicylic acid (aspirin), salicin, oil of wintergreen, be begun in doses of gr. v to viiss. (0.33-050 Gm.) every two hours to a child of ten years or twelve years, half the dose at five years, and gr. x to gr. xv (0.6&-1.0 Gm.) hi adults. This may be given with or without alkaline salts. 1 If with, give sodium bicarbonate in double the doses 1 Alkaline salts are said to be incompatible with acetyl salicylic acid but prob- 414 TREATMENT OF ACUTE INFECTIOUS DISEASES of the salicylates, until the urine is alkaline and then diminish the dose gradually, just keeping the urine alkaline. As the symptoms subside lessen the dose. If the joints suppurate they must be treated on surgical principles. Aspiration under surgical precautions should determine the presence of the suspected pus. The joint may then be aspirated through a canula and thoroughly irrigated with sterile salt solution. It may be well to inject a half ounce of 10 per cent, formalin in glycerin. If the joint does not resolve under these procedures it should be opened. Myositis may occur instead of the arthritis, most commonly a lum- bago. This is to be treated locally and by internal medication like the arthritis. Nephritis. Scarlatinal nephritis adds much to the dread in which scarlet fever is held, not only because of the immediate danger entailed by it, but also because of the haunting possibility of the in- sidious development of a chronic process, it may be, long after every indication of kidney damage has passed and because its' onset comes at the time when we are beginning to congratulate ourselves on a happy convalescence. Early in the fever a slight albuminuria, such as one may get in any acute infection, from acute degenerative processes of no lasting or im- portant significance in the parenchyma occurs. This need give little alarm, but the increase of albumin at the height of the disease or at the beginning of the third week or the beginning of the fourth has a differ- ent meaning. Delafield describes the nephritis occurring at the height of the disease as an acute exudative nephritis (non-productive) and while this may prove fatal, if it does not, the lesion clears up entirely; but the late nephritis, post scarlatinal, he says is an acute productive nephritis, which, if not fatal, is likely to go over into a chronic nephritis and it is this feature that makes this late nephritis so serious. Every day throughout the continuance of the infection and even more imperatively throughout the convalescence the urine should be examined for albumin. It is well to have the paraphernalia for the simple heat and acetic acid or the cold nitric acid test in the sick room or bath-room and do the test at each daily visit. We must keep in mind, too, that a mild attack can in no way warrant the assumption that nephritis and severe nephritis will not occur. In fact, there seems to be a dissociation in the degrees of severity of the attack and the onset of the nephritis. ably small doses are not objectionable. For discussion see Acute Rheumatic Fever, Chap. III. SCARLET JFEVER 415 We know that the severe form of nephritis is most common in the second lustrum and that the appearance of albumin in children after ten is more likely to be an albuminuria simply; hence, redoubled vigi- lance in the younger children. Nephritis is said to occur in 10 per cent of the cases. Treatment .really begins with the beginning of the attack for we believe that. the efficiency of the nursing, care in the diet, a sufficiency of water ingested, especially care of the mouth, firmness in keeping the patient in bed during the convalescence, avoidance of draughts upon the patient's back, all tend to make the incidence of the nephritis much less. The type of the late nephritis is, as has been said, an acute productive nephritis. Its onset may be insidious or abrupt. Everything is going nicely in convalescence when suddenly an attack of vomiting, a rise of temperature or in rarer instances a convulsion tell of the onset; or the daily examination is rewarded by the first indication in terms of albumin, casts and blood. With the more insidious attacks a dropsy develops; in the more ful- minating cases uremic manifestations. The urine is diminished. Fortunately the vast majority of those attacked recover, the urine be- comes normal in amount in about ten days and becomes free from blood and albumin in two to six weeks. Studies of the renal function, by the phthalein test, determination of urea nitrogen or non-protein nitrogen and creatinin. in the blood and observation of blood pressure will give one some idea of the seriousness of the lesion. Normal phthaleins run from 60-80; urea nitrogen less than 20 mg. ; non-protein nitrogen less then 35 mg. and creatinin 2 mg. or less in each 100 c.c. of blood. In uncomplicated cases of scarlet fever Veeder and Johnston found that the systolic pressure in young children averaged about 90 mm., in older, 110 mm. When the kidney function is impaired, the phthalein figures fall, the nitrogen increases and in very severe cases the creatinin increases and the blood pressure is likely to go up. In all cases of acute nephritis early or late certain definite lines of action are to be pursued. 1. Rest the kidney, by utilizing other organs to perform its functions vicariously in some measure and add as little as pos- sible to its burden by the proper arrangement of dietary. 2. To treat the symptoms that cause distress or danger. 3. To support the strength of the patient during the attack. To consider the last first, this object is attained by a more rigid def- inition of rest, if the rules have been relaxed in beginning convalescence; 416 TREATMENT OF ACUTE INFECTIOUS DISEASES by using blankets on the bed and a flannel night-gown, if one is not al- ready in use and by giving the warm sponge bath between the blankets with a renewal of the precautions taken earlier in the illness. Diet. If the onset is explosive with,, nausea, vomiting and fever and with anorexia, no food should be offered until the gastric symptoms subside. During this tune cracked ice may be given to jnitigate the nausea and vomiting and furnish some water to the tissues. If there is suppression or marked oliguria, only water with sugar and fruit juices, the sugar affording some food value, should be given and it should be remembered that if the kidney has lost its function for eliminating water and is even shunting it into the tissues to the production of anasarca, the ingestion of large quantities of water will only add to their burden. The amount of water should be increased as the increased water output betokens a restoration of function. We may then begin to give milk in increasing quantities. Our prob- lem from this stage on is to approximate in the diet the caloric needs of the body by a food that shall offer the least amount of work for the kidneys. We may give milk, with some cream if well borne, rice, arrowroot, cornmeal or oatmeal gruels, bread or zwieback and butter and sugar. Van Noorden has suggested as a suitable diet in an adult 1,500 grams of milk (1 1/2 quarts), 375 grams of cream (12 oz.), 50 grams of rice, 50 grams of butter, 20 grams of sugar, which has a heat value of 2,900 calories, as much as that in over 4 quarts of milk. In a child of twelve the demands are less, some 1,600 calories, and the cream should be used much more sparingly. The kidney eliminates water, salts and nitrogen. Such a dietary is economical in all these substances, considering its high caloric value. If there is cedema, all the articles taken should be salt free, salt free bread and butter and no salt added to the gruels. Milk contains one and one-half grams of salt to the liter and enough for the metabolic needs. If the oedema continues still, cut down on the quantity of fluid. I have seen an cedema kept up simply because the intake of water was forced beyond the powers of elimination of a kidney in the process of resolution. Drinks. Water in large quantities is often advised as a sort of a panacea. When cedema is present it should be much limited. The blood will recover water from the cedematous tissues to meet its needs. When the kidney begins to eliminate freely, a freer intake of water will be followed by a diuresis and in uraemia without cedema this may be a desirable means of effecting it. There is rarely danger in giving water SCARLET FEVER enough to meet the demands of the patient's thirst. Plain or aerated water, mineral waters, lemonade, orangeade or imperial drink may be used. As convalescence is established other cereals, vegetables, and lastly fish and meat may be added. Rest to the kidney is afforded, as shown by the choice of the dietary and is further accorded by the assistance lent in elimination by the other emunctories. Purgation. One of these emunctories is the intestine. The movements should be rendered watery and fairly copious by the use of salts, such as Rochelle salt, Epsom salt or sodium phosphate, in doses of gss. to i (15-30 Gm.) in adult and half the dose to the child. Compound jalap powder is also of use, especially in the adult in doses of 3i (4 Gm.). It must be remembered that purgation may be carried to the point of exhaustion and do more harm than good. Diaphoresis. The second great emunctory is the skin. To effect copious sweating perhaps the best measure is the hot pack. It can be given once or twice a day, depending on the urgency of the attacks. The technique follows: " Hot Packs. To give the hot pack: Cover the patient with a blanket, folding down the upper bed-clothes to the foot of the bed. Slip two blankets with a rubber between them under him. These must extend from the head to the feet. Put an ice-cap or an ice-compress on his head, changing the latter every two minutes. Line a foot tub with a large rubber sheet rubber side upward. Put in the tub hot-water bags four, if possible. Soak two small blankets one of which is kept doubled in water 150 F., leaving out two ends to hold while twisting. Wring the blankets quite dry, put them in the tub with the hot-water bags, and cover with the ends of the rubber sheet in order that they may be kept hot while being taken to the bedside. Slip the doubled blanket under the patient. Stretch the other blanket over his chest and around his arms and legs, without exposing him, and tuck it snugly around him, especially at the neck. Place one of the hot-water bags at his feet, one under his knees and one in each axilla and cover all with the rubber which has been lining the tub. Draw up the ends of the under blankets and rubber tightly around the patient, tuck them in and pull up the bed-clothes. Take the pulse frequently at the temporal artery. En- courage the patient to drink copiously hot drinks, seltzer or vichy. After 20 or 30 minutes remove the wet blankets and rubbers, and roll the dry blankets tightly around the patient. Let him remain thus for an hour, keeping the ice-bag at his head and hot-water bag at his feet. At the end of the hour give him an alcohol rub and remove the blanket. 418 TREATMENT OF ACUTE INFECTIOUS DISEASES Rubbing the body with alcohol under such circumstances, energises the nerve centres and transforms the passive activity of the skin into active vascular excitability." Practical Nursing, Maxwell-Pope, p. 122. " Modified Hot Packs. Modified hot packs are sometimes given in connection with diaphoretic drugs, to further their action. To apply such a pack, remove the patient's night gown, roll, him in a hot dry blanket place hot-water bags at his feet and along his sides, and cover him with a rubber sheet tucking it firmly under the mattress. Leave him thus for half an hour, an hour or longer if necessary." Ibid., p. 123. The difficulty in a household of achieving the technique of a hot pack often results in the patient's being rolled in a blanket cold by the time it is accomplished. I have found the following modification ex- cellent : A blanket folded to a little more than the width of the patient's body is wrung out as described, quickly laid on the rubber sheet and the patient, rolled in a dry blanket, laid upon it. Over the patient are placed more blankets and sometimes an impermeable rubber sheet over these. The whole procedure lasts about an hour. During the pack water is given and ice kept at the head. Another procedure is the hot-air bath, to which some patients respond better than to the pack. " To give a hot-air bath in bed, the following articles will be needed: An ice cap. A hot water-bag and cover. Three blankets. Two large rubber blankets. Bed cradles, the number depending on their size. A bath-thermometer. A hot-air pipe and support. Asbestos to put around the top of the pipe. A Bunsen burner or alcohol lamp. Hot drinks. For a vapor bath a croup kettle will be needed instead of the hot-air pipe, and a gas or large alcohol stove will be better than a Bunsen burner. In a private house the elbow of a stove pipe, five or six inches in diameter, can be substituted for the hot-air pipe, and an old screen, clothes-horse or wooden chairs for the bed cradle. Method of Giving Bath. Cover the patient with a blanket. Fold down and remove the top bed clothes. Put a sufficient number of bed cradles over him to extend from his neck to his feet and cover these with rubber. Draw out the blanket covering him and pass it up over the cradle under the rubber. Take off his nightgown, put the ice-cap on SCARLET FEVER 419 his head and the hot-water bag, covered, at his feet, wrapping the latter in a portion of the blanket on which he is lying. Hang the atmospheric thermometer on the cradle at the top. Draw the ends of the rubber and blanket, which are under the patient, up over the cradle, under the rubber and blankets covering it. Tuck in the latter under the patient on both sides and around the shoulders and neck. At the bottom, tuck them in under the mattress folding them around the air pipe. Put the top end of the air pipe in under the cradle three or. four inches and cover this part of the pipe and as much more of it as the clothes are likely to touch, with asbestos or cold blanket dampened. Tie the pipe to the cradle at least four inches above the feet. See to it that the feet and lower part of the legs are securely covered and apart. Put the bed clothes over the cradle. Tuck them in only at the foot and treat them there in the same manner as the blanket, taking care that the asbestos protects them from the hot pipe. Put the lamp or burner in the pipe and light it, so regulating it that the temperature inside the cradle will be raised from 150-175 F. Give the patient hot drinks of Vichy while he is in the bath and watch his pulse carefully. The bath is generally continued twenty minutes after the stated temperature is reached. The after treatment is the same as for the pack." Practical Nursing, Maxwell-Pope, p. 124. Where there is electricity the most convenient sort of heat is from electric light bulbs suspended from the top of the cradle. Three 100 watt 120 Volt bulbs hung 12 to 14 inches apart will suffice to give the desired temperature. Care must be used to avoid the patient or the bedding coming in contact with these bulbs. The common wire cage used to protect electric light bulbs will serve well. Another procedure is the hot bath, beginning at 95 F. and slowly increasing the heat to 100 F. This is kept up for ten or fifteen minutes, then the patient wrapped in a dry or hot moist blanket or pack and con- tinued for another half hour. It has been again and again noted by clinicians that the hot pack in the cedematous has seemed to precipitate an attack of uraemia. Close observation must be kept upon the patient for any evidence of the same, headaches, twitchings, nausea and vomiting or hypertension. Drugs. Pilocarpine has been used and will usually induce a marked diaphoresis. It is, however, fraught with dangers, the most imminent of which is oedema of the lungs, and may well be dispensed with. Treatment of symptoms that cause distress or danger. Congestion of the kidneys as evidenced by diminished urine or at times by lumbar pain. Cupping. Two or more cups may be placed over the kidney 420 TREATMENT OF ACUTE INFECTIOUS DISEASES region on either side and left on for 15 to 20 minutes or until the capil- laries are well dilated. (For technique of cupping, see Pneumonia, Chap. IX.) Wet cupping or the application of leeches is advised by some author- ities. I am not convinced that the letting of blood here relieves conges- tion in the kidneys better than venesection elsewhere. .So far as the withdrawal of blood relieves the circulation in the presence of hyper- tension or uraemia, these measures do good. (For the technique of wet cuppijig and leeching, see Pneumonia, Chap. IX.) Such good as these measures do, I believe is to be referred to reflex processes, starting in the skin area operated on and impinging on the deep vessels. Counterirritation. For this purpose hot poultices, mustard paste or hot fomentations may be used. (For the technique of applying poultices, fomentations, mustard paste, see Pneumonia, Chap. IX.) Diuretics. When the acutest stages have passed, we may ven- ture to encourage diuresis by the mildest of diuretics, milk and water, and the drinks mentioned. These may be followed by the alkaline salts, potassium citrate, potassium acetate or bicarbonate of potash or so- dium in doses of gr. xx to xxx (1.30-2 Gm.) every two or three hours, or the dose for children according to age until the urine reacts alkaline, then reduce until an amount is continued just enough to keep the urine alka- line. These alkaline salts are often mixed in equal parts. The use of diuretics of the purin series, theobromine, caffeine, etc., in acute nephritis I advise against. They have been shown to be dis- tinctly irritating to the epithelium of the kidney. If used at all in the subacute stages it should be with caution; then one may use the double salt of sodium salicylate and theobromine or diuretin in doses of gr. v to gr. x (0.30-0.60 Gm.), according to age, three times a day for 2 days only, or the double salt of sodium acetate and theobromine, in the same doses, or theocine gr. v (0.33 Gm.) three times a day for one day only. If the heart is weak caffeine in the form of the soluble double salts of sodium benzoate or sodium salicylate gr. iii to v (0.20-0.30 Gm.) three or four times a day or gr. i to gr. ii (0.060-0.120 Gm.) in a child of five years has been advised. The same objection to its use obtains, however, as in the case of diuretin and theocine. Caffeine has a selective action on the renal vessels causing dilatation, facilitating blood supply and diuresis. If the heart, however, is a factor in the condition, increasing congestion of the kidney, by its own decompensation, digitalis is em- phatically indicated and is to be used as described under the cardio- vascular apparatus. (Edema is as a rule not massive and is relieved by the measures SCARLET FEVER 421 already mentioned. It is possible, however, for fluid to accumulate in the subcutaneous tissues and in the serous sacks to a degree demanding immediate interference. If the anasarca is marked or obstinate, the tissues should be drained By far the neatest method is by the Southey tubes. I have seen the most gratifying results follow this procedure in a young child when all other measures failed. Southey tubes are small silver or silver-plated trocars and cannulas, about 1-1 1/2 inches long of small calibre, usually four in a set. They are introduced one behind each internal and external malleolus, at such an angle as to drain well. The trochar is withdrawn and the cannula se- cured by a bit of silk tied about a groove near the end for that purpose and secured with adhesive plaster. No blood should be drawn; crystal clear water flows freely, and the quantity in 24 hours is often amazing, amounting to quarts. Tissues so infiltrated scarcely feel the introduction of the tube. When Southey tubes are not obtainable, multiple punctures, 6-12 on the dependent part of each leg with a bistoury protected 1/8" to 1/4" from the point with adhesive plaster may be made or the parts may be cross-hatched with a scalpel. The methods are cruder and it is less easy to prevent infection. None should draw blood. If the legs hang down or are bent at the knee when the patient is recumbent drainage is facilitated. Whatever the method used, strict asepsis must be observed in the procedure and the legs dressed with loose gauze handkerchiefs or fluff. With any signs of irritation about the puncture withdraw the tubes. If the hydrothorax is sufficient to embarrass either the circulation or respiration, it should be removed by a paracentesis. The same procedure must be undertaken for ascites, if the fluid in the peritoneal cavity embarrasses respiration or cardiac action. Uraemia. With the first premonition of ursemia one should have recourse to vigorous purgation and diaphoresis. With hypertension, twitching foretelling convulsions, venesection is indicated, the amount depending on the age and size, 10 to 16 ounces in the adult, 3 to 6 in a child of five years. This may be followed by a saline infusion of twice the amount taken; but is not imperative in the stronger patients. The muscular twitching demands sedatives, chloral, given by the rectum in a couple of ounces of warm milk, gr. xxx to 3i (2-4 Gm.) in the adult, gr. v to gr. x (0.30-0.60 Gm.) in the child of five to six years. This can be repeated in a couple of hours if needed. The hot pack often affords relief, but the patient's condition, pulse, respiration, color and his general response should be studied. The 422 TREATMENT OF ACUTE INFECTIOUS DISEASES length of the time, 1/4 to one hour, and number; one, two or three a day, depends on the patient's response to the procedure. (Technique, see above.) Convulsions. The one drug efficacious at the moment is chlor- oform, continued until the attack ceases. This is followed at once by a hypodermic of morphine sulphate to prevent recurrence^ in the adult gr. 1/4 (0.015 Gm.) and repeat in a half hour if needed; in the child gr. 1/24 (0.0025 Gm.) and in an hour gr. 1/48 (0.0015 Gm.) if needed. An enteroclysis of normal salt solution, two quarts at a time and several times a day, given at 104 F. to 108 F. acts often as a vigorous diuretic and assists in elimination of the toxic agent. With hypertension, amelioration of the condition may follow upon the administration of nitroglycerin, gr. 1/100 to gr. 1/50 (0.0006-0.0015 Gm.) every two hours in the adult or gr. 1/200 (0.0003 Gm.) every hour for five or six doses at five years. Headache is best relieved by an ice bag to the head or the nape of the neck. Small doses of the milder coal-tars may be used cautiously, acetphenetidin (phenacetin) gr. i to gr. iss. (0.060-0.10 Gm.) every hour for three or four doses in the child; gr. v (0.30 Gm.) at a dose in the adult. Codeine phosphate gr. 1/4 (0.015 Gm.) hypodermically for an adult or according to age for children is useful. Lumbar Puncture. Recurring convulsions or excruciating head- ache may find relief in a lumbar puncture, a comparatively simple procedure in the child. (For technique, see Cerebro-Spinal Meningitis, Chap. XXV.) Nausea and Vomiting. This is an expression of uraemia and will improve with the elimination of the causative agent. For immediate help, we stop all effort at food administration, give cracked ice, apply mustard paste to epigastrium of one part of mustard to four, five or six of flour, depending on the sensitiveness of the skin, mixed with cold or tepid water and leave until the part is reddened, or give internally bismuth subnitrate, gr. x to gr. xv (0.60-1 Gm.), bicarbonate of soda gr. v to gr. x (0.30-0.60 Grin.), or oxalate of cerium, gr. ii to gr. v (0.15- 0.30 Gm.), or they may be combined, as Bismuth Subnitratis 15. 5ss. Sodii Bicarbonatis 10. gr. cl i Cerii Oxalatis 5 . gr. Ixxv M. et div. in chart, no. xv. S. One every two hours in a little water or food. Rare complications in the course of the nephritis, such as pneu- monia, pleurisy, endo- or peri-carditis must be treated as if primary. (Edema of lungs occurs as a cause of death in nephritis. SCARLET FEVER 423 Anaemia is a striking feature of a nephritis. In convalescence iron is indicated. It may be given as Blaud's pill or Vallet's mass in doses of gr. iii to gr. v (0.20-0.30 Gm.) three times a day or as Basham's mixture, Liquor Ferri et Ammonii Acetatis, which contains 4 per cent, tincture of ferric chloride, converted into acetate. Dose 3i to iv (4-8 c.c.) three times a day. Convalescence. After an acute attack great care must be taken to prevent a recurrence by too early exposure. The patient should remain in bed until albuminuria ceases or for four or five weeks. If the albumin persists after that, one must consider the depressing effect of too long confinement to bed and the patient be allowed to sit up tentatively, the albumin, casts, total quantity and specific gravity being carefully noted with each increase of license. If the condition is not aggravated, the patient may be allowed about the house or out of doors in suitable, weather; but with the slightest indication of recurrence should be put to bed again. If the evidences of nephritis continue and the patient is able to take advantage of a change of climate he may be removed to such a place as allows much out of doors life. Woolen underclothing must be worn and outer clothing care- fully adapted to the weather. Warnings against remaining in wet clothes and undue exposure to the weather must be reiterated. On the occasion of any acute infection the kidneys should be watched with especial care. From time to time, for years after, the urine should be examined at intervals of 3 to 6 months to appreciate the insidious advance of a chronic process. The sum total of prophylaxis is after all the observance of the laws of hygiene, clean bodies, fresh air, good food and right living. The Heart. Mention has been made of the heart in consider- ing the cardio-vascular apparatus and its part in nephritis has been touched upon ; but in addition to these there may rarely be an endocar- ditis (in something less than 1/2 per cent.) and still more rarely a peri- carditis; the cardiac complications are most common in septic cases, and with post-scarlatinal nephritis and streptococcus pneumonia. Myocardial changes occur as well. All this may be found with or without articular involvement. Acute dilatation may be the cause of death. (Holt.) More rarely there may be a toxic arteriosclerosis or even an aortitis. The treatment of these conditions are the same as under other circum- stances, rest, the ice bag, and if the myocardium becomes involved and shows signs of weakening, digitalis. .(See Acute Rheumatic Fever, Chap. III.) Broncho-Pneumonia is likely to follow upon septic cases, but 424 TREATMENT OF ACUTE INFECTIOUS DISEASES may more rarely happen during desquamation. It is a far less serious complication than in measles or whooping cough. The treatment is as elsewhere. (See Pneumonia, Chap. IX.) Pleurisy occurs not infrequently and occasionally, early or late, an empyema, always a grave condition, demanding prompt operative interference. (See Pneumonia, Chap. IX.) Still more rarely one meets noma. It is to be combated by curetting and the application of fuming nitric acid and if this fails to stop its extension, excision must be done. McGuire advises application of thick paste of bismuth subnitrate and water. Chorea, peritonitis, symmetrical gangrene and other very rare happenings are to be met as under other conditions. Relapses. Relapses may occur, as often, it is said by some au- thorities, as 1 per cent. It is most usual in the fourth or fifth week, but may be delayed until the sixth or seventh. It is in all particulars like the original attack and is to be treated in the same manner. Recurrences are possible, usually many years later, but are very rare. Discharge of Patient. The patient should not be released from isolation until desquamation is completed and all discharges from the mucous membranes or suppurating tissues, organs or structures cease. Even in the mildest cases, however soon the desquamation may seem complete, the patient should be isolated at least four weeks and six weeks is safer. In fact the average case has to be isolated for this time. But even then, if the desquamation is not complete (and the feet have especially to be attended to) isolation must continue. It is to be remembered, as before mentioned, that harsh measures to effect des- quamation may set up a dermatitis and defeat the purpose. If, however, when desquamation is quite at an end, there is a discharging nose, ear or gland, the patient must not be released until this ceases. When all symptoms have ceased and the patient is released from quarantine, if a child, he should not mingle with other children for a month to come nor sleep with them for three months. (Holt.) When the child is ready for release he is given a thorough soap and water bath and then one of phenol (carbolic) 1 to 50 or bichloride 1 to 5,000. The scalp and hair are thoroughly shampooed. No more excellent guide for routine procedure can be taken than Northrup's description of that in use in some of the New York Hospitals. (NothnageFs Encyclopedia of Practical Medicine, 1902, English Trans- lation, 611, quoted from Weaver in Musser and Kelly's Practical Treat- ment.) " During the week preceding discharge patients have their ears SCARLET FEVER 425 irrigated with bichloride solution 1 to 8,000 X and the scalp shampooed on alternate days." When discharged "(1) The ears are irrigated with bichloride solution 1 to 8,000; (2) the scalp is shampooed with soap and water; (3) the scalp is shampooed with bichloride 1 to 2,000; (4) a tub-bath is given of soap and water; (5) a tub-bath is given of bichloride solution 1 to 8,000 for twenty minutes; (6) a sponge-bath is given of bichloride solution 1 to 2,000; (7) the bichloride is sponged off with sterile water; (8) a nasal spray is given of bichloride solution 1 to 8,000; (9) the mouth is cleansed with saturated solution of boric acid." The child is then taken into a clean room and clothed in clean clothes. Fumigation and Sterilization. Washable clothing should be disinfected by steam or by boiling an hour. Mattresses, heavy blankets, pillows and articles that cannot be washed should be steamed where it is possible to have recourse to a properly constructed plant. All articles that have little value should be burned and toys certainly. No child should ever be given a toy once in the sick room, no matter how sterilized. Metal objects may be immersed in strong phenol (carbolic acid). The room should be cleaned by having the floors, woodwork and the smooth walls washed down with cloths wrung out of 1 to 2,000 bichloride solu- tion. Then the room should be fumigated with sulphur or formaldehyde. These gases should be generated in the presence of moisture to be effec- tual. Sulphur destroys many fabrics and injures other articles and is less effectual than formaldehyde. Where it is possible skilled assistance should be sought in this important procedure; where this may not be obtained, the room is to be sealed with strips about the doors and win- dows, the key holes plugged and formaldehyde gas generated by some of the contrivances on the market. Candles are made for this purpose, but too implicit faith in their efficacy must not be granted. They should be burned in the presence of moisture, such as may be obtained from a dish of water over an alcohol lamp, and the room sealed for some twelve hours. Such fumigation does not excuse one from the duty of repainting, repapering, or recalcimining this room. Fumigation. At the present moment there is a considerable controversy among the authorities as to the necessity of terminal fumi- gation; The Board of Health of the City of New York, following the lead of Chapin of Providence, R. I., considers terminal fumigation in all 1 This in cases in which there may be no otorrhea. 426 TREATMENT OF ACUTE INFECTIOUS DISEASES infectious diseases except anterior poliomyelitis, typhus fever and small pox as unnecessary, providing proper isolation of the patient during the disease with destruction of infectious discharges has been properly carried out. There can be no question tiiat if these precautions are heeded the necessity for terminal fumigation is materially lessened. Beginning in 1914 the New York Board of Health ceased to fumigate in the Boroughs of Manhattan and the Bronx after all the minor con- tagious diseases including scarlet fever, diphtheria and measles while the practice was continued in the Borough of Brooklyn. After a long series of cases had been investigated the Health authorities of New York could determine no particular difference in the number of late cases reported from controls. This was in agreement with the observations of Chapin in Providence. Moreover, it is well known that most of the pathogenic organisms have but slight viability after separation from the host and after exposure for an appreciable time to drying and sunlight. In place, then, of putting reliance upon fumigation at the end of the clinical course of the disease emphasis is laid on the attention to the discharges during the course of the disease and thorough cleansing with soap and water or boiling of the articles that have been soiled by dis- charges from the patient. On the other hand at the date of this writing the Health Department of the District of Columbia still continues to disinfect premises after diphtheria, scarlet fever and the major contagious diseases. In a treatise of this kind the author feels that he can only put the pros and cons before the reader and would advise that in those environ- ments where the rules and regulations laid down for the isolation of patients and destruction of discharges cannot be carried out or are wilfully neglected terminal fumigation be carried out, but would em- phasize the inefficiency of most of these terminal fumigations and the great danger of considering them as excuses for neglect of instructions heretofore cited. Prophylaxis. This subject has already been covered in part as regards disposition of contacts, discharge of patient and fumigation. It includes, furthermore, school inspection of children daily with prompt attention to early signs of infection, following up absentees from school to determine sickness and its nature, supervision of milk supply, enforce- ment of law against spitting in public places and public lectures on modes of conveyance of disease. SCARLET FEVER 427 SUMMARY Incubation. Two to four days. Ten to twelve days. Period of isolation of those exposed should be eight days. An excess of precaution would set it at three weeks. Onset and diagnosis. Vomiting, fever, sore throat. Erythematous eruption (twelve to twenty-four hours after onset). Throat shows bright injection. Tongue shows hypertrophied papillae at tip and edges. Leucocytosis and polynucleosis. Later. Desquamation. Eosinophilia. Nephritis. Distribution of the family. Adults. Those who have not had Scarlet Fever should come in con- tact with the patient as little as is compatible with their duty. All adults should avoid contact with children outside. If contact with children outside is imperative, adults should remove from the environment of infection during its course. Teachers in the family should move from contact with patient and notify health authorities and resume working only with their consent. No member in contact with case should handle food supply for eight days. Other children of the family. Removed to another house, until end of illness. Kept from contact with other children for eight days. Excess of precaution sets it at three weeks. Should not go to school for three weeks from beginning of isola- tion. Should not go to school at all during patient's illness, if there is any communication between them and members of the family in contact with the patient or from the home of the patient. If it is not possible to remove the children to another house, avoid direct or indirect contact with patient. All contacts should have throats and skin inspected and temperature taken two to three times a day for a week to determine early signs and symptoms of disease. Physician should attend to them before seeing patient. Room. Sumcient air space. Good ventilation. Light. Top floor excellent. Nearness to a bath-room desirable. Affording ingress and exit without passing through family apart- ments desirable. Approach through balcony or verandah for example. 428 TREATMENT OF ACUTE INFECTIOUS DISEASES Open fire place a convenience. Strip room of furniture, carpet, adornments. Floor bare or covered with carpet lining and over this unbleached muslin. Sealing doors, except those in use. Entrance to all rooms protected by sheets. One sheet on outside of doorway attached to top and right side. One sheet inside of doorway attached to top and left side or vice- versa. Floor and woodwork. Rubbed from time to time with 1-1,000 bichloride of mercury (burn the cloths used). If the floor is covered sprinkle with same solution. The nurse. One for day and one for night or one with a member of the family. If member of family must be nurse, she must be isolated from the rest of the family. She should wear gown and cap. Handling secretions she should wear rubber gloves. She should use an occasional throat spray of a mild antiseptic, 2-4 per cent, boric acid solution, or half strength Dobell's solution. Must not come in contact with other members of the family or susceptible people outside. Should not sleep or eat in the sick room. Should have own room adjacent. Should take air and exercise. Should change clothes in going out and if coming in contact with others should wash hair. The physician. Leave overcoat and coat and vest in bath-room. Don gown, long and tight at wrists rubber gloves. Failing this a sheet. Failing this wear overcoat and street gloves, cap. Wear rubbers, and turn up trousers. Leave all instruments in sick room or bath-room (including stetho- scope). Disinfect before using again. Visit as short as compatible with proper examinations. On leaving. Wash face and hands with soap and water. Follow with alcohol or bichloride of mercury 1-1,000 or phenol or lysol 1 per cent. A careful physician will change his clothes and take a bath before seeing other children. At least plan to see Scarlet Fever cases either early or late in the day. Spend some time later in the open air, and do not visit a child immediately. Do not take an obstetric case. Precautions in the sick room. Thermometer. Leave the thermometer in the sick room always. Keep it in 2 per cent, to 5 per cent, phenol solution. Tongue depressors. Should be of wood or glass; better wooden ones. Keep glass in phenol solution 2 to 5 per cent. SCARLET FEVER 429 Syringe nozzles. Glass (not to be used for young children). Hard rubber. Keep in phenol 2 to 5 per cent, solution. Dishes, knives, forks, spoons, etc., boiled for half an hour or more. If sent out of sick room to boil, soak in 5 per cent, phenol half an hour. Urinals, bed-pans, sputum cups, rectal tubes; disinfect and allow to stand in 1-20 phenol. Bed-linen, night dresses, towels, handkerchiefs, etc. Soak over night in 2 to 5 per cent, phenol, then boil for half an hour before sending to the wash. Discharges from mouth, nose, ears caught in pieces of gauze or cloth and burned. Domestic pets excluded. Books, toys, etc., destroyed after illness. Temperature of room. Cold air desirable if the body is well protected. When body is exposed for any purpose temperature should be at 70 F. Bed. For technique of bed-making, see Chap. IX. Patient. Keep in bed no matter how mild the case may be, especially on account of the kidneys. Sponge bath with tepid water daily. In a warm room, under a blan- ket, exposing one part after another. Nightgown. Should be flannel or cotton or silk undervest under the flannel nightgown. Diet. Person preparing food for family should not come into contact with patient. Nurse should not handle general food supply of family. For fundamental principles see Chap. II. Do not push feeding in first few days. Milk. Milk has proven empirically to be the best article of diet in scarlet fever. Two quarts of milk equal 1,280 calories; adding 1 ounce of cream and J^ ounce of milk sugar to each glass of milk in- creases the caloric value to 2,000. Milk modifications, such as koumys, buttermilk, whey, may be substituted in part or in whole. Cereals and cereal gruels, arrowroot, rice, barley, cornstarch, wheat flour, farina, imperial granum, jellies of barley flour, tapioca, sago. Vanilla ice cream. 430 TREATMENT OF ACUTE INFECTIOUS DISEASES Feed at two-hour intervals. Do not interrupt sleep at night. For caloric values see text. After the period for nephritis has passed, add eggs, custard, potatoes, other vegetables, oysters, fish and finally meat. Give no meat soups. Drinks. Water freely. Lemonade, orangeade, juice of grape-fruit, grape juice. Imperial drink (cream of tartar, a tablespoonful to 3 pints of boiling water, add sugar and lemon juice to suit taste). Give 2 quarts or more of fluid a day. Offer water every hour. Care of skin. Sponge bath with tepid water once or twice a day. Itching and burning. Cocoa butter. Cold cream. Sponge with sodium bicarbonate 3i-0iii (4 Gm.-l,500 c.c.). Bran bath. Handful of common bran in a clean cloth or muslin bag, swished about in 1 gallon (4,000 c.c.) water until slightly milky. Calamine 3i (4 Gm.) to 1 pint (500 c.c.) of lime water. Severe itching, 1 per cent, or 2 per cent, phenol in olive oil; }/ per cent, dilution of liquor cresolis compositus (Sturtevant) . Desquamation. Cocoa butter. Vaseline (petrolatum) may add Phenol 1 per cent, or 2 per cent, if itching is severe. Soaking hands and feet in warm water. Do not pick, rub or scrape skin; may cause infection. Apply to soles of feet over night 6 per cent, salicylic acid ointment (Sturtevant) . Itching of scalp. Wash with alcohol, rub in white vaseline (Sturtevant). Care of mouth. Cleansing solutions. Physiological salt solution (3i-0i) (4 Gm.-500 c.c.). Boric acid solution 2 per cent, to 4 per cent. Dobell's solution (Sod. bicarb, and borax aa 3ii~0i (8 c.c.-500 c.c.) with about 1/3 per cent, phenol) quarter to half strength. Rinse the mouth with one of the solutions after each feeding. Dead spaces between cheeks and teeth searched. Teeth cleansed; interstices freed from food; use cotton swab on wooden tooth picks, soaked with a cleansing solution. Coated tongue and sordes on lips and teeth, one-half strength peroxide of hydrogen (official) to soften, then cleansing solution. Scrape tongue with edge of whalebone after coat is softened. Very dry mouth. SCARLET FEVER 431 Two per cent, boric acid solution and liquid petrolatum (albolene) equal parts; add lemon juice to flavor. Fetid breath, foul mouth, stomatitis. Apply following solution: I* Phenol (water solution 1-20). Glycerin. a a 3i (4 c.c.) Boric Acid (saturated watery solution) gviii (240 c.c.) Follow this with a milder solution as above. Care of nose. Dried secretions softened with olive oil or vaseline. Follow with cleansing solutions on cotton swabs or as a sprav. Do not use irrigations. Care of throat. Spray with cleansing solutions. Irrigate with hot physiological salt solutions (110 F.) or 4 per cent. sod. bicarb, solution. Bag a foot above the bed. Gargles of little use. For Angina, see below. Care of eyes. Cleansed with boric acid solution, 2 per cent, to 4 per cent. Conjunctivitis. Cleanse with boric acid solution; drop a drop of epinephrin (adrenalin) chloride in eye and follow with 5 per cent, to 10 per cent, argyrol. Care of genitals. Nurse or physician should inspect them each day. Use boric acid solution, 2 to 4 per cent. Care of bowels. When first seen. Calomel, gr. % (0.015 Gm.) every quarter hour for five or six doses r(well borne by children). Follow with salts in three to four hours; in adults Epsom, Rochelle or Glauber's gss.-i (15-30 Gm.) in one-quarter glass of water. In children follow in two hours with Milk of Magnesia gss. (15 c.c.). Liquor Magnesii Citratis 5vi-viii (180-240 c.c.). Rochelle Salt 3ii (8 Gm.) in one-half glass of water. Later keep open with enemata or mild cathartic, Liq. magnesii citratis, Hunyadi water or cascara. For nausea. The calomel in divided doses as above. Sodium Bicarbonate gr. xv (1 Gm.) in 5" (60 c.c.) water, or Bismuth Subnitrate gr. xv (1 Gm.), or Cerium Oxalate gr. v (0.30 Gm.) or in combination, e. g. 432 TREATMENT OF ACUTE INFECTIOUS DISEASES Bismuth Subnitratis ......................... gr. xv 1 . Sodii Bicarbonatis ........................... gr. x . 60 Cerii Oxalatis ............................... gr. v 0.30 M. Give one such, stirred in a little .water, every two hours. When severe: Large dose of Bismuth Subnitrate, e. g. Subnitrate of bismuth 3i <4 Gm.) Six drops of 1 per cent, cocaine hydrochloride in a wine-glass of water every fifteen minutes for four doses (Sturtevant). Treatment of fever. Is largely treatment of toxemia. Treatment of pyrexia per se. When temperature is excessive, hyperpyrexia. When long sustained above 104 F. Cold. Infants, sponge baths. Children, cold packs and sponge baths. Early or middle adult life, the bath or cold pack. With children begin with relatively warm water 95 F. to 90 F. and increase the cold to 80 F. to 75 F. to 70 F. or colder. Discontinue the bath or pack when patient's temperature is 102 F. If patient shows evidence of collapse stop the bath, wrap patient in dry blanket; apply heat to extremities. Give hot drinks. Treatment of angina. When membrane is present always take culture for diphtheria bacillus. If culture cannot be taken, give 10,000 units of diphtheria anti-toxin. If case is very severe and no culture can be taken treat as a case of diphtheria. If laryngeal symptoms are present it is pretty surely diphtheria. Take culture, but do not wait for return but give diphtheria antitoxin 10,000 units and repeat in eight or six or four hours, according to severity. Keep the throat clean but use the mildest solutions. Do not use astringents. Avoid injury to throat by solutions or procedure. Solutions. Sodium Chloride 3i-0i (4 Gm.- 500 c.c.). Two per cent, to 4 per cent, boric acid solution; half to quarter strength Dobell's solution. Mode of application. Irrigations, gargles, sprays, topical application with swabs. Inhalation. Irrigation with hot salt solution the best. Boric acid and Dobell's solution can be used in the same way. If there is much tenacious mucus give Preliminary irrigation or spray with Sodium bicarbonate solution, gr. xx (1.30 Gm.) to 5i (30 c.c.) SCARLET FEVER 433 or Sodii Bicarbonatis. Sodii Biboratis aa gr. xxxii (2.00) Aq. Destillat.q. s. ad 5iv (120.00) If there is much membrane apply gently peroxide of hydrogen with a swab or an applicator. Use full strength (official) or spray with same diluted one, two or three times. Then follow with alkaline irrigation as above to clear mucus. Then follow with hot saline solution as above. To afford comfort. Apply between the irrigations sprays of any of the cleansing solutions named. Inhalations of hot steam, medicated with compound tincture of benzoin or oil of eucalyptus or oil of pine. 3i (4 c.c.) of any of these on hot water or on sponge of croup kettle amount of water indif- ferent. Use croup kettle. Simple inhalers. Common kettle with cone of paper attached to spout. Pitcher of hot water with cone of paper over opening. Gargles far less efficacious than other methods. Use same cleansing solutions named. Cracked ice. Cold applied to neck as compresses. Coils. Ice-bags (throat-bags). Heat applied to neck. Fomentations. (See Chap. IX or XIV.) (Modify to sirit site of ap- plication.) Gangrenous cases Irrigate with potassium permanganate solution 1-2,000. (Other suggestions in gangrenous cases have been, Sprays of adrenalin. Gargles of alcohol diluted six to eight times. Touching with Tr. Iodine. Application of Loffler's solution once or twice a day.) Rhinitis. Cleansing solutions same as throat. Sprays best, or swab. Do not use irrigations unless specially indicated. If membrane is present, smear and culture for diphtheria. Spray with peroxide of hydrogen diluted three or four times. Then use cleansing spray. When nares are blocked or purulent discharge is profuse, irrigate. (For procedure, see text.) Late Rhinitis, muco-purulent, sero-purulent or severe. Is infectious. Same measures of cleanliness. 434 TREATMENT OF ACUTE INFECTIOUS DISEASES Staphylococcus aureus usually present. Vaccines. 50,000,000 first dose. 100,000,000 200,000,000 300,000,000 Twice a week. Usually three or four doses enough. If temperature continues think of sinuses. Circulatory failure. Digitalis. If the need is immediate and urgent give Strophanthin (Boehringer preferred), gr. 1/120-1/60 (0.0005-0.001 Gm.) into muscle. This dose should not be repeated more than once, at an interval of twelve hours. Follow the first dose by digitalis, either the infusion, the tincture or the leaf. Give three or four times a day. Dose. Infusion 5 ss. (15 c.c.) Tincture m. xxx (2 c.c.) Leaf gr. iii (0.20 Gm.) This is a daily dose of 9-12 grains (0.60-0.80 Gm). Keep this up for twelve to fifteen doses (three to four days) or until desired results are obtained or some evidences of toxicity obtain. Child of five years, a quarter dose. If not urgent omit strophanthin. Begin with digitalis. I am becoming more and more convinced of the value of digitalis in circulatory failure of acute infections and am giving it preference to the vaso-motor stimulants mentioned. (See Pneumonia, Chap. IX.) Usually vaso-motor. Vaso-motor stimulants. Caffeine. Soluble double salt of sodium salicylate or sodium benzoate and caffeine. Adult dose, gr. v (0.30 Gm.) into muscle. Child of five years, gr. ss.-i (0.030-0.060 Gm.). Child of eleven years, gr. i-ii (0.060-0.13 Gm.). Frequency every four, three or two hours. Camphor. In solution in olive oil or sesame oil 10 per cent, or 20 per cent. never in paraffin oil; or in ether, 10 per cent. Adult dose, gr. iii-v (0.20-0.30 Gm.). Child of five years, gr. ss.-i (0.030-0.060 Gm.). SCARLET FEVER 435 Child of eleven years, gr. i-ii (0.060-0.130 Gm.). Give hypodermically or intramuscularly. Frequency every four, three or two hours. Caffeine and camphor alternately. Strychnine sulphate or nitrate. Adult dose, gr. 1/60-1/30 (0.001-0.002 Gm.). Child five years, gr. 1/200-1/150 (0.0003-0.00045 Gm.) Child eleven years, gr. 1/100-1/80 (0.0006-0.0008 Gm.). Adrenalin (epinephrin). In collapse. Give intramuscularly, 1 :1000 solution. Dose m. x (0.60 c.c.). or Intravenously m. ii-iii (0.150-0.20 Gm.). At ten years, a half dose. At five years, a quarter dose. Nervous symptoms. Stupor and delirium. Cold air. Cold water. Sponges. Packs. Baths. Ice-bag or coil to head. Restlessness. Bromides of potash, sodium, or ammonium or a mixture of equal parts of each. Dose, gr. xv-xx (1-1.30 Gm.) three or four times a day for adults; gr. iii-v (0.20-0.30 Gm.) three or four times a day for children. Phenacetin, gr. i-ii (0.060-0.130 Gm.) at four-hour intervals may be given to children. Sleeplessness. Cold baths. Cold sponges. Warm sponges. Bromides. (See restlessness.) Phenacetin. (See restlessness.) Trional, gr. x-xv (0.60-1 Gm.) in capsules or in a little warm water or wine, whisky or brandy. Repeat in two hours if needed (adult) . Chloralamid, gr. xx-gr. xxx (1.30-2 Gm.) in powder, cold water or wine, whisky or brandy, and repeat in two hours if needed (adult). Wild delirium. Morphine sulphate, gr. 1/8 (0.008 Gm.) hypodermically for adult; gr. 1/48-1/24 (0.0015-0.003 Gm.) for child. 436 TREATMENT OF ACUTE INFECTIOUS DISEASES Specific treatment. Convalescent serum. 1 Convalescent blood. ! (See text.) Normal human blood, j Vaccines. Indicated in some of the subacute and chronic streptococcus com- plications of the disease. (See below.) Polyvalent sera. Moser serum. New York Board of Health serum. (See text.) Otitis. Examine ears daily. With involvement of drum. (See text.) Incise. For technique and after care, see text. Earache. Dry heat, to avoid maceration of drum. Hot salt bag. Hot water bag. Applied to the ear. Hot plate. Take a wine-glass made hot by dipping into hot water, put in a pledget of cotton; in this 10-20 drops of chloroform; apply in- verted glass over ear. (Yeo.) Drop into ear two or three drops of 5 per cent, phenol in glycerin. If irrigations are used, use hot water first and drop in 4 per cent, cocaine hydrochloride solution after. Mastoid. (See text for symptoms.) Surgical procedure. Remember that the discharges from the ear are highly infectious. Destroy by burning or 1-20 carbolic or 1-1,000 bichloride of mercury. Sinus involvement. . , f Surgical procedure. Cerebral abscess. J Vaccine treatment of discharge from ear. Determine organism by culture. It may be staphylococcus aureus. Staphylococcus albus. Bacillus pseudo-diphtheriae. Bacillus pyocyaneus. Streptococcus pyogenes. Vaccine should be autogenous when possible and should be fresh. Time to begin 8th to 16th day of discharge. Contraindications. High fever. Nephritis. SCARLET FEVER 437 Toxemia. Inter current affections. Dose beginning. Streptococcus 5,000,000. Staphylococcus 20,000,000. Increase depends on reaction; no reaction, double each dose for three or four doses; then add 20,000,000-30,000,000 streptococci at a dose; 50,000,000-100,000,000 staphylococci at a dose. Frequency, twice a week or every five or six days. Duration, six to twelve doses. Reaction. (See text.) Adenitis. The severe suppurating forms are later manifestations, third or fourth week or later. Cold. Ice bags or bladders. Ichthyol, 25 per cent, in vaseline to pure product painted on. Heat. Fomentations.! /CI . . Poultices. } ( See to** to value ') Wet dressings. Huge, very wet dressings at the temperature of melting ice. Use following solution for dressings. Plumbi Acetatis 60 5ii Alu minis Pulveris 60 5ii Alcoholis 250 gviii Glycerini 120 giv Aquae 1,000 Oii M. et. Shake. (Sturtevant.) At the first sign of suppuration incise. Arthritis. Usually in second week. Treat as in rheumatism. (See Chap. III.) Suppuration is rare. Treat on surgical principles. (See text.) Myositis. Local treatment and medication as in arthritis. Nephritis. Examine urine daily. Keep reagents for albumin test at the patient's. Severe attacks occur late in third or early in fourth week. Prophylactic. Good nursing. Bed during convalescence. Avoidance of draughts. Diet largely of milk. 438 TREATMENT OF ACUTE INFECTIOUS DISEASES Treatment. 1. Rest to the functions of the kidney. 2. Treat symptoms. 3. Support patient. Patient is put between blankets. Flannel nightgown. Diet. If explosive with nausea and vomiting give only cracked ice until these symptoms subside. Suppression or oliguria. No more water than the kidney eliminates. Food, only sugar added to water or fruit juices. Increase water intake as urine output increases. Then begin to add milk tentatively, observing effect on total output of urine and albumin. (Edema. Make all articles salt-free; salt-free bread, salt-free butter. With increasing oedema cut down water intake. Diet outlined for Scarlet Fever. Milk and cereals, bread and butter, are suitable for the nephritis. Drinks. Plain water, mineral waters (no sodium chloride) lemonade, orange- ade, Imperial drink. Amount not more than 1 pint to 1^ pints more than urine out- put. Purgation. Fairly copious watery movements by salts. Rochelle, Epsom or Glauber's salt, or sodium phosphate. Dose, ss.-i (15-30 Gm.) in three-quarter glass of water for adults, half this dose for children, or Compound Jalap powder, 5i in warm water (adult dose). Purgation must not induce fatigue. Diaphoresis. Hot pack once or twice a day. (Technique, see text.) Hot air bath. (Technique, see text.) Hot bath. Begin at 95 F. for ten or fifteen minutes. Then wrap in a dry or hot moist blanket or pack for another half-hour. Drugs. Pttocarpine, only when pack is not attainable, has its dangers. (See text.) Cupping. Especially indicated in early stages of congestion and acute sup- pression; two or more cups over either kidney for fifteen to twenty minutes or until capillaries are well dilated. (For tech- nique, see Chap. IX.) SCARLET FEVER 439 Counterirritation . Hot poultices. (For technique, see Chap. IX.) Fomentations. (For technique, see Chap. IX.) Mustard paste. (For technique, see Chap. IX.) Diuresis. After acutest stages have passed. Mildest diuretics first. Water and drinks mentioned, milk. Then alkaline salts. Potassium citrate. Potassium acetate. Potassium bicarbonate. Sodium bicarbonate. Any one or combination. Dose, gr. xx-xxx (1.30-2 Gm.) every two to three hours. Children half dose. Continue until urine reacts alkaline; then reduce dose in frequency, but keep urine just alkaline. Little later. Diuretin, gr. v-x (0.30-0.60 Gm.) three times a day. (The smaller dose in children or even half this.) Agurin. Same dose and frequency as diuretin. Theocin. Same frequency as diuretin for one day only. Dose gr. v (0.35 Gm.) adult. Caffeine; especially if the heart is weak. Use double salt of sodium salicylate or sodium benzoate or citrated caffeine. Dose, ii-v (0.20-0.30 Gm.). Frequency, three times a day. Child of five years, dose, gr. i-gr. ii (0.060-0.120 Gm.) three or four times a day. (Edema. Diaphoresis. ] Diuresis. [ (See above.) Purgation. Hydrothorax, paracentesis. Ascites, paracentesis. Anascara, scarification. Southey's tubes. (For technique, see text.) Uraemia. ee above.) Hypertension and twitching foretelling convulsions. Venesection. Adult, 10 to 20 ounces. Child (five years), 3 to 6 ounces. 440 TREATMENT OF ACUTE INFECTIOUS DISEASES Sedatives. Chloral by rectum. Dose, gr. xxx-3i (2-4 Gm.). Child (five years), gr. v-gr. x (0.30-0.60 Gm.). Give in 2 ounces of warm milk or starch paste. Repeat in two hours if needed. Convulsions. During the convulsion. Chloroform inhalation until the attack ceases. Follow at once by Morphine sulphate, gr. 1/4 (0.015 Gm.). Repeat in half hour if needed. Child (even infant), gr. 1/48-gr. 1/24 (0.0015-0.0030 Gm.). Repeat in an hour if needed. Enteroclysis. Salt solution, 5i-0i (4 Gm.-500 c.c.) 2 quarts (2 litres) at 104 F.- 108 F. several times a day. Lumbar puncture. (Technique, see Cerebro-spinal Meningitis, Chap. XXV.) Hypertension. Nitroglycerin, gr. 1/100-gr. 1/50 (0.0006-0.0015 Gm.) every two hours. Child of five years, gr. 1/200 (0.0003 Gm.). Headache. Ice bag to head and nape of neck. Acetphenetidin (Phenacetin) cautiously, gr. v (0.30 Gm.) every hour for three or four doses. Child, gr. i-iss. (0.060-0.10 Gm.). When excruciating, lumbar puncture. Nausea and vomiting. Cracked ice. Mustard paste to epigastrium 1-4, 5, or 6 of flour. For technique, see Chap. IX. Bismuth, gr. x-xy-lx (0.60-1-4 Gm.). Sodii bicarbonatis, gr. v-lx (0.30-4 Gm.). Oxalate of cerium, gr. iii-v (0.20-0.30 Gm.). Or combined as Bismuth Subnitratis ...................... 15 (5ss.) Sodii Bicarbonatis ........................ 10 (Siiss.) Cerii Oxalatis ............................ 5 (gr. Ixxv) M. et div. in chart no. xv. One in a little water or milk every two hours. SCARLET FEVER 441 Pneumonia. Pericarditis, Treat as primary. Anemia. In convalescence give iron, Blaud's pill (pil. ferri carbonatis), or Vallet's mass (massae ferri carbonatis), gr. iii-v (0.20-0.30 Gm.) three times a day. (Adult dose.) Basham's mixture (liq. ferri et ammonii acetatis), 5i-iv (4-15 c.c.). Convalescence from nephritis. Remain in bed until albuminuria ceases, or for four to five weeks. After that allow up tentatively, then about house, then out of doors. Watch effects on albumin, casts, and total quantity. If aggravated, put back to bed. Wear woolen underclothing. Adapt clothing to weather. Avoid exposure to weather. Change wet clothing at once. Watch kidneys on occasion of any illness. Examine urine every three to six months. Other complications. Endocarditis.! r or Pericarditis. I * re> Treat as under other circumstances. (See Rheumatic Fever, Chap. III.) Bronchopneumonia. Treatment. (See Pneumonia, Chap. IX and Streptococcus Pneu- monia, Chap. X.) Pleurisy. Treatment. (See Pneumonia, Chap. IX.) Noma. Application of bismuth subnitrate and water to form thick paste; apply several times a day. Curetting. Fuming nitric acid application, excision. Relapses. Treat like initial attack. Discharge of patient. Four weeks in the mildest case. Six weeks is safer. 442 TREATMENT OF ACUTE INFECTIOUS DISEASES If still desquamating at the end of six weeks, isolation must continue until desquamation ceases. If nose, ears or glands are discharging when desquamation ceases isolation must continue still until the discharges cease. When patient is released from quarantine, he must not mingle with other children for a month after. Should not sleep with other children for three months (Holt). Preparation of the child for release. Soap and water bath, then carbolic acid (phenol) solution (1-50) bath, or Bichloride of mercury bath (1-5000). Head shampooed. Northrop's rules. 1. Ears irrigated with bichloride 1-8000. 2. Scalp shampooed with soap and water. 3. Scalp shampooed with bichloride 1-2000. 4. Tub bath of soap and water. 5. Tub bath of bichloride 1-8000 for twenty minutes. 6. Sponge bath of bichloride 1-2000. 7. Bichloride sponged off with sterile water. 8. Nasal spray of bichloride 1-8000. 9. Mouth cleansed with saturated solution of boric acid. 10. Taken to a clean room and clad in clean clothes. Fumigation and sterilization. (For discussion, see text.) Washable clothing boiled one hour. Mattresses, pillow, heavy blankets, etc., sterilized by steam under pressure. Toys. Always destroy; never attempt to sterilize. Metal objects. Sterilize in 1-20 phenol. Room. Smooth walls, woodwork and floors washed with 1-2000 bi- chloride, then Fumigated with formaldehyde or sulphur. Formaldehyde best. Obtain skilled assistance when possible; otherwise seal room, win- dows and doors with strips of paper glued together by mucilage of tragacanth over cracks. Burn formaldehyde candles or use other generator. Must be burned in presence of moisture (water over alcohol lamp). Sulphur less reliable and more injurious to fabrics. After fumigation. Repaper, repaint and rekalsomine. CHAPTER XVIII DIPHTHERIA SINCE the genius of Jenner made the treatment of Smallpox a rare experience for the general practitioner, no other triumph of medicine is comparable to serum-therapy in Diphtheria. Where four children died before the introduction of diphtheria antitoxin, but one dies to-day and the statistics that show a fall in mortality from 40 per cent, in pre- antitoxin days to 10 per cent, at the present do but scant justice to the efficacy of this treatment, because so much depends on the promptness and mode of administration of antitoxin, that the figures are vitiated by the neglected cases. More recently the method devised by Schick to determine beforehand what individuals are susceptible to diphtheria and the mode of inducing active immunity lessen still further the terrors of this dread disease. While the organism responsible for the disease may be found in a certain per cent, of cases distributed to various organs of the body, the disease can scarcely be called a septicaemia, but essentially a toxemia, the toxins in which are elaborated at the site of the membrane formation in the upper air-passages. Success in treatment depends essentially on an early appreciation of the condition and an early appreciation can be had only by a fidelity to thoroughness in routine procedure. The early symptoms are not distinctive; a malaise, a headache, a chilliness and a sore throat; but the sore throat is often trivial or indeed does not occur and in infants there is little to suggest that the throat is the seat of the trouble. Malaise, a little temperature and a depression and apathy out of proportion to the temperature may be all the child offers to one's observation. The finding of the local lesion comes, then, often enough as a surprise, awarding the routine of examination of the throat. There are two examinations too often overlooked or slurred that should be made in every instance of infection in infancy, unless the lesion is more than obvious and even then, in search of complications; namely, the ear and the throat. Humiliation comes to almost every man who wilfully or inadvertently overlooks these procedures. In the case of the ear not a little skill is needed to see at all or intelli- gently with the older otoscopes, but with the more modern magnifying otoscopes, changes in the ear can be scarcely overlooked. The examina- 444 TREATMENT OF ACUTE INFECTIOUS DISEASES tion of the throat is more commonly made, but is often a meaningless convention, carelessly done. In the infant a little skill in placing the depressor well back on the tongue gives a momentary, but excellent view; but often this is insufficient and a conscientious examination is put off rather than persist with the crying and struggling child. The tonsils, the pillars of the fauces and the pharynx must be seen. Such a routine does nob allow the condition to be overlooked. But there is one other fact on which much emphasis must be laid, namely, that diphtheria may be present when the clinician is quite sure that he is dealing with a follicular tonsillitis and, more, diphtheria may be present when no exudate, membranous or follicular is evident and hence, in any inflammation of the throat in a child, even when only catarrhal, a culture should be made. Again and especially in infants, nasal diphtheria may be present when no membrane is anywhere visible and a persistent nasal discharge, particularly if excortiating or bloody should demand a culture. Finally, a laryngitis, more particularly of a croupy character and certainly if persisting in the daytime should make a culture imperative. The Culture. A tube of fresh culture medium must be ob- tained; the suspected parts thoroughly rubbed with the swab, the surface of the medium thoroughly smeared with the contaminated swab; great care must be taken to bring the swab into contact with no other object in the procedure; the culture submitted to a competent bacteriologist for incubation and diagnosis. The Family. When diphtheria is determined in any one indi- vidual, all the members of his family at once become suspects. The children are to be kept from school and adults who have intimate rela- tions with children, such as teachers, should temporarily interrupt their occupation. A Schick reaction should be done on all members of the family and those who react positively should be given an immunizing dose of serum and measures taken to induce active immunization. Authorities should be informed of the case and inspection of the school or suspected groups of people, who may be the source of infection, should be made. Children should be isolated until cultures can be taken from their throats and a report made on the cultures. Adults in the family should submit to the same procedure. In this way those who are ''car- riers" can be determined and can be kept in isolation until their throats are free from infection. All the children in the family who react to Schick should be immunized with antitoxin, 500 units for the infants and 1,000 units for the older DIPHTHERIA 445 children and adults. All adults in intimate contact with the case who react positively should be immunized. Children, free from infection as proved by negative cultures and with negative Schick, should be removed from the house, if possible, lest they become carriers. It is wise to repeat such cultures at least once. The immunization should be repeated every two weeks in those reacting positively to Schick unless active immunization is practiced. When a Schick reaction cannot be practiced all the children of the household and adults in close contact with the patient should receive immunizing doses, this should be repeated every two weeks in succession. Children found to be infected or to be carriers should be isolated, but never with the sick case, and the isolation of these cases should be separate. The Schick Reaction. This reaction depends upon the fact that if diphtheria toxin is introduced into the skin it causes an irritation in the tissues of that structure, which is easily recognized, unless there is circulating in the blood and tissue juices of the individual inoculated antitoxin, which, neutralizing the toxin, shelters the tissues from its noxious action and thus prevents a reaction. Briefly then a (positive) reaction means absence of antitoxin or in other words susceptibility to diphtheria; an absence of (negative) reaction means the presence of antitoxin or immunity. This important contribution to the warfare upon diphtheria was made by Schick in 1913. The details to follow are derived largely from the publications of the Department of Health of the City of New York. Technique. The material used is a fresh solution of diphtheria toxin containing 1/50 the minimum lethal dose for a 250 gram guinea-pig. This should be contained in 0.2 c.c. of the diluent. How to attain such proportion should be found in instructions accompanying the material furnished; e. g., the Health Department of the City of New York furnishes the toxin in capillary tubes, the contents of which when expelled into 10 c.c. of a normal saline affords such a dilution that 0.2 c.c. of this dilution contains the desired 1/50 M. L. D. (minimum lethal dose.) One tube will answer for many tests and the saline solution will keep 12 hours if kept cool in the ice box. The syringe used should, of course, be graduated to fractions of a c.c. such as a ' 'Record" or a Sub Q. tuberculin syringe, though an ordinary syringe can be used if necessary. A fine steel or platinum iridium needle is selected, a # 26 gauge, 1/4 or 1/2 inch in length is excellent. The flexor surface of the arm chosen and prepared by cleansing with alcohol. The injection must be intradermal, between the layers of the skin, not subcutaneous. To effect this, one sees, a fine needle is required and 446 TREATMENT OF ACUTE INFECTIOUS DISEASES its insertion should be so superficial that one may see the oval opening of the needle through this superficial layer of the skin and the injection fluid should raise a wheal that brings out pitting of the openings of the hair follicles. ., The positive reaction is indicated by a trace of redness at the site of the injection in 12 to 24 hours, distinct in 24 to 48 hours and at its height on the 3rd or 4th day when it presents a circumscribed area of redness with some infiltration one to two centimeters in diameter. This continues for 7 to 14 days. After this it gradually disappears until only a brownish scaling area is left, which persists for 3 to 6 weeks. The negative reaction is determined by failure to respond to the irritating effects of the toxin and, as has been said, means immunity. Repeated tests over a period of years makes it almost certain that this natural immunity in individuals over three years of age is permanent. The susceptibility at various ages to diphtheria as determined by the Schick reaction is shown in the following table published by the New York Department of Health: Age Susceptible Under 3 months 15% 3 to 6 months 30% 6 months to 1 year 60% 1 to 2 years 60% 2 to 3 years 60% 3 to 5 years 40% 5 to 10 years 30% 10 to 20 years 20% Over 20 years 12% The low susceptibility under 6 is attributable to antitoxin from the mother's blood still persistent in that of the infant. The pseudo reaction. Unhappily the determination of a positive reaction is embarrassed by another reaction in the skin provoked not by the diphtheria toxin, but by the protein substance of autolyzed diphtheria bacilli to which a certain number of individuals are anaphy- lactic. It is easy enough to state differences in the true and false reac- tions; but at first, before the eye becomes practiced, the differentiation may present difficulties. The pseudo reaction occurs earlier, in 6 to 18 hours; it make its full development in 36 to 48 hours and disappears on the 3rd or 4th day. It leaves a little brownish discoloration but rarely scales. When at its height it shows a dusky red centre with a secondary areola; it some- what resembles a hive (urticaria). DIPHTHERIA 447 Patients who develop only this false reaction are immune. It has the significance of a negative reaction. Here again we are met with the annoying fact that a patient may react to both the toxin and the protein of the autolyzed bacilli; that is, he may show a combined reaction. This combination of positive and pseudo reaction shows features of both. There is more central redness and more infiltration; the pseudo element fades and leaves the brown, scaling area of the true. Control. One may obtain and use diphtheria toxin heated at 75 C. for 5 minutes to control the Schick reaction. This heating de- stroys the toxin but not the protein products of the autolyzed bacilli. This is diluted in saline and injected, in the same amount and manner as the toxin, in the other arm or far enough away from the site of the other injection to avoid intermingling. A negative reaction to the toxin will also give a negative reaction to the heated toxin. A positive reaction only to the toxin will give a negative reaction to the heated toxin. A pseudo reaction to the toxin will give also a pseudo reaction to the heated toxin and the comparison of the reactions and their course will determine their nature. A combined reaction to the toxin will call out a pseudo reaction to the heated toxin. The difference in character and course of the two reactions will determine their nature. Of course the control may be used after the unheated toxin has given a doubtful reaction. If such controls are not used, any doubtful case should be retested or failing this or being still in doubt, any doubtful reaction should be treated as a true one. One can see at once the great value of the Schick reaction; how readily in hospitals, institutions and schools the immunes and non-immunes can be separated; what a great saving in antitoxin this means; how it leads to preventive treatment of the non-immunes and what a relief it must afford to the family into whose midst diphtheria has been brought. Active Immunization. This, of course, is practiced on those only who give a positive reaction to the Schick test. It is brought about by introducing small amounts of toxin under the skin, which provokes the formation of antitoxin. Diphtheria toxin, however, is so virulent that very small quantities carefully given and cautiously increased, necessitating a considerable period of time in its performance, are alone feasible; but fortunately, it was found that if antitoxin sufficient to neutralize the toxin to the point of not being poisonous was administered with it, this toxin-antitoxin combination 448 TREATMENT OF ACUTE INFECTIOUS DISEASES lost but little of its efficacy in eliciting antitoxin formation by the tissues and as very much more toxin could be used in the combination a great deal more antitoxin was manufactured by the body in a much briefer period. The injection used at any age is about 400 times the fatal dose for a half-grown guinea pig and the amount of antitoxin required to neutralize it is about 4 units. The dose is 1 c.c. of the toxin-antitoxin so prepared, repeated every 7 days for 3 doses. For children under one year, 0.5 c.c. at weekly intervals for 3 doses. The method, a subcutaneous injection into any convenient site, such as the insertion of the deltoid. Reactions. These are usually less marked than after the more com- monly used typhoid vaccine and like the latter consist of more or less redness and swelling at the site of injection with or without a constitu- tional reaction, such as one attributes to a mild infection. It lasts one to three days. Infants as a rule have neither local nor constitutional reactions. Older children and adults suffer the reaction in something less than one-third of the cases. The acquisition and duration of immunity. Antitoxin is slow in its formation. Rarely is the amount protective in less than three weeks and as a rule not until the second month and in some cases dallying along even to the sixth month. Tested three months after the injection nearly 75 per cent, are immune after one injection, 90 per cent, after two and 95 per cent, after three. The Department of Health found that in young infants harboring their mothers' antitoxin the immunizing powers were not as complete, giving 50 per cent, immune only after a year later. The best period for active immunization is 6 months to 5 years. Antitoxin once started by this method seems to keep on forming and 90 per cent, of a small number (100) observed by the Department were immune after 4 years. Active immunization has certainly won a second great battle in our campaign against this disease; for owing to certain factors, seemingly almost impossible to overcome, the results of antitoxin administration had come to an impasse as shown by the unchanging statistics of mor- tality in diphtheria for a number of years past; antitoxin cut the mor- tality more than a half, from about 28 per cent, to a little under 12 per cent., but the neglect of families to call medical assistance until late in the first week, when antitoxin can do but little, or even delay until the patient was moribund or failure to recognize the disease on the part of the physician are all factors contributing to mortality that it seems impossible to correct by mere words of warning. DIPHTHERIA 449 It is easy to see how by determining susceptible individuals by the Schick reaction applied in schools, hospitals, institutions, in communities the seat of an epidemic, and in families invaded, the definite determina- tion of susceptibility brings the weapons of fear and moral obligation to enforce active immunization to prevent spread. It will be seen in dis- cussing carriers how impossible it is to eliminate these from a community and how safety can be found only in a community rendered immune to diphtheria by active immunization. The Schick and immunization to diphtheria should be as compulsory as vaccination against small pox and the results would probably be equally efficacious. If the case cannot be isolated in the home it should be removed to a hospital, if one is accessible. Treated at home one chooses a Room. The choice, preparation and maintenance of the room in a case of diphtheria is the same as in a case of scarlet fever. (See Scarlet Fever, Chap. XVII.) Nurse. Identical instructions should be given and precautions taken as in a case of scarlet fever. (See Scarlet Fever, Chap. XVII.) It is to be remembered, however, that the great danger comes from the secretions of the throat and nose and every precaution must be taken in the treatment of the throat or nose to avoid receiving a cough or sneeze direct in the face. All the secretions should be received on cloths that may be burned. The nurse may use mild sprays and gargles as a precautionary meas- ure, but no astringents. It is to be remembered that the healthy mucous membrane is resistant to invasion by the bacillus, but when abraded, irritated or inflamed becomes the site of infection. A wise measure on the part of the nurse is to submit to a Schick reaction and in case it proves positive to accept an immunizing dose of antitoxin, 1,000 units, repeated at an interval of three weeks. A nurse liable to contact with diphtheria should receive active immu- nization if the Schick reaction indicates it. The bacillus is not air borne and the antiseptic bath and shampoo when the nurse is likely to meet others outside the house is not so im- perative as in the case of scarlet fever, but she should not see children on these occasions nor come into so close contact with others that she might convey bacilli from her own throat, by coughing, sneezing, close conver- sation or kissing. Physician. Such precautions as the physician takes in visiting a scarlet fever case he takes in treating diphtheria. (See Scarlet Fever, Chap. XVII.) He, too, remembers that his danger lies in examining the throat and in the cough he provokes. He may use mild gargles or sprays, 450 TREATMENT OF ACUTE INFECTIOUS DISEASES one-half strength Dobell's solution or saturated solution of boric acid; but if the patient has coughed in his face he should certainly have re- course to an immunizing dose of antitoxin, 1,000 units, if he has not already done so as a matter of precaution^ The physician who in his practice is likely to treat diphtheria should by a Schick reaction determine his susceptibility and in case of a positive reaction fortify himself against infection by active immunization. With the knowledge of the organism, its origin and mode of trans- mission, he finds the antiseptic bath after the case less compelling than in scarlet fever, but is doubly cautious about his mouth and throat and the danger of conveying infection from them, as he may well do in his own family. Precautions in the Sick Room and the temperature of the room are the same as those observed in scarlet fever. (See Scarlet Fever, Chap. XVII.) Bed. (See Chap. IX.) Patient. The patient must be made to go to bed, no matter how light the attack may appear to be, explanations being made to him, or to the parents, of the insidious effects of the disease on the cardio- vascular apparatus and the kidney and the meaning of rest, such only as the bed can afford, to these structures. Bath. A warm sponge bath of soap and water is given each day for cleansing purposes. Nightgown. Such an one as can be easily opened for examina- tion of the heart and lungs without effort to the patient. To the parents or friends the physician must talk frankly of the dangers that any phj r sical effort on the part of the patient entails in terms of cardiac failure. They must understand that this danger is greatest as convalescence approaches. It is the only way in which the insistency of the patient and especially the little patient can be met. The rest, even in the mild cases, must be absolute; the patient re- maining in recumbency, not allowed to turn himself without help, if the case has in any measure been severe and, indeed, in all cases the bed-pan must be insisted on. During the height of the illness only one low pillow should be allowed and another not until the end of two weeks and not even then if he has been very ill or there are any indications of nerve involvements. Diet. There are certain fundamental principles that determine the dietary in all acute febrile diseases. An occasional review of these principles is extremely helpful in doing justice to a field of therapy grossly neglected. (See Diet in Acute Febrile Diseases, Chap. II.) Tissue destruction in acute infections is due to three causes: (1) DIPHTHERIA 451 pyrexia; (2) toxemia; (3) starvation. In diphtheria the first factor is feebly operative, for as a rule there is little fever and in many of the worst cases none at all; but the second factor, the operation of toxins is perhaps more potent than in any of the common infections, while the third factor is enhanced by the difficulty of swallowing in angina. Moreover, it has been shown that tissue destruction continues well beyond the febrile period, as if a late autolysis had occurred in tissue attacked by the toxin earlier in the infection. This tissue destruction both early and late has been lessened or stayed by a sufficiency of diet and considering the important organs attacked by the toxins, heart, kidney, nerve tissue, enough food to meet the daily metabolic demands and furnish material for repair is in this disease especially urgent. The details of such a dietary are to be found under Diet in scarlet fever (see Scarlet Fever, Chap. XVII), and needs no modification for diphtheria. In diphtheria, however, both the angina and pharyngeal paralysis may make the feeding exceedingly difficult. If from pain, regurgitation through the nose and disinclination, the diminution of food intake threatens the strength, the food must be administered by gavage or by rectum. The stomach tube is the best means to effect this end. In the adult one may feed by the tube, milk 500 c.c., sugar 50 grams, and one egg three times a day, or one may fortify this food by adding milk sugar 1 to 2 ounces and cream 1 to 2 ounces or even more, at each feeding. In this way one may get in well over 2,000 calories. In young infants the stomach tube is preferable, but over the age of three years more difficult than the use of a nasal tube. Rectal feeding is not so satisfactory, but when the feeding by the mouth is difficult or impossible may answer in some measure for a brief period. When swallowing is painful an insufficiency of water is ingested and a pint of water twice a day by the rectum or a Murphy drip may supply the needy tissues. A nursing infant affected should be taken from the breast but fed the mother's milk obtained by the use of a pump or by expression and if this is insufficient, the milk of a wet nurse can be used to advantage. Mixed feeding may be cautiously undertaken, but it is a bad time to institute artificial feeding of any kind. Water or diluted fruit juices should be given as freely as the patient wishes and, indeed, should be offered every hour or two, as apathy induces on the part of the patient neglect. ' Mouth, Throat and Nose. The toilet of the mouth, throat and nose is important. It is rather prophylactic than curative. When 452 TREATMENT OF ACUTE INFECTIOUS DISEASES properly carried out, it lessens the probability of mixed infections and extensions. Whatever is done must be done with care and gentleness; for any trauma suffered by the invaded tissues, enhances the spread and severity of the diphtheritic process and invites the invasion by other organisms. The purpose is cleanliness and nothing subserves this .purpose better than physiological salt solution, as spray, or irrigation. DobelFs solution in one-half or one-quarter strength may be used for the same purpose. After taking food the mouth should be rinsed with one or the other of these solutions and the teeth, the spaces between the teeth and the dead spaces in the mouth, cleansed of particles of food by cotton on a tooth-pick as an applicator soaked in these solutions. When there is sordes, the milder applications may well be preceded by half strength hydrogen peroxide. The softened coat on the tongue may be removed in part by scraping with the edge of a whalebone. A dry mouth is relieved by equal parts of 2 per cent, boric acid solu- tion and albolene (liquid petrolatum) to which a little lemon juice has been added; if there is fetor or a foul stomatitis the following prescription is useful: S Phenol (watery solution 1 in 20) Glycerin aa 5i 30 Boric Acid (saturated watery sol.) 5 viii 240 M. Follow this with the milder applications. For the nose use the same mild solutions with the applicator or spray, but avoid the douche. For dried secretions, use a little olive oil on an applicator to soften before using the saline or DobelFs. The genitals are freed from secretions by the use of the same so- lutions. With angina or nasal involvement the above procedures are modified or supplemented. Bowels. Putrefactive processes in the large intestine, enhanced by constipation and possibly by other conditions attendant upon infec- tion will only add to the burden the patient has to carry; hence, attention to the bowel early in the illness is of importance. Calomel and salts may be given to the production of one or two loose movements. Calomel in gr. 1/4 (0.015 Gm.) doses every 15 minutes until 1 or 1 1/4 grains (0.060-0.075 Gm.) are taken work well in the child and may be followed in 2 or 3 hours by a half ounce of milk of magnesia. In young children or adults, salts, Epsom or Rochelle, in doses of i DIPHTHERIA 453 5ss. to i (15-30 Gm.) in a half to three-quarter glass of water are effica- cious or we may give 1 1/2 to 2 grains (0.10-0.120 Gm.) of calomel and follow in about 3 or 4 hours by the above dose of salts. The bowels should be kept open either by the use of an enema or a mild saline water of the type of Hunyadi or Liq. Magnesii Citratis given every other day. Serum Treatment. The success of modern medicine is the re- ward of an effort to discover Nature's method of combating disease. Nowhere has that success been more unqualified than in the* field of serum therapy in its application to diphtheria. The bacillus diphtherise is one of the relatively few organisms which secretes its poison to operate at a distance from the site of its growth and multiplication. This deleterious material is called a toxin. Many more pathogenic organisms exert their toxic effect upon the host by a material so closely associated with their substance that its liberation depends on the destruction or damage of their own structure. These toxins are called endo-toxins. We do not know the chemical nature or intimate structure of the toxins, but we know something of their effects and none are more remarkable than their effect to excite in the tissues of the animal invaded the production of substances that neutralize their toxic action, that is, antitoxins. Invading the tissues of the upper air-passages, the diphtheria bacillus finds a suitable soil for multiplication. Here it secretes its toxin, which operating locally causes inflammation with destruction of tissue, which produces the characteristic membrane and passing into the circulation attacks various tissues, for some of which it has an especial affinity and upon which it exerts its toxic effects peculiarly; such are nervous tissue and those of the heart and kidney. These toxic molecules are believed to consist of a nucleus with certain chemical groups, assumed to be akin to the side chains of a benzol ring. One of these side chains has an affinity for certain side chains in the molecules composing the tissues concerned and effect through these an attachment of the toxin to the cell. This side chain, seizing the cell, as it does, is called a haptophore group. The toxin, too, has another side chain, which thus brought into intimate contact with the cell exerts an injurious effect upon it. This is the toxophore, or poison bearing group. The damage done the cell by this toxophore group, if it does not kill it, stimulates it to reparative processes. The part repaired is the group damaged, that is, the haptophore group of the cell, seized by the hapto- phore group of the toxin. This process of repair is, however, in excess of actual need and the superfluity of haptophore groups of the cell are set free from it into the blood stream and, combining with the toxins not yet 454 TREATMENT OF ACUTE INFECTIOUS DISEASES attached, divert them from the cells. This substance, that is, these haptophores of the cells, are called antitoxin. When the antitoxin has been manufactured in sufficient abundance to neutralize successfully the toxin, the animal is said to have acquired an immunity and this process is one of active immunization, active because the tissues have been physiologically active in the production of their own mechanism of defense. But if the blood of the animal, so cured, or the blood of an animal in whom the same process had been induced by introducing the toxin gradually, that is, giving him the disease by degrees and repeatedly inducing ever increasing degrees of immunity, is drawn off and this antitoxic substance be isolated, it can in turn be injected into another animal and neutralize toxins circulating in his blood or tissue fluids and render him immune; but as this latter animal's tissues have not been actively engaged in the manufacture of this antitoxin injected, he is said to have a passive immunity conferred on him. Diphtheria antitoxin, then, is manufactured by the horse in the process of acquiring an active immunity to the diphtheria toxins in- jected into the tissues in increasing doses. This is withdrawn, sub- mitted to certain processes for isolation and preservation and used in the treatment of diphtheria in man, on whom its injection bestows a passive immunity. Methods of preparation have improved since first this agent was offered to therapy and appreciation of its close relation to certain glob- ulins in the serum has made it possible, by isolating these, to avoid in some measure certain disagreeable results attendant on its usage and has at the same time procured a more concentrated product. Some measure of its activity had of course to be sought, and the unit that has been established is in terms of its power to neutralize toxic doses in definite animals of definite weights. The unit agreed upon is the amount of antitoxin which will just neutralize 100 minimal fatal doses of toxin for a 250-gram guinea-pig. Antitoxin coming from reliable sources is fairly stable, if properly preserved. According to Park if kept cold and not exposed to light and air, it will not deteriorate more than 30 per cent, in a year. It loses some 10 per cent, in two months. Allowance may be made for this in dosage. Dose. We cannot estimate the amount of toxin in a given case and so cannot use it as a measure of the quantity of antitoxin to be used. Our dose is established empirically largely. The dose is not determined by age, except in very young children, under two years, when it is slightly less. Park and Biggs think weight should have some consideration. DIPHTHERIA 455 No amount is known to be injurious in any measure. The limit of the dose is set by the needs of the case and by expense. The dose is modified by two considerations : 1. The severity of the disease. 2. The day of the disease when first seen. The tendency in this country is to be liberal in the dosage. It is a good rule when in doubt whether to give a larger or smaller dose to choose the larger. When Seen Early. In mild cases, that is, in cases of simple con- gestion from which the bacillus has been recovered, or in those with a small patch confined to one tonsil, give 3,000 to 5,000 units. This should be repeated in twelve hours if there is no sign of improve- ment. If better, one may wait for twelve hours longer, repeating the dose if improvement does not continue. A More Severe Case, such as involves both tonsils, requires a larger dose 5,000 to 6,000 units and should be seen again in six hours. If spreading, repeat; if not, wait another six hours. If no signs of im- proving, give the second dose and repeat at six or twelve hour intervals until the improvement is satisfactory. If the process has spread from the tonsils onto the pillars or pharynx give 8,000 units and repeat at six to twelve hour intervals as above. If a pharyngeal case shows (1) decided toxic symptoms or (2), if there are any laryngeal manifestations, such as hoarse cry, stridor or laryngeal cough or (3), if in addition to pharyngeal involvement there is nasal involvement give 10,000 units. In these cases and especially in the laryngeal, the case should be continuously watched, both to be prompt in repeating the dose and to intervene with the intubating tube, if needed. The dose should be repeated every six hours until there is improve- ment and if the spread is increasing one may repeat in four hours. In malignant cases, cases in which the spread is very rapid and the symptoms toxic 15,000 to 20,000 units should be given. If the dose can be given intravenously the result will be best. If the vein cannot be entered, as is the case often in small children, go into the muscles of the buttock, as the wide net-work of veins in the muscle facili- tates absorption. These doses are repeated at four, six or twelve hour intervals and are sometimes carried to total amounts of 60,000 to 100,000 units. Apparently hopeless cases sometimes rally under this large dosage. Both McCollom of Boston and Weaver of Chicago are advocates of these large doses. 456 TREATMENT OF ACUTE INFECTIOUS DISEASES In severe or laryngeal cases under two years the dose is 5,000 to 6,000 units, repeated at six, eight or twelve hour intervals. Cases Seen Late. Every day of delay increases the dangers, both in terms of death and complications, heart, kidney or nerve involve- ments. When antitoxin is administered on the first day the results are most brilliant, the mortality amounting to only a little over 1 per cent, and in some considerable series with no mortality. But on the second day the dangers have increased and the statistics show about 4 per cent, to 5 per cent, and in some series a still higher. The mortality of cases treated on the third day has doubled and tripled over the second, running from 9 per cent, to 13 per cent, and on the next day still higher, 15 per cent., 17 per cent., even 24 per cent, in some series. This means larger doses with each day. Holt has said if the case has been three days ill he should have three times the ordinary dose. The tendency, I think, is toward liberal dosage. Park has pointed out that the "larger the amount injected into the tissues the quicker will a considerable amount be absorbed into the blood and pass into the body fluids. Only a small percentage of what is in the blood passes out of the vessels into the tissue fluids. It is for this reason that, if we would neutralize toxin that has passed from the blood stream, but has not yet united with the tissue cells, very much more must be given than the amount of antitoxin that would be required in a test-tube to neu- tralize the toxin." Moreover it has been shown that the toxin is not a simple body, but that a certain portion, called protoxoid has to be neutralized before the toxin is affected and neutralized and that then there is a portion, called toxon, which is believed to be responsible for the toxic changes in nerve tissue which does not combine with antitoxin until all the toxin molecules are satisfied. It is necessary, then, to give such large doses as may reasonably assure us that this portion, the toxon, shall be neu- tralized. It must be remembered that the body is at the same time manufacturing its own antitoxin which may have increased the richness of antitoxin content of the blood enormously. The following is the dosage advised by the Board of Health of the City of New York and quoted from its circular sent with its diphtheria antitoxin : DIPHTHERIA 457 AMOUNT OF ANTITOXIN REQUIRED IN THE TREATMENT OF A CASE Mild Cases Moderate * Severe * Malignant Infants, 10 to 30 Ibs. in weight (under 2 years of age) ( 2,000 units to [ 3,000 units 3,000 units to 5,000 units 5,000 units to 10,000 units 7,500 units to 10,000 units Children, 30 to 90 Ibs. in weight (under 15 years of age) 3,000 units to 4,000 units 4,000 units to 10,000 units 10,000 units to 15,000 units 10,000 units to 20,000 units Adults, 90 Ibs. and over in weight (3,000 units to 5,000 units 5,000 units to 10,000 units 10,000 units to 20,000 units 20,000 units to 40,000 units * When given intravenously one-half the amounts stated. Cases of laryngeal diphtheria, moderate cases seen late at the time of the first injection, and cases of diphtheria occurring as a complication of the exanthemata should be classified and treated as " severe" cases. It is recommended that the methods of administration be as follows: Mild Cases Subcutaneous or intramuscular. Moderate Cases Intramuscular or subcutaneous. Severe Cases Intramuscular or J^ intravenous and }/% intra- muscular or subcutaneous. Malignant Cases Intravenous or intramuscular. Some point on the surface of the body should be chosen for the in- jection, as where there is an abundance of subcutaneous cellular tissue, the abdomen or intrascapular region. Before the remedy is administered, the skin should be sterilized at the point of injection with tincture of iodine or other disinfectant. The syringe should be thoroughly sterilized, It is better not to employ massage over the point of injection. THE EARLY ADMINISTRATION OF ANTITOXIN The earlier the remedy is administered the more certain and rapid is the effect. In cases of any severity where diphtheria is suspected, and in cases of croup, it is far better to administer the remedy at once, making a culture at the same time, than to delay the treatment until a diagnosis has been made by bacteriologic examination. The first injection should be large enough to control the disease. One large dose given early is far more efficacious than the same amount in divided doses. Severe cases and those in which the administration of antitoxin has been delayed, or cases which are progressive because of an insufficient first dose, should be given a large intravenous injection whenever feasible. In this way the full value of antitoxin is obtained at once, whereas the absorption from 458 TREATMENT OF ACUTE INFECTIOUS DISEASES the subcutaneous injection is so slow that many hours must elapse before any great amount of antitoxin has found its way into the general circula- tion. It must be warmed to the body temperature and given very gradually. Technique. The operator's hands should be cleansed with soap and water and alcohol or 1 to 1000 bichloride. The skin of the patient should be cleansed with soap and water and alcohol, or a good scrubbing with alcohol may answer, or the skin painted with the tincture of iodine. Antitoxin is now put up by a number of reliable firms, sent in con- tainers which are themselves the syringes, with sterile needles accom- panying. This needle may be dropped into alcohol before using, as an extra precaution. If such conveniences are not at hand, a glass syringe or one that, like it, may be subjected to boiling should be used. The needle should be boiled and attached by a short piece of sterile rubber tubing to the syringe. This is intercalated to prevent breaking or bending or wounding other structures if the child struggles. A syringe from which the plunger may be withdrawn is preferable because the serum may more readily be poured into the barrel of the syringe than drawn up through the needle. When this is done the little air must be expelled through the needle before it is used. Site. An excellent one is the loose tissue of the back at the angle of the scapula, into the loose tissue of the abdominal wall or into the buttock or in the nipple line between the nipple and costal margin. This last is a site upon which the patient rarely lies and if a local reaction occurs, local applications are readily made, and if it is desired to give it into the muscle in an urgent case the buttock serves well. I prefer the side of the buttock. As has been said, in profoundly toxic cases an intravenous injection is to be preferred, if possible. (For technique of intravenous injection see Pneumonia, Chap. IX.) Evidences of Improvement. First, a pause in the spread of the membrane; then, in twelve hours to twenty-four hours the mem- brane softens, loosens, recedes, disintegrates. With this the swelling of the mucous membranes diminishes and there is an amelioration of the general condition, a betterment of the pulse, and a lowering of the temperature. In laryngeal cases, the stridor lessens, there is an improvement in the cry or voice and the cough is looser. In nasal cases the breathing is less obstructed and the discharge lessened. Disagreeable or dangerous results of antitoxin administration. Skin rashes are by far the most common, but far less frequent with DIPHTHERIA 459 the use of the refined and concentrated serum than with the old. An erythema may be seen in a few hours, but it soon disappears. After a period of days, seven to fourteen, a rash occurs, either erythematous, that may be mistaken for scarlet fever (the mucous membranes of the mouth and pharynx are not affected, a distinguishing feature from scarlet fever) and which may desquamate; morbiliform, mistaken for measles, or most commonly, urticarial, which may give much annoyance. This eruption is often accompanied by other manifestations of intoxi- cation; a little temperature, swelling of the glands and at times enough joint pains to suggest rheumatism and perhaps a little albuminuria. The whole process and the period intervening between it and the injection suggest a period of incubation of an infectious disease and is attributed to the effects of certain proteins in the serum and their effects on the tissues to the production of toxic substances. It occurs commonly after the first injection and is not to be confounded with that more sudden and explo- sive reaction that may follow an injection repeated ten days or longer after the first injection, the result of a sensitization of the tissues by the first serum introduced, constituting the phenomenon known as anaphy- laxis. The most important part of the treatment of this condition is an explanation of its meaning to the parents or patient who may be alarmed by its manifestations. The pains may be allayed by fomentations applied to the joints or by the use of acetyl salicylic acid (aspirin). The urticaria is best treated by sponges of water containing sodium bicarbonate or bran. Often adrenalin (epinephrin) 1:1000 in doses of five to fifteen minims affords marked relief. It lasts but two or three days. Sudden Deaths. Very rarely sudden deaths or a condition threatening death occurs. It is possible that some of these sudden deaths may be attributed to status lymphaticus; but more commonly they have occurred in people who are asthmatics and of these a con- siderable number are of that type of asthmatics whose attacks are excited by the presence of horses. These people seem to be sensitized to some protein of the horse given off in the secretions or discharges of the animal which are carried a considerable distance through the air. Injection of antitoxin into these people introduces directly the sub- stance to which they are sensitized and an anaphylactic seizure is the result. I saw one attack in a physician, a victim of horse asthma, precipitated by an immunizing dose of antitoxin given by himself. The attack was characteristic of its kind and copied the reaction in the animal exactly. 460 TREATMENT OF ACUTE INFECTIOUS DISEASES The reaction was immediate, before the needle was withdrawn. He was seized with most urgent dyspnoea, intense cyanosis and prostration. His lungs were filled to the utmost and he was incapable of expelling air from his chest. He was relieved only by having his chest encircled by the arms of his attendant and compressed until air was expelled that might be replaced. So great was this distension that acute emphysema ensued with rupture of the air into the mediastinum and fascial planes of the neck. Atropine and morphine and adrenalin were liberally administered. Cupping also afforded some relief. Asthmatics should receive the antitoxin with great precaution. For the determination of sensitization and the method of disensitiza- tion see Pneumonia (Chap. IX). In sensitized patients Park recommends a concentrated antitoxin, calling attention to the fact that antitoxin can now be procured with the value of 3000 units to 1 c.c. Give of this 0.2 c.c. If no bad results ensue give in an hour another 0.2 c.c. and in another hour 0.4 c.c. and repeat this amount at hourly intervals until the desired dose is attained. Immunizing Dose. The immunizing dose touched upon should be 500 units in infants and 1000 in older children and adults. The effect lasts but a short time. Park says that at the end of five days 90 per cent, has been eliminated and at the end of two weeks 99 per cent. Hence, in the presence of continued danger a second dose should be given at the end of a week and certainly at the end of two. Park also advises the use of human serum, which can be obtained containing 50 units to 1 c.c. for immunizing asthmatics. Laryngeal Diphtheria. The gravity of this condition and its frequency, for it is said to occur in 40 per cent, of children attacked under three years, make it imperative to appreciate its earliest mani- festation. While it is true that a catarrhal laryngitis may occur in pharyngeal diphtheria, such an assumption should not modify our procedure in the least. When any laryngeal symptoms occur in the course of a pharyngeal diphtheria, it is to be treated as such and treated promptly. When, however, the laryngeal diphtheria is primary, the differentiation from catarrhal laryngitis and spasmodic croup is not so easy. If the child has been exposed, the assumption should be that the case is diphtheritic and one should not wait upon the return from the culture. When there has been no exposure, however, one has to obtain a culture and study the course of the disease. A positive culture, of course, settles the matter, but a negative culture DIPHTHERIA 461 does not exclude it, as some 40 per cent, of the cases coming to operation and studied by McCollom were negative. Spasmodic croup is usually at its worst at night and with the morning finds a decided amelioration or cessation of the spasm, but when the spasm continues into the succeeding day or dyspnoea comes on, that is, the lesion shows progression, the condition should be assumed to be diphtheritic, on the symptoms alone. The symptoms are. in the beginning, hoarseness of the voice and cough, which takes on a metallic character. This is in the catarrhal or earliest stage. Soon true croup begins, characterized by spasm of the larynx with stridor and dyspnoea but with remissions. It is due to the same irritative causes as spasmodic croup. This is the second stage. Follow- ing this comes the evidences of continuously increasing obstruction with dyspnoea, cyanosis, restlessness, prostration, feeble pulse, a rising tem- perature and stupor. No such clear cut stages are to be anticipated, however, in each case. The stridor is of a peculiar, hissing or sawing character which con- tinues throughout inspiration and expiration. The important symptoms are hoarseness, metallic or croupy cough, restlessness, prostration, increasing dyspnoea taking on a sawing char- acter. McCollom adds one other symptom upon which he lays great diag- nostic stress, namely, a rigidity of the sterno-cleido-mastoid muscles, which he says is always present and even early, both in adult and chil- dren. Antitoxin should be given, as noted above, at the earliest moment and in large doses, 10,000 units and repeated in six hour intervals, if there is spread and in six or twelve hour intervals until decided improve- ment is seen. Intravenous administration is always to be preferred. In young children the condition may prove fatal in thirty-six to forty- eight hours. One sees, then, how urgent the early administration is. Before antitoxin treatment 90 per cent, of these cases came to opera- tion; since the introduction of the serum, 40 per cent. Other Treatment. Besides antitoxin nothing has more than a palliative effect and one should not allow any measure undertaken to delay the administration of antitoxin an instant. Steam. Inhalation of steam seems to relieve the spasm to some extent, though of course not the obstruction. The best way to administer it is with the croup kettle or two or three croup kettles directing their steam as close to the child's head as is safe. A tent may be made by putting a sheet over the upper third of the bed, so 462 TREATMENT OF ACUTE INFECTIOUS DISEASES that the body will not be bathed in the steam or one may lash an open umbrella to the head of the bed and pass a sheet over this or put a clothes-horse around the head of the bed and drape a sheet over this. This should not be kept up for long periods, as the heat is depressing. The steam lessens the spasms and is said to facilitate the discharge of secretions. Hot fomentations to the throat have been advised and some authors say relief is sometimes afforded by the ice-bag applied to the neck. INTUBATION BY MINER C. HILL, M. D. Procedure. 1. Select intubation tube of suitable size for age of child, according to scale, and be sure that braided silk thread is attached. 2. When tube is on the obturator the broad flange of the head should point away from the instrument. The silk thread is then to the opera- tor's right. 3. Assistant wraps child in a mummy sheet and places some padding under the neck or holds the patient's head over edge of table. Mouth gag is inserted in left side of mouth. 4. Operator takes his position on right side of patient, inserts left index finger along tongue, parallel with median line, until tip of finger locates epiglottis pulling it forward. 5. Handle of intubator is held in right hand close to the patient's chest with one finger through loop of thread and thumb upon the re- leasing knob. nfau 6. The tube is then advanced along midline of tongue parallel to left index finger until epiglottis is reached. 7. As the tube engages the larynx the handle of intubator is raised and the tube is quickly, but without force, inserted into the larynx. Any undue force is liable to cause a false passage. 8. Tip of left index finger holds tube in place while releasing knob is pushed forward and obturator is withdrawn. 9. When tube is felt securely in place tip of left index finger is again placed upon head of tube while loop of silk is cut and withdrawn. 10. A tracheotomy set should always be in readiness in case intu- bation is unsuccessful. A successful intubation is made evident by a characteristic expiratory cough and inspiratory whistling sound and the patient's attitude changes from one of horrible restlessness and fighting for air to one of peaceful quiet and a desire to sleep. DIPHTHERIA 463 The patient should be watched intently after intubation. Occasionally the tube is coughed up and with it a membranous cast of the larynx and reintubation may not again be necessary. If the tube is coughed up and dyspnoea returns, intubation must be repeated using the same tube and not one of next larger size, for fear of causing pressure necrosis of the cricoid cartilage. Indications for Intubation. Laryngeal diphtheria is diagnosed by croupy cough, stridor, 'interference with voice production, increas- ing dyspnoea and cyanosis. No signs of pharyngeal or nasal involvement need be present. When the dyspnoea has so far progressed that there is retraction of the episternal notch and supra clavicular regions and a pulse that disappears with each inspiration, intubation is indicated. If one wait until there is cyanosis the exhaustion will be so great that the chances of successful intubation are greatly diminished. Post-intubation Treatment. Our first apprehension after intuba- tion is the danger of expulsion of the tube during a fit of coughing and constant watching is necessary. If the cough is troublesome, the croup kettle and the use of antipyrin or small doses of codeine may give relief. The next difficulty is the feeding of these cases. At first it is often difficult for the patient to swallow, particularly liquids. Milk toast, thick cereals, custards and ice cream are preferable to liquid food. To facilitate swallowing the patient may be fed while reclining with the head lower than the body (Casselberry Method). When even this method fails, gavage or rectal feeding may be employed. EXTUBATION When the temperature subsides, usually about the fourth day, it is safe to see if the child can do without the tube. The sooner the tube can be removed the less danger there is of pressure injury to the larynx. Procedure. 1. Have near at hand an introducing instrument with a tube of the same size as the one to be removed. 2. Wrap child in a mummy sheet to prevent struggling, and insert mouth gag. 3. Place tip of left index finger upon head of tube and left thumb against cricoid cartilage externally. 4. Introduce extractor, parallel to median line of tongue, guided by left index finger until one is sure that tip is within lumen of tube. 5. Raise handle until it touches the upper incisor teeth, then the jaw of the extractor will pass well within the lumen of the tube. Now press the lever on handle and, reversing the motions used in intubation, remove the tube. 464 TREATMENT OF ACUTE INFECTIOUS DISEASES The secret of successful intubation or extubation is in keeping the instruments, throughout the whole manipulation, parallel with the median line of the tongue. Auto-extubation. May occur early or late in the disease. When it occurs early, on third or fourth day, the patient has usually sufficiently recovered to be able to go without the tube. When it occurs later, from tenth day to third or fourth week, it is usually persistent and tube may be coughed out as many as thirty times in twenty-four hours. This persistent coughing up of the tube is due to a perichondritis at the cricoid level and therefore the tube can no longer be held in place by the retention swell for the firm cartilaginous larynx at the cricoid level is converted into a collapsible tube. This condition occurs in from 3 to 5 per cent, of intubation cases. The treatment of these cases is by a bul- bous tracheal tube which is longer than the O'Dwyer tube and reaches well down into the trachea. These tubes will practically put a stop to auto-extubation. Tracheotomy. For this procedure one should have recourse to surgical text-books. DIFFERENTIAL DIAGNOSIS Spasmodic Croup. Sudden onset and sudden subsidence. No aphonia. No progressive dyspnoea but a succession of attacks during the acute stage with marked improvement during the intervals. Retropharyngeal Abscess. Absence of aphonia but there is a muffled voice with a throaty stridor.. Dyspnoea is greater when mouth is open. Head is held thrown back. Digital examination reveals a fluctuating mass on posterior wall of pharynx. Foreign Bodies. Onset is very sudden, there is a paroxysmal cough and violent dyspnoea. If the foreign body is not coughed out but becomes impacted death may rapidly follow from occlusion of the glottis. Bronchopneumonia. When the pneumonia is bilaterial in chil- dren, there may be marked retreaction of the chest and sinking in of the epigastrium. There is absence of a croupy cough and the different character of the dyspnoea together with the physical signs in the chest clears the diagnosis. Subglottic Edema. May give rise to the same symptoms as laryngeal diphtheria and an examination of the larynx is necessary to differentiate. Phlegmon of Glottis. No croupy cough or aphonia. Examination shows marked inflammatory swelling of epiglottis and arytenoid region. DIPHTHERIA 465 Nervous Diseases. In certain acute infections as poliomyelitis, superior basilar meningitis, encephalitis and cerebellar abscesses there may be laryngeal symptoms due to irritation of the basal ganglia. Dr. H. L. Lynah has reported two interesting cases, one, a case of cerebellar abscess where the respiration simulated that of laryngeal obstruction. Evacuation of the abscess relieved the respiratory condition. Another, diagnosed as laryngeal diphtheria, proved at autopsy to be an encepha- litis with an enormous increase of fluid in the ventricular spaces. Recurrent Laryngeal Nerve Paralysis due to mediastinal tumors simulates laryngeal diphtheria but is differentiated by laryngoscopic examination. In this condition the obstruction is below the larynx and there is no loss of laryngeal function. The expiratory dyspnoea is greater than the inspiratory and percussion, X-ray and course will clear the diagnosis. TREATMENT OF SYMPTOMS Fever. A high temperature is not characteristic of the disease; on the contrary, the temperature is relatively low. Treatment for it, as such, is not indicated and antipyretics are absolutely contraindicated on account of their depressant effect on the circulation. Sponge baths, luke warm or cool so far as they increase the patient's comfort may be given. Angina. In many cases there may be very little discomfort in the throat, again the throat and mouth may be extensively involved, with much fetor, while with the invasion of other organisms, the in- flammatory reaction and discomfort may be much increased. External Applications. Cold or heat applied to the neck, pref- erably the former, afford relief. Cold may be so applied in the shape of the ice-bag, the coil or compresses. Heat. If heat is found the more grateful, it may be afforded by the use of hot fomentations. Applications to the Throat. It must be remembered that no applications that can be made will kill the organisms concerned and the best we can do is to make such applications as preserve the maximum amount of cleanliness of the part and so lessen the likelihood of spreading, of inviting the invasion of other bacteria or of permitting decomposition and putrefaction. We must remember, however, that these very efforts, unless judi- ciously carried out may do damage to the invaded tissues and hasten the very processes they were designed to prevent. Applications are made by the gargle, spray, irrigation or swab. A gargle is painful and does not reach the parts most affected and serves 466 TREATMENT OF ACUTE INFECTIOUS DISEASES for little better than a mouth wash. The spray is a better method, but by all odds the best is the irrigation. The best irrigating fluids are those blandest to the inflamed mucous membranes, such as sodium chloride in physiological solution (one dram to the pint) or 2 per cent, boric acid solution or Dobell's solution diluted two to four times. It should be as hot as the patient can comfortably stand it, 100 F. in a child, 110 F. to 115 F. in an adult. A fountain syringe or irrigator is held above the head at a height sufficient to give free movement to the stream, but not force; a nozzle of hard rubber or metal, or in older children a catheter may be used. The patient, unless the case is of the mildest, should not sit up in bed, lest cardiac failure should occur, but lying on the side at the edge of the bed, with a towel about the neck and a pus-basin or other receptacle under the chin to catch the fluid. In older patients the tongue may be depressed by a wooden or glass depressor or the nozzle may be inserted between the molars and the stream directed in various directions. One should use from a pint to a quart or more. If the mouth is foul they may be given every two or three hours, in less severe cases three times a day. If there is a great deal of mucus, the throat may receive a preliminary spraying with a solution of sodium bicarbonate gr. xx to the ounce (1.30 Gm.-30 c.c.), the membranes gently touched with half strength solution of hydrogen dioxide and then the irrigations be given. Sprays of the same substances as the irrigations may be given as often as they afford comfort. No measures that cause pain should be persisted in. Many authors are impressed with the cleanly appearance afforded by applications of Loffler's solution. (For formula see Scarlet Fever, Chap. XVII.) It should be applied with a swab on an applicator and held pressed against the membrane not swabbed around. This may be made two or three times a day. Cracked ice held in the mouth gives much relief at times. The pain of swallowing when great may be alleviated by the appli- cation of 1 per cent, to 2 per cent, cocaine. In very foul mouths 1 to 2000 permanganate of potash may be used as an irrigation before using the saline. Nose. Most authorities are in agreement that in nasal diph- theria, irrigations are indicated. McCollom, however, deprecates the procedure, because he is convinced that the number of middle ear cases increase under it. It would seem, however, that in the great danger attending these cases, with involvement of the rapidly absorbing naso-pharynx that DIPHTHERIA 467 some means of cleansing the area involved were necessary and that irrigation was the only efficacious means. The same solutions may be used as in the throat, namely, warm physiological salt solution, 2 per cent, boric acid solution or DobelPs diluted one to four times. A fountain syringe, held at such a height as to just force the solution through in a gentle stream and a glass nozzle or a small rubber catheter, with holes cut in the side are used. It should be done as often as every two hours in severe cases with profuse excoriating discharges, less often in the milder cases. If a fountain syringe is not at hand or difficulty is experienced in its use, a piston syringe may be substituted. The patient should keep the mouth open during the procedure and the irrigation should be directed first to the side most obstructed, so that a damming up behind the obstruction will not force the fluid back into the Eustachian tube. If irrigation is objected to, applications gently made with a swab and sprays must take its place. Calomel may be insufflated. Where there is much hemorrhage from the nose, adrenalin in dilution of 1 to 2000 to 3000 may be used ; in some cases dry packing of the nares is necessary or if that fails the gauze used for packing may be saturated with adrenalin, l.to 3000. Thromboplastin and Kephalin contain thromboplastin from brain tissue which is a coagulant. They may be applied locally to the bleeding point on cotton or gauze and left in situ for 5 to 10 minutes. Coagulen is a preparation from blood platelets put up as dry powder. A 10 per cent, solution of this is applied to the bleeding vessel on cotton or gauze. Care must be used in removing the application lest the blood clot formed be loosened. This may be eliminated by not allowing the cotton to dry and leaving some of the solution in situ. Hemostatic serum (hemoplastin) may be applied on gauze or cotton packing. If it does not stop the bleeding after 5 to 10 minutes, 1/2 to 2 c.c. of the clear solution may be injected locally at the site of the hemorrhage. Cardio-Vascular Apparatus. The prophylactic treatment of circulatory failure lies in the promptness and thoroughness of the serum treatment. No complication in diphtheria, excepting laryngeal involvement and its sequelae, is so grave as that which includes the circulatory ap- paratus. One may distinguish an early and a late form of circulatory dis- turbance. The early form manifests the same evidences of circulatory 468 TREATMENT OF ACUTE INFECTIOUS DISEASES inefficiency as one sees in any other acute infection and is in the main due to the same cause, namely, a vaso-motor failure, referable particularly to the vaso-motor center. However, it must be said that such experi- mental evidence as we have points to a greater implication of the cardiac muscle in diphtheria than in the case of the other acute infections; but still, it is the vaso-motor center that has to be chiefly considered in this disease too. What has been said about the cardio-vascular apparatus in discussing scarlet fever (see Chap. XVII), is applicable in all details both with reference to its etiology, its symptomatology and its treatment here, and the reader may consider that discussion as referred to this subject. These circulatory disturbances may come on at any time in the first two weeks, depending on the severity of the infection, but at the end of the second week up to the fourth week, seldom later there occurs a Late circulatory failure, which has been attributed to degen- erative changes in the heart, especially its nervous mechanism and has been spoken of as pneumogastric paralysis. It comes in convalescence, at a time when other nerve degenerations are made manifest. It is a most serious condition, often abrupt, usually first appreciated by an attack of vomiting. This becomes repeated, is accompanied by precordial distress, epigastric pain and tenderness, dyspnoea, great restlessness, sometimes a clear mind, sometimes marked cerebral disturb- ance, syncopal attacks, pallor, sweating, very feeble pulse, strikingly slow, though sometimes rapid, and death. Sometimes the first premonition is given by a sudden change of the pulse rate to a considerably higher or slower rate. Occasionally one encounters such functional disturbances as auricular fibrillation and heart block. The latter may be attributable to degenera- tive changes in the bundle of His though this is not always demon- strated at autopsy. One of the most ominous facts about the heart of diphtheria is the tendency to sudden syncope and death and coming out of a clear sky, without a particle of warning in many cases, even when assiduously watched for. Nearly every writer of note frankly admits his inability to give a reasonable explanation for this appalling accident. There may be lesser manifestations with very slow and irregular heart as the major evidence of disturbance and recovery take place, but one is never sure of the result and faces the possibility of a turn for the worse or a sudden issue. The early and characteristic vomiting, the cerebral disturbance, the vaso-motor implication, the association with other paralyses and its DIPHTHERIA 469 time of onset has suggested the sudden death as a manifestation of cerebral degeneration rather than essentially cardiac. But that there is a toxic effect wrought on the myocordium not evidenced by histological findings or by the character of the histological changes found is shown by the sudden failure of the organ when neither sign nor symptoms are evidenced and the child has begun to resume normal activities. Diphtheria is another disease in which toxic arteriosclerosis occurs as is shown by slight increase in blood pressure and increase in second aortic sound and thickened palpable arteries. This is likely to disappear after a few weeks. Furthermore aortitis occurring after diphtheria has been often noted. It is said to be a necrosis confined to the media. The treatment begins with efficient and prompt serum administration at the earliest moment of diagnosis; it continues by great care to avoid even slight physical exertion during and well into convalescence in all cases, even the mild, but especially those that have been very toxic and when there have followed nerve paralyses, or there is evidence of kidney involvement. Therefore daily examinations should lay stress on the deviation from the normal heart rate, high or low, muffling or splitting of heart sounds, irregularity of the pulse and least of all murmurs; upon subjective sensations such as dypsncea, precordial distress, gastric nausea or vomiting, syncope or even pallor. It must be further emphasized that the later the minor cardiac disturbances such as changes in rate, rhythm or sound occur, the more serious is the cardiac complication. It should be further emphasized that the subjective disturbances noted above are even more ominous than the objective. The condition is most dire and sudden death threatens with the least exertion, such, for example, as is induced by vomiting or sitting up in bed, or mental excitement. For this reason absolute rest is imperative and nothing will do so much to secure and relieve the distress and pain and anxiety as morphine sulphate, hypodermically, every four hours if needed, in such doses as to effect the purpose; e. g., gr. 1/48 (0.0015 Gm.) in the child of two years, gr. 1/24 (0.002 Gm.) to gr. 1/16 (0.004 Gm.) at six and gr. 1/12 (0.005 Gm.) or gr. 1/8 (0.008 Gm.) at twelve years. With late cardiac manifestations food must be cut down in quantity especially at any one feeding; less food given at more frequent intervals. This applies when no gastric symptoms have occurred. On the appear- ance of gastric disturbance, food by the mouth must be stopped as the vomiting makes its retention impossible and is perhaps aggravated by it. Such nourishment as is given must be by the rectum. Procedures of all kinds, about the mouth, nose, etc., must be decreased to a minimum. 470 TREATMENT OF ACUTE INFECTIOUS DISEASES As nutrient enemata one may use the following : Nutrient Enemata. 200 c.c. peptonized milk . 140 calories 2 eggs 120 " Physiological saline solution 500 c.c. Introduce by Murphy drip. (Bloodgood.) or 500 c.c. milk 45 Gm. lactose. 600 to 650 calories 30 c.c. whiskey or brandy Add salt 3i to 500 c.c Give slowly as above. Heat over the precordium may allay pain and distress to some degree. There is no unanimity of opinion about drug administration in this condition. I believe, however, that those drugs that we use in circulatory failure earlier in the disease and hi other acute infectious diseases should be used here; caffeine, camphor, strychnine, which affect the medullary centers, adrenalin (epinephrin) and digitalis. If we accept the theory of pneumo- gastric degeneration in this condition and fear the effect of digitalis on this structure, we may administer atropine with the digitalis, to eliminate the vagus influence, giving gr. 1/100 (0.0006 Gm.) of the sulphate with each dose of the digitalis. Of the vaso-motor stimulants I have said my favorites are caffeine and camphor. The rationale of caffeine is discussed under scarlet fever. (See Chap. XVII.) It may be used hypodermically as the double salt of sodium salicylate or sodium benzoate and caffeine. For a child of 5 years the dose is 1/2 to 1 grain (0.030-0.060 Gm.) ; at 11 years 1-2 grains (0.060-0.120 Gm.); adult 5 grains (0.33 Gm.). Camphor, while it has little obvious effect on either a normal heart or vaso-motor center, has been demonstrated experimentally to produce a stimulating effect on both when they have been depressed by poisons. Upon the heart it seems to have a marked effect on the function of irritability. Its mode of administration in circulatory failure and its results are found under scarlet fever. (See Chap. XVII.) It is best given in olive oil or sesame oil hypodermically. The dose at 5 years is 1/2 to 1 grain (0.030-0.060 Gm.); at 11 years 1-2 grains (0.060-0.120 Gm.); adults 3 grains (0.2 Gm.). Strychnine : The dose of the sulphate is at 5 years gr. 1/200-1/100 (0.0003-0.0006 Gm.); at 11 years gr. 1/100-1/80 (0.0006-0.00075 Gm.); adults gr. 1/60-1/30 (0.001-0.002 Gm.). An enteroclysis of hot salt solution 3i to Oi (4 Gm. to 500 c.c.) may be DIPHTHERIA 471 of great value in collapse or on the occasion of syncopal attacks. It should be given with a rectal tube, to which is attached a Y tube, one branch of the Y being attached to a rubber tube to carry off the water, while the other is attached to the syringe. By pinching the discharge tube the amount in the bowel and its discharge can be regulated. This apparatus can be utilized with little disturbance to the patient, a matter of the greatest importance during the attack. The hot saline raises the body heat which is subnormal as a rule and by direct contact with the mucous membrane over a considerable area affords a powerful stimulant to the peripheral vaso-motor supply of the splanchnics; thus raising blood pressure effectually. A cup of hot coffee may well be added to the saline. The temperature of the fluid should be 110 F. to 115 F. A saline injected into the tissues, at a temperature of 100 F., that is, a hypodermoclysis, is another excellent stimulant. Cold Air. The splendid effect of cold air upon the circulatory system obtains in this disease as well as in other acute infections. (See Open Air Treatment of Pneumonia, Chap. IX.) It must be mentioned that most of the authors advise the use of alcohol as a stimulant, Sss. to $i a day in divided doses in children and more in adults as a cardiac stimulant and as having some beneficial effect on the toxemia. I am opposed to this teaching, both because it seems irrational to add day after day to the nerve tissues undergoing the degenerative effects of the toxin a substance which is itself capable of inducing a similar process and because I do not believe it is a true stimulant. That it has some food value cannot be denied, but that it has advan- tages Over the other class of foodstuffs in this condition is more than questionable. Paralyses. Upon the nerve structures the poison of this dis- ease has a selective action. Nearly all the nerves are susceptible to its action, but some more than others. The results are rather partial disability, paresis, than total paralysis and the continuance of this disability is brief. The importance of the lesion lies in the vital significance of the nerve structure affected, such as the medullary centers or the vagus nerve. The preventive treatment depends on the promptness with which antitoxin is administered, for once the toxin is in combination with the nerve tissue there is no known way of ousting it and antitoxin is believed to be ineffectual in achieving such a desideratum. It depends, too, on the sufficiency of the early doses, for it seems as if the neurotoxic substance was that portion of the toxin designated 472 TREATMENT OF ACUTE INFECTIOUS DISEASES the toxon, which has a less avidity for the antitoxin than the rest of the toxin particle and hence is not neutralized until the rest is satisfied. Another preventive measure, preventive rather of the disaster than of actual nerve involvement, is to assume that the nerve may be affected and insist on absolute rest and recumbency in all but the very mildest cases and even in these to realize that risk is not eliminated. The effects of the toxin on the nerve structures are not evident until it has time to produce a certain degree of degeneration, so that the clinical evidences of paralysis are not as a rule manifest until the end of two weeks. The likelihood of its occurrence is increased in proportion to the severity of the disease. The earliest evidences are seen in the palate and the heart; hence, the insistency on rest and recumbency when the patient is seemingly entered upon convalescence. The plain facts of the dangers and risks in a case at this time must be told the parents or the patient if an adult or older child. It is more common in young children, but in pure laryngeal cases is relatively rare. The incidence of the complications is set at figures that range from 11 per cent, to 40 per cent. Heart involvement has just been discussed. Soft Palate. This is the most frequent of the paralyses. It is important, too, because of the difficulty of feeding in decided cases, as the food will regurgitate through the nose. This entails feeding by gavage,. through the stomach tube, which may be more readily accomplished in the adult or through the nose in a child. This manner of feeding will not be continued long, because of the brief period of paresis. Pharynx. When the pharyngeal nerves are affected, swallowing is rendered difficult and choking may ensue. Here again, the feeding by the tube is indicated. Respiratory Muscles. Either set, intercostals or diaphragm or both, may be involved. Everything to lessen respiratory effort, such as weight of clothes or doubled up position should be avoided. Not infrequently, affection of the pharyngeal muscles and larynx occur simultaneously. Secretions collect in the bronchi or food particles gain entrance and quantities of secretions gather in the pharynx. The cough is ineffectual to expel these secretions and foreign body pneumonia threatens. The foot of the bed should be raised a trifle, but not enough for the pressure of the abdominal viscera on the diaphragm to further embarrass respiration. The secretions from the pharynx may be as- DIPHTHERIA 473 pirated off with a small rubber tube and a syringe and the swab of cotton on a dressing forceps or other form of applicator may be used. Atropine sulphate gr. 1/100 (0.0006 Gm.) three or four times a day may lessen the secretions. Occasional compression of the chest may help to expel the bronchial contents. The other forms of paralysis, such as the oculo-motor, the facial and that of the extremities (the upper are very rare) need no especial treatment, considering the natural progress of events. The only drug that it seems rational to administer is strychnine, in doses of gr. 1/400 (0.00015 Gm.) to gr. 1/150 (0.00045 Gm.) at two years, and gr. 1/100 (0.0006 Gm.) to gr. 1/40 (0.0015 Gm.) at twelve yeais three or four times a day. Nephritis. There seems to be a considerable difference of opin- ion about the frequency of nephritis in diphtheria and its clinical im- portance. There is, as in every acute infection, a trace of albumin that is ref- erable to the acute degeneration of the epithelium of the tubules and tufts; but there may also be an acute diffuse nephritis, with no con- stancy of lesion, that is the glomerular changes may predominate in one and the interstitial in another. There seems, however, to be a good deal of tubular involvement as a rule with an abundant albuminuria. Dropsy is rare and uraemia not common. In severe cases anuria may prove fatal. Serious kidney complications come on earlier in diphtheria than in scarlet fever, are less serious both during the disease and later. The urine should be examined daily. The treatment again begins with early and effective serum therapy. When developed, however, it is to be treated like the nephritis of scarlet fever (see Scarlet Fever, Chap. XVII), but hot packs are less well borne as, indeed, are any measures that entail much manipulation with conse- quent strain upon the heart. OTHER COMPLICATIONS Bronchopneumonia. This complication is to be particularly dreaded in the laryngeal cases which come to operation. It is to be treated like any bronchopneumonia. (See Pneumonia and Streptococcus Pneumonia, Chaps. IX and X.) Adenitis may occur in severe angina and in mixed infections. It is treated with the application of ice and incision as soon as fluctua- tion is detected. Otitis is said to occur in 4 per cent, of the cases. It may be followed by mastoiditis, sinus involvement or cerebral invasion. (For treatment, see Otitis in Scarlet Fever, Chap. XVII.) 474 TREATMENT OF ACUTE INFECTIOUS DISEASES Convalescence. In no other disease must the convalescence be handled with more care and discretion. The dangers of cardiac failure, even when there have been no clinical evidences of the involvement of that organ and even in mild cases make it imperative to explain the situation fully to the patient or in the case of children to the parents. If the case has been mild the patient may be propped up in bed at the end of the third week and sit up in bed at the end of the fourth and a little later be put in a chair and then allowed to walk in a few days. All this time, the effect on the circulation must be watched. Some authors make it a rule in mild cases to allow the patient out of bed a week after the throat has cleared up, especially applying the rule to adults or those in whom the tonsil alone has been mildly affected. All, however, are in agreement that in severe cases the patient should remain in bed six or eight weeks and in no case be allowed up as long as there are signs of heart involvement. When the patient is up good food and good air are of prime importance. For the anemia that in some degree is sure to have followed iron may be used. Blaud's pill, made fresh, or the Vallet's mass in doses of gr. iii to gr. v (0.20-0.30 Gm.) three times a- day. Strychnine Sulphate in doses of gr. 1/200 (0.0003 Gm.) to a child of five years and gr. 1/40 to gr. 1/30 (0.0015-0.002 Gm.) to an adult three times a day. Quinine in doses of gr. 1 (0.060 Gm.) three times a day have been credited with tonic properties. It can be combined with the strych- nine. In children Cod Liver Oil, in doses of 1/2 to 1 dram (2-4 c.c.) three times a day is given for the same purpose. Release from Quarantine. A patient should not be released from quarantine until two successive cultures taken from the sites of the lesion are negative. Three are safer at three-day intervals and an effort should be made to get material from the crypts of the tonsils by gentle expression of their contents with a spatula. Cultures should also be taken from the naso-pharynx and nose. In the larger number this occurs in a week after the throat is cleared from membrane, but it may be three, four, five or more weeks before the cultures are returned negative. When the bacteria are persistent an effort may be made to rid the throat or nose of them by a spray, irrigation or application of an anti- septic. Holt advises bichloride 1 to 10,000 mixed with glycerin one part in eight. This is rarely successful. See Carriers. If the organisms are not to be gotten rid of by such means, the cultures should be tested for their virulency. DIPHTHERIA 475 On release from quarantine the patient should be given a bath with warm water and soap and a shampoo with the same. This should be followed by a bath of 1 to 5000 bichloride of mercury. Sterilization and Fumigation. For discussion of terminal fumi- gation, see Scarlet Fever, Chap. XVII. The disinfection is to be car- ried out as in a case after scarlet fever: the washable clothing and linen should be boiled for an hour after soaking over night in carbolic 1 to 50 to 1 to 20. Mattresses, blankets, pillows and unwashable clothes may b.e subjected to steam under pressure. If not obtainable, submitted to formaldehyde gas. Articles of no value and all toys should be burned or destroyed. Articles made of metal or china ware may be immersed in 1 to 20 carbolic acid. All the woodwork, the floor, the ceiling and walls should be rubbed down with cloths wet in 1 to 2000 bichloride of mercury. The room should then be fumigated with formaldehyde gas. The room must be sealed with strips of paper pasted over cracks and holes and the gas generated from one of the numerous devices on the market, such as paraldehyde candles and left closed twelve to twenty-four hours. McCollom recommends the method of the Maine State Board of Health. This consists in putting potassium permanganate (commercial) in a pan or other receptacle and pouring over it formalin (40 per cent.). It is used in the proportions of 6 1/2 ounces of the permanganate to 1 pint of formalin. This quantity will fumigate 500 cubic feet of space. The room should then be repainted, repapered and recalcimined. In case of death, the funeral should be private, the body wrapped in strong antiseptics and the coffin sealed. Carriers. The detection, disposal and treatment of carriers con- stitute the most serious problem in combating the disease. It is the carriers that perpetuate the disease and they constitute such a con- siderable number of the community, often entirely unsuspected either by themselves or others, that their elimination can be achieved only by stamping out the disease through rendering a community immune. The examination of the upper ah* passages of large numbers of the civil population lead us to the conclusion that about 1 per cent, are carriers; so far as it can be determined one-half of these have had no contact with cases of diphtheria. Happily, not all these carriers harbor virulent organisms. The per- centage of virulent organisms depends on previous contact with the disease. Wadsworth found that carriers who had had the disease yielded 90 per cent, of virulent organisms from the day of onset up to one year; 476 TREATMENT OF ACUTE INFECTIOUS DISEASES that healthy contacts, that is, individuals who had been in touch with the disease during an epidemic but had not themselves had it, showed 80 per cent, of virulent bacilli, while among healthy non-contact carriers only 10 per cent, of the organisms were virulent. Studies of doctors and nurses in contact with diphtheria demonstrate a considerable number of carriers. A few important points to remember about carriers are as follows; A single negative culture has been shown over and over again to be fallacious. The surface of the tonsils and naso-pharynx may be clear when the deep crypts of the tonsils are still infected. Nasal cultures should be taken in each instance as well as throat cultures. In one large series of carriers over 25 per cent, of nasal cultures were positive. Chronic carriers are such by virtue of some pathologic condition of the upper air passage or accessory sinuses. In the great majority of cases the bacilli are to be found in the tonsils, often in both tonsils and nose; occasionally hi nose alone; next is the naso-pharynx. Cultures from chronic carriers should be tested for virulency. This is done by injecting a guinea-pig intracutaneously with cultures of the organism. Virulent bacilli at the end of 24 to 48 hours give rise to an area of redness and induration followed later by necrosis. Cats and dogs may be carriers and for that reason, if for no other, should be excluded from the sick-room. Treatment. Operative and non-operative. Non-operative treatment has universally failed. Sprays of all kinds, argyrol, DobelTs solution, Dichloramin T, Dakin's solution, crystal violet, antitoxin in water have all proved equally ineffectual. Operative Correcting the condition that affords a pathologic basis, is the only measure that promises success. All these cases should be submitted to examination by a competent nose and throat man. Dis- eased tonsils should be enucleated and adenoids removed, septum deformities, erosions or other abnormalities receive attention, and acces- sory sinus disease be corrected. Patients with atrophic rhinitis and other chronic inflammation of the nasal passages prove the most persistent carriers. It is interesting that all chronic carriers seem to give a negative Schick. Diphtheria cases should show 3 negative cultures at 3-day periods before discharged. Prophylaxis. The subject of prophylaxis has been covered on the sections on Schick reaction, active immunization and carriers. DIPHTHERIA 477 SUMMARY In the case of children examine the throat as a routine in all condi- tions. Taking of cultures. In all inflammations of the throat in a child, whatsoever be the clinical diagnosis and howsoever mild, take a culture for Klebs- Loffler bacilli. Persistent and especially bloody and excoriating nasal discharges in children demand a culture. Laryngitis, especially of a croupy character and more particularly croup lasting into the day makes a culture necessary. For technique of taking culture, see text. Disposition of the family. Other children in family kept from school. Adults in family kept from contact with children. Health authorities should be notified. Authorities should inspect the school or suspected groups. Children should be isolated and cultures taken from throats and nose. Adults should submit to the same procedure, as they may become carriers. S chick reaction should be done on all members of the family. All the children and adults reacting positively to the S chick should be immunized at once. Immunizing dose. (Read text.) Infants 500 units. Children 1,000 units. Adults 1,000 units. Children whose cultures are negative should be removed from the home if the patient remains there. If these children cannot be removed and react positively to the S chick test, they should have the immunizing dose repeated every three weeks; every two weeks is safer. (For particulars see below under immunizing dose.) Children having a positive culture should be isolated, but never with the patient. If case cannot be isolated at home he should be removed to the hospital. Schick test. (See text.) Should be done on all members of the family. Active immunization, see text. Should be done on all those reacting positively to Schick. Room. (See Room under summary in Scarlet Fever, Chap. XVII.) 478 TREATMENT OF ACUTE INFECTIOUS DISEASES Nurse. Schick test. Active immunization, if Schick is positive; both passive and active. (See Nurse under summary in Scarlet Fever, Chap. XVII.) Special precautions to avoid infection by cough or sneeze in treat- ing throat or nose. Secretions should be burned at once. Nurse should use mild sprays of boric acid 2 per cent, to 4 per cent., or half strength Dobell's solution; but no astringents. Should receive an immunizing dose of 1000 units every three weeks and better every two weeks. Should avoid coming in contact with children when off duty. Should avoid close contact with others, realizing danger of her cough- ing, sneezing and kissing. Physician. Should submit to Schick test and active immunization if Schick is positive. (See Physician under summary of Scarlet Fever, Chap. XVII.) Should use mild sprays but no astringents. If especially exposed, as by a cough into his face, should receive an immunizing dose. Should realize that he may be a carrier. Precautions in the sick-room. (See same in summary of Scarlet Fever, Chap. XVII.) Temperature of room, same as in Scarlet Fever. (See Chap. XVII.) Bed. (See Chap. IX.) Patient. Must go to bed even in mildest cases on account of danger to the kidneys, and cardio-vascular apparatus. Bath. Soap and tepid water each day. Sponge between blankets, or in warm room. Nightgown. Open down side to facilitate examinations. Diet. For general principles see Chap. II. For details of diet see summary of Scarlet Fever, Chap. XVII. Difficulties of feeding accruing from angina or paralysis are met by Feeding by gavage. 500 c.c. (1 pint) of milk. 50 Gm. (2 ounces) sugar. Adult. 1 egg. Give three times a day. Can add cream to above mixture. DIPHTHERIA 479 Technique of gavage. Adults, use stomach tube. Children over three years, nasal tube. Infants, stomach tube. Rectal feeding. Less satisfactory, but may be necessary. Nursing infant. Take from mother's breast. Feed with mother's milk obtained by pump or massage to assist with wet nurse's milk obtained in the same way. Water should be given freely and offered every hour or two. Fruit juice may be given made into lemonade, orangeade, etc. An insufficient water intake because of painful swallowing is to be met by Water by the rectum or Murphy drip. Care of mouth, nose and genitals. (See same in summary under Scarlet Fever, Chap. XVII.) Bowels. (See same in summary of Scarlet Fever, Chap. XVII.) Dose. Determine by 1. The severity of the disease. 2. The day of the disease when first seen. 3. Somewhat by age (Wright). In mild cases (simple congested throat with positive culture or one patch on one tonsil) Give 3000-5000 units. Repeat if there is no improvement in twelve hours. In more severe cases (both tonsils involved) Give 5000^000 units. Repeat in six hours if there is no improvement, and repeat at six to twelve hour intervals. In still more severe cases (spreading from tonsils onto pillars or pharynx) Give 8000 units, intravenously. Repeat at six to twelve hour intervals. Toxic cases. 1. If a pharyngeal case is toxic. 2. If there are laryngeal manifestations, hoarse cry, stridor or laryngeal cough. 3. If in addition to pharynx nose is involved, Give 10,000 units, intravenously. Repeat dose in six or four hours. Watch continuously. In malignant cases (rapid spread, marked toxemia). Give 15,000-20,000 units intravenously. Repeat at twelve, six or four hour intervals. 480 TREATMENT OF ACUTE INFECTIOUS DISEASES In severe or laryngeal cases under two years Give larger doses; three days ill, three times the ordinary dose (Holt). Park as the result of a large clinical experience and from' his ex- perimental data believes a single dose only is necessary, and that the initial dose should be large. His dosage is as follows. Units in case. Mild. Moderate. Severe. Very Severe. Infants under 1 year 2,000 3,000 10,000 10,000 Children 1 to 5 years 3,000 5,000 10,000 10,000 Children 5 to 9 years 4,000 5,000 10,000 15,000 Persons over 10 years 5,000 10,000 10,000 20,000 (For New York Board of Health dosage, see text.) Mode of administration. Subcutaneously. Blood contents of antitoxin reaches maximum between third and fourth days. Intramuscularly. Somewhat earlier. Intravenously. In all severe cases. Blood content of antitoxin reaches its maximum immediately. Technique of administration. Operator's hands, cleansed with soap and water, then alcohol or 1-1000 bichloride. Skin of patient cleansed with soap and water, then alcohol or paint with Tincture of Iodine. Boil needle and a small length of rubber tube to attach needle to syringe and prevent breaking of needle, if child struggles. Syringe, boil. Use one from which plunger can be withdrawn and allow serum to be passed into the barrel. Expel air before using. Antitoxin usually sent in a syringe as a container, sterile and ready for use. Site of injection. Loose tissue of back at angle of scapula. Loose tissue of abdominal wall. Loose tissue of anterior chest in nipple line between nipple and costal margin. Buttock, especially for intramuscular. Basilic vein for intravenous. Compress vein lightly above. Draw a drop of blood to prove entrance of needle into vein, before injecting. Evidences of improvement. (See text.) Disagreeable and dangerous results (anaphylaxis) of antitoxin ad- ministration. (See text.) DIPHTHERIA 481 Precautions. If one wishes to take great precautions he may inject one or two drops at first, and if no reaction occurs in an hour give the rest. Precautions in asthmatics should always be taken. Use concentrated and purified antitoxin. Give 0.2 c.c. for first dose. Repeat in an hour. Give 0.4 c.c. third dose; repeat same hourly till full dose is attained. Give atropine sulphate, gr. 1/100 (0.0006 Gm.) at the start. Treatment of anaphylactic shock. Atropine sulphate gr. 1/50 (0.001 Gm.) Morphine sulphate gr. 1/4 (0.015 Gm.) Adrenalin (epinephrin) 1:1000. . .m. xv (1 c.c.). Expelling air from chest by brute force. Immunizing dose. Infants, 500 units. Children and adults, 1000 units. Repeat at intervals of ten days to two weeks. Precautions. Especially asthmatics. (See above under summary.) Laryngeal diphtheria. These should include any exposed child with croupy symptoms. Take culture. Even with a negative culture suspect and watch closely. If croup persists by day treat as true diphtheria. Give 10,000 to 20,000 units and repeat in four, six, or twelve hours. Give into vein always, if it is possible. Other treatment. Symptomatic. Inhalations. Steam, using croup kettle or kindred device. (See treatment of Angina in summary of Scarlet Fever.) Too long steaming may be depressing. Hot fomentations. Ice-bag to neck. Intubation. \ /G , >. Tracheotomy. J ( S <* text.) Fever. Rarely demands treatment. Sponge baths of luke warm or cool water. Angina. Cold. Ice-bags and bladders. Ice-coil. Cold compresses. 482 TREATMENT OF ACUTE INFECTIOUS DISEASES Heat. Fomentations. Applications to throat. Irrigations. Salt solution 3i to Oi (4 Gm. to SCO c.c.). Two per cent, boric acid solution. Half to quarter Dobell's solution. Technique. Read text carefully. Sprays. Use same solutions as in irrigation. Gargles. Painful and of but very little use. Avoid astringents. Give cracked ice to suck. Pain of swallowing. Paint with 1 per cent, to 2 per cent, cocaine solution. Foul mouth. 1-2,000 potassium permanganate solution before the bland irriga- tion. Nasal diphtheria. Irrigations. Exercise great care lest ears become involved. Solutions same as those used on throat. (See Angina, above.) Use glass nozzle or catheter with holes cut in sides and an irrigator or fountain syringe. Hold just high enough to cause a gentle flow. Frequency; every two hours in severe cases; less often in less severe. Piston syringe may be used, lacking a fountain syringe. Patient should keep mouth open during the procedure. Begin first on the side most obstructed. Swabs and sprays if irrigation cannot be done. Use same solution. Hemorrhage from nose. Adrenalin (epinephrin) 1-2000 or 1-3000 by swab on applicator. Dry packing. Packing with gauze soaked in adrenalin (epinephrin) 1-3000 up to 1-1000. Thromboplastin and coagulen. (See text.) Circulatory failure. Early, due to toxemia as in other infectious diseases. Treat as in circulatory failure in Scarlet Fever. (See Chap. XVII.) Late. Prophylactic. Early and efficient serum treatment. Absolute rest. Sitting up in bed may kill. Morphine hypodermically, every four hours if needed to keep patient quiet. DIPHTHERIA 483 Dose. Child of two years, gr. 1/48 (0.0015 Gm.). Child of six years, gr. 1/24-1/16 (0.0030-0.004 Gm.). Child of twelve years, gr. 1/12-1/8 (0.005-0.008 Gm.). Adult, gr. 1/8-1/4 (0.008-0.015 Gm.). Stop food by mouth. Feed by rectum. Reduce all procedures about the patient to the minimum compatible with needs. For precordial pain and distress. Heat over the precordium. Drugs. (See text.) Caffeine. Camphor. Strychnine. Digitalis. Adrenalin. Strophanthin. See their use under Cir- culatory Failure in Scarlet Fever, Summary (Chap. XVII). (See text.) For those who fear the effect of digitalis on the vagus in inducing heart block, the use is advised of atrppine sulphate, gr. 1/100 (0.0006 Gm.) with each dose of digitalis or strophanthin. For collapse or syncopal attack. Hot saline rectal irrigations at 110 F.-115 F. For technique, see text. Hypodermoclysis of salt solution 3i in Oi (4 Gm. in 500 c.c.) at 100 F. 5viii-xvi (240-500 c.c.). Cold air. (For the technique of open-air treatment; see Pneumonia, Chap. IX.) Paralyses. Preventive measures. Early and efficient serum treatment. Absolute rest during danger period up to fourth week. (Rolleston says cardiac and palatal paralyses occur in first two weeks.) Inform the patient of the risk; and the need of absolute rest. Heart. (See summary under circulatory failure.) Palatal. Most frequent and short duration, also early. Feeding by gavage. Stomach tube in infants and adults. Nasal tube in children. Pharyngeal. Feeding by gavage. Respiratory. Lessen weight of bedclothes. Avoid positions embarrassing respiration such as doubling up. Raise foot of bed a trifle to facilitate discharge of secretions from bronchi, but not to embarrass respiration. 484 TREATMENT OF ACUTE INFECTIOUS DISEASES Aspirate food particles from pharynx with rubber catheter and syringe. Swab secretions from pharynx with cotton on dressing forceps or on some other applicator. Occasional compression of chest to help expel bronchial secretions. Atropine sulphate, gr. l/100^gr. 1/200 (0.0006-0.0003 Gm.) accord- ing to age to lessen secretions. Give three or four times a day. Face and extremities need no special treatment. Nerve tonic and stimulant may be used. Strychnine sulphate. Dose for child of two years, gr. 1/400-gr. 1/150 (0.00015-0.00045 Gm.). At twelve years, gr. l/100-gr.l/40 (0.0006-0.0015 Gm.) three or four times a day. Kidneys. The urine should be examined each day. Nephritis. Preventive. Early and efficient serum therapy. Treat like nephritis in Scarlet Fever. (See Summary of Scarlet Fever, Chap. XVII.) Hot packs and other manipulations causing much handling are not well borne. Bronchopneumonia. Treated like any other bronchopneumonia. (See Chap. IX.) Adenitis. (See treatment of adenitis in Scarlet Fever Summary, Chap. XVII.) Otitis. (See treatment of otitis in Scarlet Fever Summary, Chap. XVII.) Convalescence. Explain to the parents the danger to the heart if the patient is allowed up too soon. Mild cases. Flat in bed until end of third week. Increase number of pillows two, three, four and five. Sit up in bed at end of fourth week. In a few days in chair, then In a few days allow to walk. Severe cases. Six or eight weeks in bed. In no case allow up while there is any sign of heart involvement. Food. Fresh air. DIPHTHERIA 485 Anaemia. Iron. Blaud's pill (Pil. ferri carbonatis), gr. ii-v (0.15-0.30 Gm.) three times a day. Vallet's mass (Massa ferri carbonatis), gr. ii-gr. v (0.015-0.30 Gm.) three times a day. or Vinum ferri amarum 3i~ii three times a day for children. Tonics. Strychnine sulphate. Dose for child of five years, gr. 1/200 (0.0003 Gm.) three times a day. Dose for adult, gr. 1/40-gr. 1/30 (0.0015-0.002 Gm.) three times a day. Quinine. Doses of gr. i (0.06 Gm.) three times a day. May combine with strychnine, cod liver oil (oleum morrhuse) for children 3ss.-i (2-4 c.c.) three times a day. Release from quarantine. Three negative cultures at three-day periods should be obtained before discharge. If bacilli persist Spray with bichloride of mercury 1-10,000 adding glycerin one part in eight (Holt). (See carriers, below.) Bath and shampoo with warm water and soap. Follow with bath of bichloride 1-5000. Sterilization and fumigation. (For details see Scarlet Fever Summary, Chap. XVII.) For method of fumigation of Maine State Board of Health see text. Funerals should be private. Body wrapped in strong antiseptic and coffin sealed. Carriers. Cats and dogs, as possible carriers, must be excluded from the sick- room. Convalescents released without culture or only one negative culture are possibly carriers. Individuals in contact with the patient are possibly carriers (50 per cent, to 100 per cent, of the members of the immediate family were found to be carriers; 87 per cent, of an infected school were found to be carriers). Bacilli in carriers should be treated for virulency to determine the danger entailed by an individual to his environment. Deep crypts of tonsils as well as the surface should be examined. 486 TREATMENT OF ACUTE INFECTIOUS DISEASES Cultures should be taken from nose and naso-pharynx. Nose and accessory sinuses inspected for abnormalities and infections that favor the carrier condition. Treatment. Non-operative: Sprays of all kinds proved inefficient. Spraying the throat every two hours with a virulent culture sta- phylococcus and an occasional swabbing with the same. Use of antitoxin does not affect the organisms. Operative: Correction of abnormalities. Diseased tonsils, adenoids, removed. Accessory sinus disease treated. CHAPTER XIX MEASLES MEASLES is a disease affecting individuals of all ages, but particu- larly those in the first five years of life. All children are highly susceptible. The only exception to this is in the first five or six months of life, during which the chances of escape in an epidemic are relatively good. Measles is a serious disease, a fact not sufficiently appreciated by the laity and often overlooked by the profession. In adults the occasional case of measles impressed us but little as a serious disease, though we were familiar with the history of its ravages among savage people when first introduced, but the epidemic of measles that invaded our camps during the late war gave it a new and alarming significance. What the etiological agent in this disease is, we do not know, but Hektoen declares it to be present in the nasal secretions, in the blood, and in scrapings from the skin in the early eruptive period. The mortality among infants and delicate children is very high, 15 per cent, to 35 per cent, in institutions, 4 per cent, to 6 per cent, at home under better environment (Holt), and while the mortality is low among older children and adults, complications such as pneumonia and ear involvement may be highly dangerous or fatal, while the suscepti- bility to tuberculous invasion is greatly enhanced. The mortality in camps complicated by streptococcic infection exag- gerated naturally its menace in civil life but emphasizes the warning not to consider measles a trivial disease. No more pernicious teaching can be imagined than that as a child will probably have measles some time, the sooner it is exposed and has it the better. The older the child is, other things being equal, the better will it withstand the disease and its complications. It is not the measles, per se, that affords the danger, but the fact that it reduces the resistance of the mucous membranes of the respiratory tract to the onslaughts of the pyogenic organisms, the staphylococci, the streptococci and the pneumococci, and, as has been said, renders the soil fertile for the tubercle bacillus. The incubation lasts from 10 to 14 days; it is highly infectious from the appearance of the first symptom; hence, precedes the diagnostic 488 TREATMENT OF ACUTE INFECTIOUS DISEASES rash by several days and facilitates the spread of the infection. It is the secretions of the nose and eyes that are especially contagious and the infectivity disappears with the catarrhal discharges and so is short lived. It is not air borne, but coughing and sneezing can convey it over con- siderable distances. A third person coming directly from a case can convey the disease, but the virus is readily killed and is rarely conveyed by the third person, the physician or other, as is the case with scarlet fever. Distribution of the Family. Every child directly exposed, ex- cept very young infants, are almost certain to become infected. The chances of escaping are not comparable to those exposed to scarlet fever. The young infant, being less susceptible, is still capable of ac- quiring the disease and as the mortality is high in this group of patients, every effort to avoid the infection should be taken. The child should be removed to another house until the period of incubation of measles has passed. The chances of isolation in the same house are almost nil in contrast to the partial success of such attempts in scarlet fever. Absolute isolation of all in contact with the patient is necessary for success. It cannot be too emphatically insisted that no person having a cold, sore throat or infection of the upper air passages should come in contact with the patient lest he be a carrier of streptococcus and hence a real danger to the patient. Whether another house shall be exposed to the almost certain infec- tion by removal to it of the other older children of the family is a ques- tion, but as the infection does not cling to the house and room, as in scarlet fever, I feel that inconvenience should not be set against a chance in behalf of any child. Quarantine for such children may be broken at the end of two weeks, if there are no catarrhal signs, no Koplik's spots and no temperature. Three weeks would meet the demands of great precaution. Of course, all children in the infected household should be excluded from school until the patient is convalescent and the period of incubation for those who have not had the disease is passed. Room. Fear for the eyes and for the lungs has condemned the patient traditionally to darkness and to a room deprived of air. This tradition even the profession has had great difficulty in disregarding and in no illness is the room more devoid of cheer and comfort than in measles. Light is a most potent ally in combating infection and air is not only necessary to life, but is a most valuable therapeutic agent. If an attempt at isolation is to be made, the choice and manage- MEASLES 489 ment of the room must be identical with that demanded in a scarlet fever case. (See Scarlet Fever, Chap. XVII.) It is true that the eyes have to be considered in the treatment of measles and a glaring light direct in the eyes is to be avoided ; this may be done by placing the bed or moving the bed from time to time to avoid it, by letting the eyes rest on a darker surface, such as a hanging of green material, by a screen or by the use of colored glasses. At the most the room should be slightly darkened. The degree of comfort or discomfort of the patient is really the best regulator of the quantity of light. Of air there can never be too much. Draughts are, of course, to be avoided. The temperature is to be kept at 65 F. or 70 F., but in a toxic condition a colder air is highly beneficial, provided the body is well protected. If the cough is severe a degree of moisture, obtained by the use of croup kettles or other generators of steam may alleviate it, but the air is not to be rendered heavy with moisture. Clear cold air will often prove more efficacious; patients react differently to these measures. When conditions permit of it, two adjoining rooms may be devoted to the patient, thus giving the opportunity for a thorough ventilation and exposure to bright sunlight to the room for the time unoccupied. Two children sick of measles should never be treated in the same room, lest complicating diseases like pneumonia be transmitted. In hospitals and institutions, if separate rooms cannot be secured the patients should lie in separate cubicles. These I saw in operation years ago in Grancher's clinic at L'hospital des Enfants Malades in Paris. They reminded me of horse stalls, the partitions being of glass, 3 to 4 feet high raised from the floor to allow the air to circulate. The glass afforded the nurse in charge an uninterrupted view down the ward. In our camps gauze screens were used and are readily adaptible to an emergency. The Nurse. When isolation is carried out with a view of pro- tecting other children of the family, the nurse should be as carefully restricted to the sick-room and her own room as in scarlet fever. When there are no other children in the family, such restrictions are hardly necessary. She should, however, have no direct contact with adult members who have never had the disease. Again, in her outings, she should keep away from children, but need observe no such precautions as if on a scarlet fever or diphtheria case. If the nurse has recently been in contact with an acute infectious case, it would be wise to determine whether or no she was a carrier of streptococcus hemolyticus. If she has more than one child in charge in a family, she should wear a gauze mask to prevent her acting as a carrier, having a mask for each room. She should also wear a gown. 490 TREATMENT OF ACUTE INFECTIOUS DISEASES The Physician. The rarity with which this disease is trans- mitted through the third person makes the extraordinary precautions exercised by the physician when on a scarlet fever case unnecessary, particularly if he is for a time in the open air after a visit and does not go directly from a measles case to another child. He should, however, wear a gown in the sick-room and cleanse his hands with soap and water and alcohol or other antiseptic before leaving. Wearing a mask in the sick-room will help to prevent his acting as a carrier. Precautions in the Sick-Room. While the virus is far less persistent than that of scarlet fever and diphtheria and so the danger of .transmission less, one ought to observe the same precautions with reference to the infectious material contaminating the articles in use by the patient as in these other conditions. This will be found in detail under Scarlet Fever. When there are no children in the house and isolation is not carefully observed, the soaking of the clothes in disinfectants before going to the wash, if that is done at home, need not be carried out. Bed. For the proper kind of bed and the preparation see Scar- let Fever, Chap. IX. The covering should be light unless cold air is admitted to the room, just enough to afford the patient comfort. PATIENT Nightgown. Should be of linen or cotton, unless cold air is admitted to the room, or draughts cannot be avoided; then the flannel nightgown is to be preferred. It should be open down the front so that the chest can be readily exposed for examination. Bath. Great fear seems to be entertained, by many physicians, of the bath. I cannot see any danger, but much good, in a cleansing bath of soap and water with the sponge. If the patient is exposed, the room should be previously warmed to a little over 70 F. If concern is excited by this hygienic procedure, the patient may be put between blankets and one part after the other exposed and bathed or the patient may be sponged under the blanket. Not only does it keep the skin clean and assist the inflamed structure in its normal functions, but it is decidedly refreshing to the patient. The bath water should be lukewarm or cool. Diet. The energy demands of the body continue during an in- fection as in health; for a man at rest, indeed, the demands during fever are greater, because of certain additional demands made by the pyrexia, per se, and by the destruction worked by the toxins of the disease. The derangement of the functions of the alimentary canal during MEASLES 491 a prolonged and severe infection is remarkably little (see Diet in Acute Infectious Disease, Chap. II), but such as there is is more marked at the incipiency of the infection. In short acute infections, then, there is no necessity for urging food to meet theoretical demands, both because of the temporary derangement of alimentation and because of the brief period of the infection. At such a time anorexia should be respected as of conservative significance. When, however, the infection is prolonged in its regular course, or prolonged because of added, that is, mixed infec- tion, the necessity for supplying enough food becomes of great moment. Measles runs a short febrile course and the amount of food can be left to the patient's inclination ; but if complicated by a bronchopneumonia, continuing for some time, the caloric and protein needs must be reckoned. In young infants on the bottle, the food should be diluted with water or thin cereal water one-half or one-quarter. In older infants the milk had better.be diluted. In older children and adults, milk and gruels made of arrowroot, barley, wheat flour, cornstarch, farina or imperial granum or small quantities of the cereals themselves with milk or cream and sugar, jellies of barley, tapioca and sago, boiled rice, milk toast; or some of the other modifications of milk such as buttermilk, koumys, matzoon, afford variety. If the fever continues, add bread and butter, eggs, custard, scraped beef, vegetable soups. As the fever becomes normal, add small quantities of scraped beef, raw oysters, chicken or squab, finely minced. The additions are made in convalescence of the shorter attacks. For the caloric values of articles here mentioned, see Scarlet Fever, Chap, XVII. Water is to be administered freely. It is to be given whenever asked for, but it is also to be offered during each waking hour. Plain or alkaline waters, lemonade, orangeade, imperial drink, may be used. The latter may be sweetened freely, every ounce of sugar adding 120 calories of food. The administration of water is too often neglected, while it is infinitely more important than many drugs, the intervals of whose administration is jealously observed by physician and nurse. Skin. A warm cleansing bath is given each day and a second may be given if it adds to the patient's comfort. Often there is a good deal of itching and burning. This may be re- lieved by sponging with a solution of sodium bicarbonate, 3i to 3 pints (4 Gm. to 1,500 c.c.) of water or dabbing on bran water, made by putting a handful of bran in a muslin or cheesecloth bag and moving this about in a gallon (4 liters) of water until it becomes milky. For more severe 492 TREATMENT OF ACUTE INFECTIOUS DISEASES itching 1 per cent, to 2 per cent, carbolic acid (phenol) in oil or vaseline may be used. When desquamation begins the body may be anointed with vaseline after the daily bath. 1 V Phenolis gtt. xx-xl (1 . 3-2 . 6 c.c.) Pulv. Zinci Oxidi Pulv. Amyli , Pulv. Calaminae aa 3ii (8 Gm.) Glycerini 5ij (8 c.c.) Aq. Calcis q. s. ad. . . 3 iv (120 c.c.) M. Mop on or apply cloths wet with the solution. Do not rub. Mouth. When one considers that the most common and serious complications of measles is due to the presence in the mouth of pyogenic organisms, the staphylococci, streptococci and pneumococci, which have invaded the air passages to the production of bronchitis and broncho- pneumonia, one appreciates the importance of measures aimed at keep- ing the mouth and nose clean. After each meal the mouth should be rinsed with normal salt solu- tion (3i to the pint) (4 c.c.-500 c.c.) or 2 per cent, to 4 per cent, boric acid solution of 1/2 or 1/4 strength Dobell's solution. Swabs on wooden tooth-picks, saturated with the same solutions, should be used to cleanse the teeth and the spaces between the teeth and cheeks or lips. For sordes or coated tongue, half strength solution of hydrogen dioxide, peroxide of hydrogen (official) may be applied first, the tongue gently scraped with the edge of a whale-bone and the solutions mentioned then used. If the mouth is dry equal parts of 2 per cent, boric acid and liquid petrolatum with a little lemon juice affords a pleasing application. Sprays of the same solutions should be used for the throat. Gargles are not efficacious for this purpose. Nose. Dried secretions should be moistened with sweet oil and then cleansed with the same solutions as the mouth. The swab on the tooth-pick may be used for these purposes. Sprays of the same materials should follow. Eyes. The eyes should be cleansed twice a day, or oftener, if needed, with saturated boric acid solution. Vaseline may be smeared on the edges of the lids to prevent gluing. One drop of 20 per cent, solution of argyrol in each eye every two hours from the beginning of conjunctivitis until it clears up is an excellent procedure. (Bingham.) 1 Hubbard recommends for itching, if much surface is involved, the pre- scription cited. MEASLES 493 The genitals should be attended to and kept free from irritating secretions, using the saline or boric acid solutions. Bowels. When first seen a free catharsis should be given. To the infant or very young child, castor oil, 3i to oii (4-8 c.c.) or calomel, gr. 1/10 to gr. 1/4 (0.006-0.015 Gm.) at 10 to 15 minute intervals until 1 grain (0.060 Gm.) is taken. In older children and adults, a salt, Epsom, Rochelle, Glauber's, or Sodium phosphate in doses of 3ii to iv (8-15 Gm.) in 1/2 glass of water, alone or preceded by calomel gr. i to gr. iss. (0.060- 0.10 Gm.) in divided doses. To children Liquor Magnesii Citratis 3vi to viii (180-240 c.c.) is more grateful or milk of magnesia 3ss. (15 c.c.) following the calomel. The bowels should be moved by an enema or Liq. Mag. Cit. or Hunyadi water at least every other day. Fever. A moderate degree of fever, that is 104 F. or below is to be let alone or even 105.5 F. if only for a few hours. As a rule measles is not accompanied by greater degrees of fever than these mentioned and the course is short. When, however, a sudden impulse of temperature to 106 F. or above occurs or a temperature of 104 F. to 105 F. persists, an effort should be made to reduce it. Craster has shown that the liabil- ity to a fatal issue increases directly as the temperature. Drugs should not be used for this purpose. Nothing equals cold water as an antipyretic. For young infants sponging is the best, for children the pack or sponge and for older children and adults the pack or bath. The younger the child, the warmer the water used. Baths for children should be graduated. The water used in these procedures should begin at 95 F. to 98 F. and be gradually reduced to 85 F. or lower, depending on the reaction of the patient and the fall in temperature. One should be satisfied with a fall to 102 F. and at this point intermit the procedure. Ice to the head adds to the efficacy of the other measures. If there is any sign of collapse during the bath, one should take the patient out, wrap him in warm blankets, put heat to the extremities and give warm drinks. If with a high temperature the extremities are cold, the patient's color poor and pulse small, the hot mustard bath should be given with ice applied to the head. The mustard bath is made by using mustard in the proportion of a tablespoonful to the gallon. Put the mustard into a small part of the water at a tepid temperature to cause the formation of the oil from the mustard, then add the rest of the water, in a few minutes bringing it up to the temperature of 100 F. After the child is immersed to the neck, warmer water to bring the whole to 105 F. can be added if desired. The 494 TREATMENT OF ACUTE INFECTIOUS DISEASES child may be left in five to ten minutes, then dabbed dry, rolled in a warm blanket, with heat at the feet and ice at the head. Cardio- Vascular. Except in the rare instances of malignant measles and in bronchopneumonia as a complication, the heart does not demand serious attention. When, however, the circulation fails in this condition, the same causes may be deemed operative as in other acute infections, and the same measures should be undertaken to combat it. These are dealt with at length under scarlet fever. In no way is the treatment modified because the infection is measles instead of scarlet fever. As most of the cases are infants or young children, the doses should be suitable for them. Digitalis and strophanthin are the only reliable drugs. Eggleston's rule of 2 minims of tincture of digitalis per pound of patient to accom- plish digitalization is applicable; e. g., a child of 30 pounds would call for 60 minims of tincture or 6 grains of digitalis. This should be adminis- tered in 36 hours. One would give 10 minims every 6 hours or in more urgent cases 20 minims; for the first dose strophanthin might be used, 1/10-1/5 of a milligram. The digitalis must be known to be fresh and of guaranteed assay and it must be remembered that a minim of tincture is not a drop. Always measure the digitalis in a minim glass. The above dosage is a guide but the dose must be modified to attain results. (See Pneumonia, Chap. IX.) Caffeine gr. 1/8, 1/4, or 1/2 (0.008-0.015-0.030 Gm.) in the form of one of the soluble double salts of salicylate or benzoate every two or three hours, camphor, gr. 1/5 to gr. 1/2 (0.012-0.030 Gm.) in oil 10 per cent., adrenalin (epinephrin) 1 to 1000 for sudden collapse, m. ii to m. v (0.150-0.33 c.c.) into a muscle, may be tried with less anticipation of results than from the digitalis bodies or may be used if digitalis fails. For respiratory failure these same drugs and atropine sulphate gr. 1/400 (0.00015 Gm.) Nervous Symptoms. In the severe cases the cerebral mani- festations may be pronounced; restlessness to delirium and even con- vulsions or there may be stupor. These expressions of toxemia in the cortex of the brain are to be com- bated like those impinging on the vaso-motor and respiratory centers at the base, by the use of hydrotherapy. The warm sponges and baths for sedative effects and the colder ones for stimulating. These baths, sponges and packs are to be used as described under the section on Fever. An ice cap to the head has a quieting effect. MEASLES 495 If these measures are not efficacious or not attainable and drugs must be used, in very young children antipyrin in doses of 1 grain (0.060 Gm.) and sodium bromide in doses of gr. iii to gr. iv (0.20-0.25 Gm.) three or four times a day may be tried. In older children of five or six, bromide in doses of gr. v (0.30 Gm.) three or four times a day, in adult gr. xv to gr. xx (1-1.30 Gm.) at the same intervals. Acetphenetidin (phenacetin) in doses of gr. i to gr. ii (0.060-0.125 Gm.) to young children may prove sedative, repeated as with the others. For sleeplessness in children, the baths and the small doses of bro- mides and antipyretics mentioned are the best. In adults trional, sulphonethylmethane in gr. x (0.60 Gm.) doses and chloralamid in doses of gr. xx (1.30 Gm.) may be used and repeated in two or three hours if needed. For wild delirium, sacrificing sleep and rest, morphine will be neces- sary, hypodermically, gr. 1/4 (0.015 Gm.) in the adult, gr. 1/16 (0.004 Gm.) in the older children, gr. 1/24, to gr. 1/48 (0.003-0.0015 Gm.) in the younger. COMPLICATIONS Bronchopneumonia. Of the serious complications of measles bronchopneumonia is far and away the most common and is responsible for the great majority of the fatal cases. In private practice the incidence of pneumonia is given at about 10 per cent., but is much more common in institutions. The mortality is very much higher, too, in hospitals than in private practice. In the hospital a child with pneumonia should be promptly removed from the environment of the simple cases, as the condition will spread readily among the cases. An abundance of air, close attention to the toilet of the mouth and avoidance of exposure of the body to draughts and chilling are prophylactic measures. Most of the cases occur in the first five years of life and the mortality is many times higher in infants under two than in the older children of the first lustrum. The appearance of bronchopneumonia in a case of measles changes the whole aspect of the case. The treatment henceforth is that of pneumo- nia, modified not at all by the fact that it complicates measles. During the late war measles in camps was so complicated by strep- tococcus hemolyticus that it modified the picture of pneumonia cases to no inconsiderable extent and was accompanied by a high per cent, of empyema and other streptococcic lesions. For discussion of these cases see streptococcic pneumonia (Chap. X). 496 TREATMENT OF ACUTE INFECTIOUS DISEASES The patient'must be kept in bed, unless a young infant, when it may be taken up from time to time. The older patients in bed must be turned from time to time to avoid hypostasis and encourage the discharge of secretions. The temperature of the room should be kept from 65 F. to 70 F. unless the cold air treatment is instituted when especial provi- sion in making the bed should be made. As the temperature is more sustained and as an additional toxemia must be combated, more fre- quent sponging adds to the comfort and refreshes the patient. The care of the mouth must be carried out more rigidly than ever and if the breath is foul or there is stomatitis a phenol solution such as the following should be applied: Phenol (Watery solution 1-20) Boric Acid (sat. watery sol.) aa 3i (30 c.c.) Glycerin 5 viii (240 c.c.) M. The diet should be more liberal than at the beginning, to meet the caloric needs, adding at least 25 per cent, to the requirements in health. (See Scarlet Fever, Chap. XVII, for the caloric requirements.) The importance of the ingestion of a sufficiency of water must be emphasized, offering it every hour. Open Air Treatment. A considerable experience with this mode of treatment has made me an enthusiastic advocate of it. The results are so striking and so satisfactory that it is tragic that the physician who is convinced is so handicapped by the traditional fear of the cold enter- tained so largely by the laity. The most enthusiastic party concerned is the patient. It must be emphasized, however, that the technique must be correct and carefully carried out. Precise instructions about the making of the bed, the protection of the patient, the watchfulness of the nurse, must be given. Detail is set forth in the article on Pneumonia, Chap. IX. Improvement is seen in the lessening of the nervous symptoms, better sleep, improved appetite, better pulse and respiration. Objections are made to the cold air treatment in the case of very young and delicate children and in cases of capillary bronchitis. Cer- tainly, watchfulness must be more vigilant in these cases. As for the capillary bronchitis, some react exceedingly well to the open air treat- ment, while others do not do so well. The response of the individual case must be studied. Next in value to the cold air in the combat with toxemia is cold water. It may be applied in the shape of cold chest compresses, cold MEASLES 497 sponging, the graduate bath, beginning at 95 F. and reducing to 85 F. or the evaporation bath. In the early stages mustard paste, one part of mustard to five or six of flour in infants and one in four in older children, depending more or less on the reaction of the skin, may be applied. These may be applied every 4, 6 or 8 hours. (See Pneumonia, Chap. IX.) Poultices and jackets add weight and are of little value. Fever. Continuous high temperature is exhausting. Its effects are to be met by frequent sponging with tepid water, or, if the degree of toxemia is marked with the colder applications, sponges, packs or baths. Hyperpyrexia calls for extraction of heat, as explained in the preceding section on fever. Cough. This is likely to be severe in the cases with much bron- chitis. In some the effects of the open air is highly satisfactory, in others the applications of the chest compress, but many show an in- crease of the cough or a "tightening" of the breathing, that finds relief in a warmer, moisture laden air. The effects of steam from a croup kettle in a tent made with a sheet over the upper part of the crib, or over a clothes horse or screen often has a happy effect. If the results of the plain steam are not satisfactory, compound tincture of benzoin, or creosote may be added, a teaspoonful upon the water of the kettle. A degree of moisture may be obtained by water heated in shallow dishes elsewhere in the room. It is not desirable to load the atmosphere of the room with steam. It and the heat generated are depressing, nor should the child be kept too long under the tent. The room should be thor- oughly aired two or three times a day, the child being removed to an adjoining room during the ventilation. A harassing cough sacrifices rest and sleep. It must be met by small doses of codeine phosphate, gr. 1/24 (0.003 Gm.) to gr. 1/12 (0.005 Gm.) in children according to age, in older children and in adults gr. 1/8 (0.008 Gm.) to gr. 1/4 (0.015 Gm.) every two hours. Holt advises Dover's powders in doses of gr. 1/10 (0.006 Gm.) every two hours to a child of one year. I have no great faith in expectorants and fear the disturbance to the stomach they may set up. When the secretions are abundant or the child is weak, efforts at expulsion may be ineffectual. Hot and cold water alternately applied, or hot mustard baths may excite to increased respiration and save from a threatened suffocation. Oxygen may be used diluted with air and the chest cupped. Delirium and sleeplessness are ameliorated by the effects of cold 498 TREATMENT OF ACUTE INFECTIOUS DISEASES air. A warm bath sometimes invites to sleep. An ice bag to the head is often helpful. For headache and extreme restlessness, antipyrin gr. i (0.06 Gm.) or phenacetin gr. i (0.06 Gm.) or gr. ii (0.15 Gm.) or Dover's powders gr. 1/10 (0.006 Gm.) to infants and larger doses to older chil- dren every three or four hours. Care of the diet and bowels and sufficiency of water are of prime importance when respiration is embarrassed, as the formation of gas produces tympanites; the gas presses up on the diaphragm and encroaches on the breathing space and disturbs the heart action. To relieve this mild salines as suggested, enemata, or enteroclyses of warm salt solution, fomentations (see Typhoid Fever, Chap. V), the introduc- tion of a rectal tube or a Murphy drip may be of value. Cardio-vascular failure has been dealt with under that heading above. For edema of the lungs consult Pneumonia, Chap. IX and summary. Bronchitis. Much more common and far less alarming as a complication is bronchitis in measles. In fact, a certain degree of bron- chitis may be anticipated in a well-developed case. The treatment has been outlined under pneumonia, for all gradations of bronchitis are to be met with merging insensibly into pneumonia and all severe cases of bronchitis, involving the bronchi of small size are to be considered as and, indeed, are pneumonia. For the milder grades, one may try as described above, mustard pastes, the chest compress, inhalations of steam or steam medicated with benzoin, creosote or eucalyptol, the latter especially when the secretions are thick and viscid. For the cough, if severe and exhausting, Dover's powder or codeine in doses described. Laryngitis. A laryngitis may occur early or late. When oc- curring early it probably is not diphtheritic, but a culture of the throat should be taken. If occurring late it probably is diphtheritic and should be treated as such, not awaiting upon the return of the culture which is to be made, but giving antitoxin at once, 10,000 units. Occurring early it is to be treated like laryngitis under other conditions. Local Applications. Heat or cold in the shape of compresses, though to apply cold the ice bag or coil may be used, but are not so easy of application as the compress. Cold Compress. Old linen cut into a strip folded three or four times lengthwise, long enough to go about the neck and pin. Wring out of cold water at 60 F. Apply to the throat and outside of this a dry flannel. Renew hourly. MEASLES 499 Hot Compresses. A thick piece of old flannel. Lay it in a crash towel, pour over it boiling water, wring it in the towel by twisting the ends in opposite directions, flirt in the air to expel the excess of hot steam, apply, and outside of it a dry flannel, renew every ten or fifteen minutes for three or four times and apply dry flannel. Repeat at three or four hour intervals. Inhalations. Steam from a croup kettle under the tent as above described. Compound tincture of benzoin, turpentine or eucalyptus oil may be added, 3i (4 c.c.) upon the water of the kettle. Warm drinks and warm milk. A glass of hot milk in the morn- ing will often relax the parts and aid to expel the secretions. If the secretions are thick and the patient old enough to permit it, sprays of sodium bicarbonate gr. xx to the ounce (1.30 Gm. to 30 c.c.), telling the patient to inhale as the spray is injected, will "cut" the secretions and help to discharge them. Sprays in an oily medium, as liquid petro- latum, of menthol, eucalyptus or camphor 1 per cent, or a combination of each 1 per cent, may be found grateful. If the cough is harassing, small doses of codeine as for bronchitis may be administered. Otitis. Measles is second to scarlet fever only in the frequency of ear involvement. It is said to be affected in 10 per cent, of the cases, but the degree of impairment and the seriousness of the sequelae is much less. Nevertheless the ear should be regularly inspected. The treatment is in the application of dry heat, 5 per cent, carbolic (phenol) in glycerin to relieve the pain and incision when bulging is obvious. For details of the treatment, see Scarlet Fever, Chap. XVII. Adenitis. Marked involvement of the cervical glands occur in some 2 per cent, of the cases. For treatment, see Scarlet Fever, Chap. XVII. Ulcerative Stomatitis. Noma. Both these conditions may com- plicate measles. The latter, though fortunately rare, is more commonly a complication of measles than of any other disease. Not only is it highly fatal, 70 per cent, to 100 per cent, in different series, but if it spares, it leaves a lamentable deformity and scarring of the part affected, most often the face. Its relation to ulcerative stomatitis is believed to be close, and it is believed that the noma represents a more virulent process in a less resistant individual than does the ulcerative stomatitis. Both are probably due to the fusiform bacillus of Vincent. It is for this reason that such great care should be exercised on the oral toilet in measles. When ulcerative stomatitis occurs, in addition to measures advised in the care of the mouth, one should administer chlorate of potash, 500 TREATMENT OF ACUTE INFECTIOUS DISEASES gr. ii (0.130 Gm.) every one or two hours and use a chlorate of potash solution as a mouth wash; the strength should be 1/4 per cent, to 1/2 per cent, or if this is painful more dilute. If the process is not bettered by these efforts one may touch the spots with 10 to 50 per cent, nitrate of silver, or chromic acid 5 per cent, ur tincture of iodine. If the process is succeeded by noma or begins as a noma one uses as an irrigation potassium permanganate, making a claret colored solution (1:5000), and has recourse to more heroic measures in addition to those named. The edges of the gangrenous process is touched with fuming nitric acid or with pure carbolic acid (phenol) followed by pure alcohol. The gangrenous tissue should be previously clipped away or the edges curetted. The best opinion, however, favors free excision, going out into the healthy tissue, and applying the Paquelin cautery to the edges. This should be done before the toxemia has robbed the patient of what little resistance may be left. MacGuire recommends the application of a thick paste of subni- trate of bismuth and water at frequent intervals. I have seen most intense ulcerative stomatitis clear up under this treatment. In a hospital the child affected should be removed from the ward and isolated, as the disease seems contagious. Noma may attack the vulva and is to be similarly treated. Gastro-Intestinal. As the rash fades or in convalescence an ileo- colitis may occur and is often of serious import. It should be treated as under other circumstances. During the early hours no food should be given, but water freely, in small quantities frequently; then the diet should be barley water, arrow-root water, rice-water, broths, chicken, mutton, veal or beef broth. The broths may be thickened with farina- ceous foods, barley, arrow-root, wheat flour. When the acuteness of the symptoms have passed and decided improvement in the stools have occurred milk in the shape of boiled skim milk may be begun, cautiously at first. The bowels should be moved with castor oil, 5i (4 c.c.) to a child of a year and more in accordance with age. The colon should be irrigated daily with saline solution, 3i to a pint (4 Gm.-500 c.c.), using 2 to 3 quarts (2-3 liters), at 100 F. This will often suffice, but if the stools persist, bismuth subnitrate in doses of gr. xx to gr. xxx (1.30-2 Gm.) every two hours, should be given, the dose decreased with improvement in the stools. It can be given, shaken in a little water, through which it quickly diffuses in suspension. The drug is insoluble, hence, the large doses can be given to the child MEASLES 501 as well as the adult. The object is to give enough for it to exert its protective effect on the considerable extent of the gut involved. The castor oil should be repeated every two or three days. If oil cannot be retained Rochelle salt, 5i to 5iv (4-15 Gm.) can be substituted. Only when the gut is certainly clean and when the diarrhea resists other measures should opium be used, in children in the shape of pare- goric, m. v (0.30 c.c.) equal to gr. 1/48 opium (0.0015 Gm.) or its equiva- lent in powder, tincture or Dover's powder, every two or three hours. Lengthen the interval promptly with improvement. The temptation to use opium early and to continue it instead of seeking more legitimate measures of relief must be strenuously combated. In severe pain or copious exhausting diarrhea, morphine sulphate hypodermically, gr. 1/48 to gr. 1/24 (0.0015-0.0003 Gm.) at a year to two years may be used. For lesser pains of a colicky nature fomentations should be applied to the intestine. Diet rather than drugs should afford relief. Eyes. More or less conjunctivitis is common enough and is to be treated with frequent applications of boric acid solution, 2 per cent, to 4 per cent. If severe, cold cloths, squares of linen or cheesecloth may be applied frequently and over a considerable period of time. These cloths are put on bits of ice in saturated boric acid solution and con- stantly renewed, as they grow warm upon the eyes. The lids are kept separated with vaseline smeared along the edges. In purulent conjunc- tivitis silver salts may be used, such as argyrol. In only the weakly and ill nourished patients may one anticipate the serious complications, an involvement of the cornea with ulceration. These cases need expert advice. In blepharitis apply yellow oxide of mercury ointment, gr. i (0.060 Gm.) of oxide to 3ii to iv of vaseline (8-15 Gm.) If there is much photophobia a drop of atropine sulphate in 1/2 per cent, solution can be applied to the eye to dilate the pupil. Use cau- tiously. The eyes must be shaded or the room somewhat darkened. Heart complications, such as endocarditis or pericarditis are very rare and are to be treated as under other circumstances. Kidney involvement, other than a transient albuminuria, is an uncommon occurrence. If nephritis does occur it is to be met as in scarlet fever. (See Scarlet Fever, Chap. XVII.) Diphtheria. As has been said, any membrane on the tonsils, or pharynx should demand immediate culture to determine whether it is diphtheritic or not, to be treated accordingly. If laryngitis inter- venes in the course of measles, antitoxin should be given, 10,000 units, 502 TREATMENT OF ACUTE INFECTIOUS DISEASES without awaitihg the report on the culture. In the hospital all cases should receive an immunizing dose of antitoxin. When many cases of measles are thrown together as was the case in our camps during the late war and when these men have been in intimate contact with many cases of infection of the upper air passages, before isolation can be effected, and with many more who are carriers of the streptococcus hemolyticus, secondary infection with this organism is inevitable and it was this secondary infection that made Measles the horrible plague it proved to be. Complications became, under these circumstances, more numerous, more varied and severe. They ranged through an extensive gamut, from tonsillitis adenitis, sinusitis, bron- chitis, otitis, erysipelas, to bronchopneumonia of the streptococcic type, empyema, peritonitis, meningitis, and septicemia and have to be treated as streptococcic infections. See Streptococcus Pneumonia, and Empyema, Septicemia, Erysipelas, Cerebrospinal Meningitis (Chaps. X, XLV, XLVI, and XXV). Tuberculosis. Measles renders the patient peculiarly suscept- ible to tuberculosis, making readily possible an infection or lighting up of an old process or causing the breaking down of and extension from tuberculous bronchial glands. Cough and fever persisting should lead to repeated careful examinations of lungs and sputum. Other tuberculous complications, such as meningitis and acute military tuber- culosis may follow. Such possibilities again heighten the importance of sedulously avoiding infection. Convalescence. The most important matter in consideration of the period of convalescence is the susceptibility to tuberculosis. Avoid- ance of exposure to a tubercular environment or prompt removal from one, hi case any member of the family has or is suspected of having tuberculosis; avoidance of colds, plenty of fresh air and sunlight, an abundance of good food and tonics, the last in fact the least, constitute our efforts. One may administer iron, Blaud's pill or Vallet's mass in doses of gr. ii to gr. v (0.130-0.30 Gm.) three times a day according to age, or the bitter wine of iron, which contains 5 per cent, of the citrate of iron and quinine, in doses of 3i to ii (4r-S c.c.) three times a day. Strych- nine or Tr. nucis vomicae, in doses according to age and cod-liver oil. This latter is best administered to children without effort to conceal the taste, in doses of 3ss. to i (2-4 c.c.) in older infants, and 3i to ii (4-8 c.c.) in children. The child should be kept hi bed until the rash has quite disappeared and then in the absence of fever or complications may be allowed up and in another week or ten days be allowed out. Release from Quarantine. The patient should be given a warm MEASLES 503 bath with soap and water and a bath of bichloride 1 to 5,000. The hair should be shampooed. Disinfection. For discussion of terminal disinfection, see Scarlet Fever, Chap. XVII. The virus of measles does not cling to rooms or articles long. If the room occupied is thoroughly cleansed and aired for some days and children are not allowed to occupy it for two or three weeks, the rigorous disinfection given to a room after scarlet fever is not necessary, but in an institution or when children must occupy the room, such rules as laid down for disinfection in scarlet fever should be carried out. Such precautions will always appeal to the careful parent. Clothes and utensils may be disinfected as in scarlet fever. (See Chap. XVII.) SUMMARY Distribution of the family. Exposed children are almost sure to catch the disease; still they ought to be isolated until the incubation period is passed, i. e., two weeks, then kept away until the patient is well. Young infants have a greater chance to escape, and their isolation is the more imperative. Exposed children should be kept from school until the patient has convalesced and the incubation period is passed. Room. In hospitals, separate cubicles. Choice and management. (See summary under Scarlet Fever, Chap. XVII.) Eyes. May be protected by the position of the bed. By the use of screens. By the use of colored glasses. By slightly darkening the room. Patient's comfort the best regulator of light. Fresh air. Temperature of room 65 F.-70 F. In toxic condition, cold air, with body properly protected. Two rooms adjoining one to be exposed to fresh air and sunlight, when not occupied, is excellent. Never treat two patients in the same room on account of the con- tagiousness of the complications. Nurse. Nurse for each patient, or if impossible wear a mask for each patient. Must have no contact with other children or susceptible adults either when she is on duty or during her hours off duty. Wear gown. 504 TREATMENT OF ACUTE INFECTIOUS DISEASES Physician. Should not go directly to another child. Wear gown and gloves in sick room. Wash hands on leaving with soap and water. Follow with alcohol or 1-1000 bichloride. Wear mask to avoid becoming a carrier. Precautions in sick-room. (See summary under Scarlet Fever, Chap. XVII.) If there are no other children in the family, soaking clothes in dis- infectant before going to the family wash is not necessary. Bed. Choice and preparation. (See summary under Scarlet Fever, Chap. XVII.). Patient. Nightgown, cotton or linen, or if cold air is admitted, flannel. Open all the way down the front or sides to facilitate examinations. Bath. Soap and tepid or cool water. Between blankets, if desired. Room temperature 70 F. or over during the bath. Diet. Do not urge food during early days. During short course of a normal measles leave quantity to the patient's inclination. When prolonged by complications the protein and caloric needs must be considered. t (See Chap. II and Chap. XIV.) ' Young infants. Dilute the milk mixture one-quarter to one-half with water or thin cereal water. Older infants. Milk had better be somewhat diluted. Older children and adults. Milk gruels of arrowroot, barley, wheat-flour, cornstarch, farina or imperial granum or small quantities of cereals with milk, cream and sugar, jellies of barley, tapioca and sago, boiled rice, milk toast, milk modifications, eggs, ice cream. As the fever declines, bread and butter, custard, raw oysters, chicken and mutton broths, thickened with rice, arrowroot, etc. With normal temperature scraped beef, squab, chicken, lamb chop minced. Water freely. Alkaline waters, lemonade, orangeade, imperial drink. Fruit juices ma} r be sweetened. (For caloric values see Typhoid Fever, Chap. XIV.) MEASLES 505 Skin. Cleansing bath each day. Itching and burning. Bicarbonate of soda 3i to Oiii water (4 Gin. to 1,500 c.c.). Bran water dabbed on skin. A handful of common bran in a cheesecloth or muslin bag swished about in a gallon of water until milky. When more severe. One per cent, to 2 per cent, of phenol in vaseline or olive oil. When desquamation begins. Anoint with vaseline after daily bath. Mouth. (For details see summary under Scarlet Fever, Chap. XVII.) Nose. Moisten dried secretions with sweet oil. Use swabs on wooden toothpicks as applicators or sprays of same solutions as in mouth. Physiological salt solution 3i to Oi (4 Gm.-500 c.c.). Two per cent, boric acid solution. Quarter to half strength DobelTs solution. Eyes. Cleansed twice a day or oftener. Use saturated (4 per cent.) boric acid solution. Anoint the lids with vaseline to prevent sticking. Genitals. Keep clean with 2 per cent, to 4 per cent, boric acid solutions. Bowels. When first seen. Infant or very young child. Castor oil 3i to 3ii (4-8 c.c.). or Calomel, gr. 1/10 to gr. 1/4 (0.006-0.015 Gm.) every ten to fifteen minutes until gr. i (0.060 Gm.) is taken. Older children and adults. Salts. Epsom, Rochelle, Glauber's or Sodium phosphate 3ii to 3iv (8-15 Gm.) in half glass of water. Give alone or preceded by calomel, gr. i to gr. iss. (0.060-0.10 Gm.) in divided doses. Children. Liquor magnesii citratis 3vi to gvu'j (180-240 c.c.) or milk of magnesia 5ss. (15 c.c.). Later. Move bowels at least every other day by enema, liquor magnesii citratis or Hunyadi water. 506 TREATMENT OF ACUTE INFECTIOUS DISEASES Fever. :^ , When moderate, below 104 F. let alone. Hyperexia. Sustained above 104 F., or sudden above 105 F., use cold water. Infants, sponge. Children, pack or sponge. Older children and adults; bath or pack. Baths for children, if given, should be graduated. The younger the child the wanner the bath. Begin at 98 F. to 95F. and cool down to 85 F. Be satisfied when patient 's temperature falls to 102 F. Keep ice-bag, cold cloths, to head or sponge head with cold water. Collapse during bath. Wrap in warm blankets. Heat to extremities. Hot drinks. High temperature, cold extremities, bad color and small pulse. Mustard bath. 5ss. (15 Gm.) mustard to 1 gallon (4 liters) water. Add mustard to a small amount of luke warm water to develop the oil, then add hot water to 100 F. Put child in. Bring temperature up to 105 F. Leave in five to ten minutes. Dab dry and roll in warm blanket. Put heat to feet and ice bag to head. Circulatory failure. (See Scarlet Fever, Chap. XVII, and see text.) Nervous symptoms. Delirium. Warm baths or sponges. Sponges, packs, baths. (See above under Fever.) Ice bag to head. Drugs. Only when other measures are not efficacious or attainable. Young children. Antipyrin, gr. i (0.060 Gm.) three times a day. Phenacetin, gr. i to ii (0.06(M).130 Gm.). Sodium bromide, gr. iii to iv (0.20-0.25 Gm.) three times a day. Older children. Sodium bromide, gr. v (0.30 Gm.) three or four times a day. Adults. Sodium, potassium or ammonium bromide or any combination of these, gr. xv to gr. xxx (1-2 Gm.) three or four times a day. Sleeplessness. Children. Warm baths. MEASLES 507 above under Delirium ' Phenacetin. Adults. Trional, gr. x to xv (0.60-1 Gm.) as a powder or in warm water, whisky, brandy or wine. Repeat in two hours if needed. Chloralamid, gr. xx to gr. xxx (1.30-2 Gm.) in powder or cold water (heat decomposes) or wine, whisky or brandy, and repeat in two hours if needed. Wild delirium. Morphine sulphate hypodermically, gr. 1/48-1/4 (0.0015-0.015 Gm.) according to age. Complications. Bronchopneumonia. Remove from the ward or other cases to prevent its spread to others. Treat as a pneumonia. (See Pneumonia, Chap. IX.) (See text.) It includes Cold air. Watch cases of capillary bronchitis. They often do better in a warmer air. Early stages. Mustard paste to whole chest every three or four hours. (For technique see Pneumonia, Chap. IX.), Fever. Sponges, packs and baths of cold water. Cough. Open air. Chest compresses. Steam inhalations under tent. Benzoin. Creosote. Water left in shallow dishes in room for moisture. Don't get air too moist. Remove child once in a while to air the room. Codeine phosphate, gr. 1/24-1/4 (0.0025-0.015 Gm.). Dover's powder, gr. 1/10 (0.006 Gm.). Every two hours at one year (Holt). Expectorants not advised. Feeble expulsion of secretions. Applications alternately of hot and cold water. Hot mustard baths. (See above.) 508 TREATMENT OF ACUTE INFECTIOUS DISEASES Oxygen inhalations diluted with air. Cupping xjhest. Changing position from time to time. Give water freely. Treatment of cardiac failure and edema of lungs. (See Pneumonia, Chap. IX.) Tympanites. Mild salines. Enteroclysis. (See Typhoid Fever summary, Chap. XIV.) Murphy drip. Rectal tube. Fomentations. * (For technique of above measure see Pneumonia, Chap. IX.) Bronchitis. Treat like a mild pneumonia. Laryngitis. Early; probably not diphtheritic. Culture should be taken, however. Late; probably diphtheritic. Give antitoxin at once, 10,000 units, preferably into vein. Early. Heat. Compresses, Technique. (See text.) Cold. Compresses, Technique. (See text.) Ice coil. Ice bag. Inhalations. Steam. Steam medicated with compound tincture of benzoin, oil of eu- calyptus or turpentine, 5i (4 c.c.) to the pint (500 c.c.) water. (For technique, see Scarlet Fever, Chap. XVII.) Warm drinks, especially in the morning. Sprays. Bicarbonate of soda, gr. xx to gi (1.30 Gm.-30 c.c.). Sprays of oils. Menthol. Eucalyptus. Camphor. Individually or in combination in 1 per cent, strength. For cough. Codeine phosphate or sulphate, gr. 1/24 to 1/4 (0.0025-0.015 Gm.) according to age. Otitis. Daily examination of the ears. For earache. Dry heat. Five per cent, phenol in glycerin. Drop in ear. MEASLES 509 Bulging. Incise. (For details and technique, see Otitis in summary of Scarlet Fever, Chap. XVII.) Adenitis. (See Adenitis in summary of Scarlet Fever, Chap. XVII.) Ulcerative Stomatitis. Usual solutions for cleanliness. Chlorate of potash, gr. ii (0.13 Gm.) in water internally every two hours. (Doubtful importance.) Chlorate of potash */ per cent, to J per cent, solution locally mouth wash. Silver nitrate 10 per cent, to 50 per cent solution touch ulcers. Tr. Iodine, or 5 per cent, chromic acid solution. Paint on ulcers. MacGuire's method; see below under Noma. Noma. Irrigate with potassium permanganate (make deep claret red solu- tion). Clip away gangrenous tissue or curette the edge. Touch the edge after curetting with fuming nitric acid, or liquified phenol, followed by absolute alcohol. Better yet free excision, cut into healthy tissue and touch edge with Paquelin cautery. MacGuire's method; cover affected area every two or three hours with a thick paste of water and subnitrate of bismuth. Remove child from other cases. Noma of vulva. Treat in same way as noma in mouth. Gastro-Intestinal Ileo-Colitis. Stop food during early hours. Give water in small quantities very frequently. Then Barley-water, arrowroot or rice water, mutton, veal or beef broth, then thicken with farinaceous foods, barley, arrowroot, rice, wheat flour, then as stools improve add boiled skim milk and gradually get back on diet. Castor oil, 3i to ii (4-8 c.c.) at one to two years. Colon irrigation to be given daily. Use salt solution 3i to Oi (4-500 c.c.) 2 to 3 quarts at 100 F. If loose stools still persist give bismuth subnitrate, gr. xx to gr. xxx (1.30-2 Gm.) every two hours, the interval being lengthened as stools decrease. Give it shaken in a little water. Castor oil should be repeated every second or third day. 510 TREATMENT OF ACUTE INFECTIOUS DISEASES If oil is not retained give, Rochelle salt 5i to iv (4-15 Gm.). If above measures fail, and only when the gut has been thoroughly emptied by the cathartic, give Opium, gr. 1/48 (0.0015 Gm.) or its equivalent m. v (tiiSO c.c.) paregoric or equivalent amounts in tincture or Dover's powder. Lengthen intervals with improvement. Copious and exhausting movements. Morphine sulphate hypodermically, gr. 1/48 to gr. 1/24 (0.0015- 0.0025 Gm.) at one to two years. Colicky pains. Fomentations; technique, see Typhoid Fever summary, Chap. XIV, or Dysentery, Chap. XVI. Very severe pain. Morphine sulphate hypodermically, gr. 1/48 (0.0015 Gm.) at one year to gr. 1/24 (0.0025 Gm.) at two years. Eyes. Conjunctivitis. Careful cleansing with saturated boric acid solutions. If severe. Cold cloths, i. e., squares of linen or cheesecloth, wet in boric acid solution and kept cold on ice until used. Apply vaseline to margins of lids to prevent sticking. Purulent conjunctivitis. Irrigation with boric acid solution. Instillation of silver salts, e. g., argyrol. Ulcers of cornea. Should seek expert advice. Blepharitis. Yellow oxide of mercury, gr. i to 5ii or 3iv vaseline (0.30 to 8 or 15 Gm.). Smear on lids. Photophobia. Shade eyes or darken room. Atropine sulphate to dilate the pupil, J^ per cent, solution. Use cautiously. Heart complications rare. Treat as under other circumstances. Kidney complications rare. Nephritis. Treat as in Scarlet Fever. (See summary, Chap. XVII.) Diphtheria. If there is a membrane on the tonsils, take a culture. Early laryngitis. Take a culture. MEASLES 511 Late laryngitis. Give antitoxin 10,000 units into vein. Don't wait for return on culture. Hospitals give all cases an immunizing dose. (See Diphtheria, Chap. XVIII, for treatment.) Tuberculosis. If cough and fever continue, suspect tuberculosis. Examine lungs repeatedly. Examine sputum repeatedly. Convalescence. Avoid exposure to a tuberculous environment. Avoid taking cold. Fresh air. Good food. Drugs. Iron. Blaud's pill, better Vallet's mass in capsule gr. ii to v (0.15- 0.30 Gm.) three tunes a day. Vinum ferri amarum (bitter wine of iron) 3i to ii (4-8 c.c.) three times a day. Strychnine sulphate gr. 1/200 to gr. 1/60 (0.0005-0.001 Gm.). Tincture of mix vomica m. i-x (0.06-0.60 c.c.), according to age, three times a day. Cod liver oil. 3i-ii (4-8 c.c.) three times a day. Allow up. When rash and fever are gone. Allow out. A week or ten days later. Release from quarantine. Give bath of soap and water. Follow with bath of bichloride 1-5,000. Give shampoo. Disinfection. Room cleaned and aired for a few days. Put no children in this room for two or three weeks. The cautious parent and institutions will prefer disinfection as in Scarlet Fever. (See summary, Chap. XVII.) Clothes and utensils may be disinfected as hi Scarlet Fever. (See Chap. XVII.) CHAPTER XX RUBELLA (GERMAN MEASLES) RUBELLA may be considered the mildest of the exanthems. Such importance as it has rests on the fact that mild cases of scarlet fever or measles may be mistaken for it and entail great risk to others. The rash is likely to be confluent, which simulates scarlet fever and is formed especially on the abdomen and the inner aspect of the thigh. It is hardly safe to make a diagnosis of German measles in an isolated case. In an epidemic the diagnosis is relatively easy. In addition to the rash the most striking feature of the disease is the enlargement of the superficial glands, especially the posterior cervical, posterior auricular and suboccipital glands. In isolated cases or in the early cases of an epidemic it is much safer to isolate the case and treat it as a scarlet fever suspect until the appear- ance of further cases settles the doubt. This disease occurs much more frequently in adults than any of the exanthems, though it is rare after middle life. The incubation period is from two to three weeks. Isolation. Many physicians think it hardly necessary, so mild is the disease and so very rare the complications, but if the physician, like the author, believes no infection is so trivial as to be neglected, other children will be sent away, if that can be done without exposing other children, and will be kept from school until the period of incubation expires, that is three weeks. If this is not done these "contacts" should be watched, and with any evidence of catarrh, trivial at the most, or with frank enlargement of the glands of the neck, they should be isolated. The fever is, with the rarest exception, of little moment and complica- tions so unusual as to be suspected of being coincidences. However, in an epidemic in and about Little Rock, Ark., observed by Geiger there occurred as complications acute arthritis in a considerable per cent, of the cases, two cases of acute nephritis and one of endocarditis. Such complications are to be treated as indicated under Acute Rheumatic Fever, for Arthritis and Endocarditis (Chap. Ill), Nephritis under Scarlet Fever (Chap. XVII). It is well to have the patient keep the bed during the few days of RUBELLA 513 temperature; allow out of bed a couple of days after and out of the house in a couple of days more. Sponge baths once or twice a day for cleanliness and comfort, moving the bowels at the beginning with calomel or salts or both and avoiding constipation after, making the diet fairly liberal, milk and milk products, broths, gruels, bread and butter, toast, cereals, eggs, rice, custards, ice cream during the febrile period and meat and vegetables after the febrile period, giving water, or lemonade freely, taking care of the mouth, by the use of boric acid or Dobell's solution constitute the treatment. Fresh air and sunlight and good nursing are the sum total of treatment. There is scarcely the necessity for the rigid fumigation and disinfection one carries out in scarlet fever and measles. If the room is thoroughly cleaned and thoroughly aired for a few days, it meets all the requirements. If disinfection is done, the rules may be found under Scarlet Fever, Chap. XVII. SUMMARY Isolation. Contacts should be kept from other children until the incubation period of three weeks are passed. Because the disease is so trivial protest is made against keeping con- tacts from school through incubation period. At least, the slightest sign of catarrh or enlargement of cervical glands should demand isolation. In sporadic cases isolation is imperative, because cases so diagnosed are repeatedly mistaken diagnoses of mild Scarlet Fever. Bed. If there is fever, keep patient in bed until gone. Baths. Sponge of soap and water for cleanliness. Bowels. Move at the beginning with castor oil Si to iv (4-15 c.c.). Calomel in divided doses gr. 1/4 (0.015 Gm.) every quarter hour for four Follow by salts 3i to iv (4-15 Gm.) or salts, Epsom, Rochelle or Glauber's alone in same doses or liquor magnesii citratis 5vi to viij (180-240 c.c.) or milk of magnesia 5ss. (15 c.c.). Diet. Fairly liberal. During fever milk or milk products, broths, gruels, bread and butter, toast, cereals, eggs, rice, custard, ice cream. Water, lemonade, orangeade, imperial drink, freely. 514 TREATMENT OF ACUTE INFECTIOUS DISEASES Care of mouth*. Use boric acid solution, 2 per cent, to 4 per cent., or DobelTs solution, half to quarter strength. Complications. EndolSditis. } (See Acute Rheumatic F ever, Chap. III.) Nephritis. (See Scarlet Fever, Chap. XVII.) Fresh air. Allow out of bed two days after fever subsides. Allow out in two days more. Cleanse room and air it thoroughly. CHAPTER XXI VARICELLA (CHICKEN POX) VARICELLA is essentially a disease of childhood and is so because it is so contagious that few children avoid it; but adults who have so far succeeded in doing so are equally susceptible when exposed. The con- tagion is usually direct, but it may be conveyed by a third person, particularly if the conveyance is immediate. Distribution of the Family. It is so trivial in its effects that much disturbance of the family to effect isolation seems hardly war- rantable and, moreover, other children are pretty sure to have been infected before the disease is recognized ; for, as a rule, the first suspicion of its presence is aroused by the eruption. There are, however, excep- tions to the statement just made and that in the case of delicate children. Mild though it be in the vast majority of instances, it is possible for it to run a severe course and unexpected and rare complications may ensue. We would not willfully, therefore, expose children and the children of the family should be kept from other children to prevent the spread of disease and that, of course, means that children should be kept from school. Some writers say it is warrantable to let children attend school for the first ten days after exposure, but that ought to mean only when the first exposure is certainly known and when there is no contact of the school child with the patient. Contacts, if removed from the patient, should be kept from other children until the period of incubation has passed, which should be considered in such cases as three weeks. Room. A light and well aired room should be chosen for this patient and isolation may not be so strict as in the more severe exanthems, unless any individuals are coming into contact with other children. The physician can convey the disease, though with a thorough airing and avoidance of visiting a child immediately, it is not likely to happen. Patient. If there is no fever nor malaise, as is frequently the case, confinement to the bed is unnecessary, but if either of the above mentioned conditions obtain, the patient should remain in bed. When the eruption is abundant a regular cleansing bath cannot be given without the risk of breaking and infecting the vesicles, an acci- dent which it is desirable to prevent. 516 TREATMENT OF ACUTE INFECTIOUS DISEASES The diet iirthe light case need in a property fed child be scarcely modified. If fever of a light grade is present, all but solid foods may be given; if, as rarely happens, the fever is high, food should not be forced, for the fever will subside in a day or two. In the meantime, milk and milk preparations and farinaceous gruels may be given. Water should be allowed freely. Skin. The one object of real consideration is the skin; for the nature of the eruption leads to scarring, which on the face, especially of a girl, is to be rigorously avoided. The eruption itches, the young child scratches and even older children, who endeavor to avoid doing so are sure to lacerate some of the vesicles, inadvertently or in their sleep and infect the lesions, causing an increased damage to the skin and in some instances setting up erysipelas. The eruption should be kept as dry as possible and dusting pow- ders of sterile talcum powder or equal parts of starch, zinc oxide and boric acid may be used for this purpose. In young children the scratching can be avoided by putting the arms in splints, by putting on stiff cardboard cuffs, reaching well above and below the elbows, thus preventing the bending of the arms and scratching of the face. Less efficacious, but less trying for the little one, are wrapping the hands in gauze and cutting close the nails. When pustules form, especially on the face, they should be evacuated by incising the edge of the pustule with a small spear-pointed lancet or a Hagedorn needle, squeezing out the pus and in very bad ones irri- gating with a fine pointed dropper with rubber bulb attached, using boric acid or diluted peroxide of hydrogen, half to quarter strength. The vesicle should not be denuded. Some men advocate painting the vesicles with equal parts of tincture of iodine and alcohol as a protective. To control the itching the skin may be dabbed with a solution of bicarbonate of soda 1 dram to the pint (4 Gm. to 500 c.c.) or stronger, or 1 to 5 per cent, phenol in sweet oil or vaseline be applied. In intense itching even 10 per cent, is used, but only over confined areas. The following prescription has been advised by Bethea : Phenolis gr. v or Camphorse gr. xv M. et adde. Hydrg. Ammon gr. xv Ung. Sulphuris q. s. ad gi Sig: Apply as directed. VARICELLA 517 In severe cases there may be some stomatitis. The mouth should be cleansed after each feeding and a mouth wash of salt solution .6 per cent., DobelFs solution half strength, or 2 to 4 per cent, boric acid solu- tion used as a preventative. Bowels. When first seen the child should be given a mild sa- line, milk of magnesia 3ii-iv (8-15 c.c.), or liquor magnesii citratis 5iv to viii (180-240 c.c.). Constipation should be avoided by a repetition of the dose or an enema. Fever. The fever is so slight as to require no treatment as a rule. In the rarer cases cold air or dabbing the skin carefully with cool water or an evaporation bath might be tried. Nervous symptoms are largely due, when they occur, to the irritation of the skin. The applications to the skin advised allay them in a measure, but bromides in doses of gr. v to gr. x (0.30-0.60 Gm.) according to the age, two years to ten years, are indicated. This may be repeated every four to six hours. Complications. Any complication is unusual, but now and then the following occur; stomatitis (for treatment see Measles, Chap. XIX), conjunctivitis (for treatment see Measles, Chap. XIX). Corneal ulcer, which may be treated with 1 per cent, atropine, pow- dered dionin and 5 per cent, yellow oxide of mercury (Wyler). Nephritis (for treatment see Scarlet Fever, Chap. XVII). Herpes Zoster, which is to be treated by careful protection, keeping the part dry by applying sterile dusting powders or painting with collo- dion, the object being to prevent infection, to which the trophic changes in the lesion render it peculiarly susceptible and erysipelas. Convalescence is rapidly established and if it has been a severe attack iron may be indicated as a tonic, but in my estimation fresh air and food are far better for such a purpose. Release from Quarantine. The patient may be considered as no longer a source of infection when the last scab has dropped off. By this time he is ready to go out and is allowed to do so after a thorough cleansing bath and shampoo. Disinfection. The room needs only good cleaning and airing for a few days. SUMMARY Distribution of the family. Rare for any member of the family to escape it. Usually is so light that isolation of other children is hardly advisable. Exception should be made in the case of sickly children, who should be removed from the environment of the patient. 518 TREATMENT OF ACUTE INFECTIOUS DISEASES School. Some physicians let exposed children go to school for ten days but only when date of first contact is surely known. Contacts should be kept from other children for three weeks, the incubation period. Room. Light and well aired. Physician. Wash hands on leaving case. Avoid seeing another child at once. Patient. Should go to bed, if there is fever or malaise; otherwise, not necessary. Bath. Cannot be given when the eruption is abundant as the vesicles may break and become infected. Diet. There need be little change from the usual unless there is fever; then exclude solids. Water should be given freely. Skin. Danger of scarring on the face. Keep eruption dry. Use sterile talcum powder or 3 starch zinc oxide \ equal parts, boric acid J To keep young children from scratching and infecting, put card- board splints around the arms at the elbows, or wrap the hands in gauze, or cut the nails short. Treatment of pustules. Evacuate by incising edge of pustules with small lancet or Hagedorn needle. Gently syringe out pus. Irrigate the bad ones with a fine pointed dropper, using boric acid solution, or Peroxide of hydrogen, quarter to half strength. Itching. Bicarbonate of soda solution. Phenol, 1 per cent, to 5 per cent, hi olive oil or vaseline. If severe, 10 per cent, over a limited area. Bethea recommends: VARICELLA 519 Phenolis ............................................... gr. v or Camphorae ............................................. gr. xv M. et. adde. Hydrg. Ammon .......................................... gr. xv Ung. Sulphuris q. s. ad ................................... 5 l Stomatitis. Mouth cleansed after each feeding with Physiological salt solution 3i to Oi (4 Gm. to 500 c.c.) or Dobell's solution, half strength, or boric acid solution, 2 per cent, to 4 per cent. (See Measles, Chap. XIX.) Bowels. When first seen a mild saline of milk of magnesia 3ii to iv (8-15 c.c.) or liquor magnesii citratis 3iv to viii (120-240 c.c.). Fever. Cold water dabbed on skin. Cold air. Nervous symptoms. Usually due to itching. Apply sedatives to the skin (see above). Bromides gr. v to x (0.30-0.60 Gm.) according to age, every four to six hours. Complications. Stomatitis. (See Measles, Chap. XIX.) Conjunctivitis. (See Measles, Chap. XIX.) Corneal ulcer. 1 per cent, atropine sulphate. Powdered dionin. 5 per cent, yellow oxide of mercury. Nephritis. (See Scarlet Fever, Chap. XVII.) Herpes Zoster. Protection against infection. (See text.) Convalescence. Fresh air. Abundant food. Iron, i. e., bitter wine of iron (vinum ferri amarum) 3i-ii (4-8 c.c.) three times a day after meals. Release from quarantine. When the last scab has come off . Give a cleansing bath and a shampoo. Disinfection. Clean and air the room. CHAPTER XXII PERTUSSIS (WHOOPING COUGH) BY the layman whooping cough is looked upon as a disease of lesser significance, an annoying inconvenience rather than a danger; by the physician in general, in spite of the statistical evidence of its high mor- tality, its gravity is not duly appreciated. Measles and whooping cough are exceedingly dangerous diseases when attacking young children under two years, but the low mortality among the older children seems to determine the attitude of the public to the disease in general. Adults are immune only by virtue of a previous attack. Whooping cough is highly contagious; few children exposed to it escape the infection and the incidence of the disease among the very young, six months and under, a period which seems to enjoy a relative immunity to many of the other infections of childhood together with the frequency of bronchopneumonia of severe grade and the difficulty of feeding when vomiting is frequent, makes it a disease to be dreaded and by every possible means averted. The mortality under one year is said to be about 25 per cent. Unfortunately, the very period during which it is most contagious is that in which it displays nothing characteristic to afford a warning of its real nature and permit of avoidance, for in the early or catarrhal stage, it is looked upon as a coryza and a tracheitis or bronchitis, until the persistency of the cough, its periodicity, its paroxysmal character or the vomiting accompanying the paroxysm give the hint of the real condi- tion, while the one or two weeks of this stage has offered abundant opportunity to infect all susceptible individuals who are in contact with the patient. When the paroxysmal or whooping stage has arrived the infectivity has materially diminished, some good authorities think has passed, though such an opinion seems to me at the present time not sufficiently substantiated to act upon. Probably three weeks corre- spond fairly well with the infectious period ; but six weeks for a quaran- tine are safer. The etiological agent is a bacillus, morphologically, but not culturally identical with the influenza bacillus of Pfeiffer. It was described in 1906 by Bordet and Gengou. The incubation period is PERTUSSIS 521 variously given from a few days to a little more than two weeks. Three weeks is a safe figure for practical purposes. Symptomatology. The course may be divided into three stages: first the catarrhal with symptoms of a "cold," tracheitis, bronchitis, cough and a little fever; the cough arouses suspicion by its persistency, its relative severity at night, and by a curious coughing down the scale so to speak, until the last breath is exhausted and the face is suffused or blue. This lasts about ten days. The second period is the spasmodic, culminating in the typical whoop. It must be remembered, however, that a whoop may be absent throughout ; another significant result of the paroxysm of coughing is the vomiting, which has diagnostic significance even in the absence of the whoop. The duration of this period cannot be definitely fixed and may last for weeks; though commonly the whole course of the disease is about six weeks. The third period is that of decline of cough and other symptoms. It not infrequently happens that paroxysmal coughing and even a whoop will recur for months on the occasion of a cold or irritation of the trachea or larynx that will be mistaken for a recurrence. The blood may show a mild leucocytosis, up to 15,000 to 25,000, and the differential count a relative increase in lymphocytes, even up to 80 per cent, at times. The most serious features of the disease are bronchopneumonia as a complication, the malnutrition incident on the vomiting, and tuber- culosis as a sequel. Others will be discussed under treatment. Excellent results with the complement fixation test reported by the workers of the New York City Board of Health make it urgent to utilize it, in suspected cases, when other children are endangered, pro- vided the technique of the reaction can be properly carried out. This test seems to be more reliable than the agglutinin test. The latter has little or no value after the first week and it is necessary that it must be positive in a dilution of not less than 1 :200. It is only fair to add that all investigations do not agree about the value of these tests. Distribution of the Family. As has been said the long delay of the diagnostic symptoms during the most infectious stage makes infection of other children almost certain when whooping cough has not been expected, but in the presence of an epidemic, the first signs of coryza or the first cough should make the individual a suspect and measures for protection of the other children be taken. So serious is this condition to infants and to weakly children that the attempt should be made under any circumstances to prevent infection. The most effica- cious means is by removing the other children to another house, unoc- cupied by children or if that cannot be done, to endeavor to preserve 522 TREATMENT OF ACUTE INFECTIOUS DISEASES a quarantine t>f the affected case in the house. This last is especially difficult, because of the long course of the disease and because of the unwisdom of cooping up in the house the infected child, who has no complications. This quarantine shorld last six weeks. The children who are removed from an infected house become suspects and must themselves be isolated until the period of incubation of the disease has elapsed. The incubation is usually set as one to two weeks, but to avoid the exceptional case these "contacts" should be isolated for three weeks. The mode of infection is by direct contact, the organism being borne in the fine spray of a cough or sneeze or even in all probability in the act of laughing and talking. It is to be remembered, however, that it is possible for a third person to carry the disease, when the conveyance is rapid; this is important to remember, when the mother or other person in contact with the patient may be tempted to go from one to the other. Another important fact to be kept in mind is that the infection can undoubtedly be conveyed in the open air and realizing the carelessness of nurses and mothers, too, in taking the affected children about, when allowed out, in the presence of an epidemic young infants should be kept from gatherings of children and decidedly so if any of them are coughing. The prophylactic use of vaccines hi children who are exposed is now generally appreciated. See Prophylaxis. Room. A large room with the possibilities of light and air should be chosen or a room opening off a balcony, verandah or even fire-escape. It is well when the opportunity affords to select two rooms opening into each other; this to permit of frequent ventilation, by changing the patient from one to the other. It is possible that the rooms become so infected that the patients reinfeot themselves, so that disin- fection of the room with a formaldehyde candle, lamp or other contri- vance, every few days is advisable. Too much fresh air one cannot have, but draughts, high winds and dust are to be avoided. Open air is most desirable, and the patient can be kept on the balcony a good part of the time, but in the colder weather, the frequent attacks of coughing, that must displace the coverings, as the child sits up, makes it less feasible than in other infections of the bronchial tree. Where such exposures are frequent it is well to keep the temperature about 70 F., not allowing it to go much below 65 F. In mild cases children may be dressed and taken out in the open air in suitable weather, but only when it can be guaranteed that no contact with healthy children may take place. A change of climate if a child can travel and entail no PERTUSSIS 523 risk to others is often of great help ; especially from the North in Winter to a milder clime. Clothing should be flannel next- the skin whether in bed or up and about to avoid the chill that comes from wet clothing drenched with the sweats after a paroxysm and from the frequent exposures. Overclothing, which keeps the skin perpetually moist and enhances the possibilities of bronchial involvement and burdens the chest, is to be avoided. Those children who are very young, very weak or have considerable bronchitis have to be watched with more care in the open air and many good men prefer to keep them to the room at an even temperature, with frequent ventilation. Nurse. Considering how highly contagious the disease is and that adults as well as children are susceptible to it, it is hardly just to ask a nurse to take a case of pertussis unless she has already had the disease, for while the danger to an adult is minimal, the length of time that she would be debarred from exercising her profession would work an injustice. A nurse who is willing might be given prophylactic vac- cines. The nurse should realize that while rare, still direct conveyance of the disease through the third person is possible and should avoid contact with other children while off duty. While on duty the nurse should not leave her patient, especially if it is a young child or infant, for suffocation may occur in a paroxysm or a convulsion may ensue. Physician. The physician should avoid the small risk of convey- ing the disease by wearing a gown and washing his face and hands on leaving the sick-room. He should not make his next visit on a child unless some little tune in the open air intervenes. If he himself has not had the disease, he should be careful not to stand directly in front of the patient during a paroxysm, unless there is some special need. Perhaps a mask, like a chloroform mask over the nose and mouth, the gauze or cover of which has been wet with 1 to 20 carbolic acid may help in avoiding infection. Vaccine might be used prophylactically, though the risk to him is not as great as to the nurse. Precautions in the Sick-Room. Strict isolation to the quarters assigned the patient, as long as he is confined to his room, and when the patient is permitted to go out of doors careful avoidance of contact with other children is the rule to be observed. All secretions are to be received on cloths and burned or into recep- tacles and sterilized. Bed linen, night clothing, towels and so forth should not be sent 524 TREATMENT OF ACUTE INFECTIOUS DISEASES to the family laundry until they have been ^boiled an hour separately or allowed to soak overnight in 1 to 20 carbolic acid. Cats and dogs are believed to carry the infection and ar^ to be ex- cluded from the sick-room. Two children should not be treated in the same room. Bed. For treatment in the open air the bed is made in a special manner, see Pneumonia, Chap. IX. All patients with whooping cough are not to be confined to bed. The indications for remaining in bed are the presence of a febrile reaction or any serious complication. In this disease the nerves are particularly affected and trivial excita- tion can precipitate the paroxysm; among these the slight chill from being put into a cold bed. Baths. A cleansing bath should be given every day with soap and tepid water. This may be done on a blanket or between the folds of a blanket, exposing only one part at a time. Diet. For older patients with the milder form of attack, who are not confined to the house, no material change in the diet need be instituted, provided, of course, that the diet is suitable for a child of a given age. It is the association of vomiting with the paroxysms and the gastro- intestinal complications that may occur that make feeding in whooping cough a difficult problem. When there are no serious complications, gastro-intestinal or pul- monary and the vomiting entails merely a loss of food ingested, the deficit can be made up by a little tact and perseverance. After the explosion of the paroxysm of coughing with which the vomiting is so closely associated, there is a period of quiescence for both the organs of respiration and digestion. One should take advantage of this to offer food, so that as large a portion of the meal as possible may be digested and passed along into the intestinal canal before the next paroxysm is due. On the other hand, as the time for the succeeding paroxysm draws near, the ingestion of food excites the coughing reflex and precipitates the paroxysm. When the paroxysms become very frequent, every hour or every half hour, no considerable period is left between paroxysms for gastric digestion ; then the problem is to introduce such food as requires a brief stay in the stomach and carries with it a maximum amount of fuel. In early childhood and infancy the staple article of diet is milk, plain or modified, and when one remembers the physiology of milk digestion, the precipitation of the curd, the digestion at the periphery and the PERTUSSIS 525 three hours required for its complete removal from the stomach, one sees the benefit accruing from small quantities of milk taken frequently, thus affording the maximum surface for digestion and the use of means or methods that lessen the bulk of the curds. Among these measures are dilution with water, half and half affording the optimum for rapidity of digestion, or the use of lime water, 1 in 20 or the use of a cereal water barley or arrowroot as a diluent instead of plain water, or the use of milk gruels, using barley, wheat flour, rice, arrowroot, or some of the malted or farinaceous foods used for infant feeding, or whey, buttermilk, koumys, or predigested milk or animal broths may be given or their food value added to by thickening with farinaceous foods, custards baked or soft, jellies or gelatin carrying sugar, junket, soft egg or albumin water, but always in giving these liquid foods, some estimate must be made of the amount of fuel value they represent in the twenty-four hours, for too often is it forgotten that considerable bulks of liquid food may be ingested that have almost no energy value, for example, animal soup and broths. Wet toast, milk toast or softened rusks, boiled rice and cereals with milk and cream or sugar may be added. No dry food should be given, lest the articles irritating the pharynx precipitate the attack of cough- ing. In infants on milk mixtures, the dilutions should be increased, and the feedings made in smaller amounts at more frequent intervals. In the worst cases with gastro-intestinal indigestion, every effort is set at naught and one has recourse to rectal feeding, but with small hope that it will be borne sufficiently long or be attended with sufficient success to more than meet short-lived emergencies. Care of the Patient. In the lighter cases, going out of doors, only the daily bath in the morning, flannel next the skin, taking care not to overclothe, ordinary oral hygiene and cleansing the nose with sprays of boric acid solution 2 per cent, or DobelTs solution quarter strength or with the same applied on a swab of cotton, with destruction of the secretions during the catarrhal stage, are all the measures indicated. When serious complications of the respiratory tract or of the alimentary tract ensue, the care of the mouth is of great importance. Bowels. Unless there are complications the bowels are to be kept open with mild cathartics, such as cascara in the older children and milk of magnesia in the younger. Fever. The fever in uncomplicated cases is so trivial as to require no treatment; it is, however, an indication for keeping the patient confined to the bed. Cough. The paroxysmal cough is the characteristic symptom 526 TREATMENT OF ACUTE INFECTIOUS DISEASES of pertussis. The frequency and severity of th.ese paroxysms deter- mine in no small measure the prognosis in the disease. Not only is the cough in itself exhausting, but in the severe. cases it may be responsible for suffocation, convulsions or cerebral hemor- rhages. More than this it is accompanied by vomiting, so frequent at times that it is absolutely incompatible with adequate nutrition and in the very young and weakly is the lethal factor. Efforts in the treatment of whooping cough are largely directed to the diminution of the number of paroxysms, to afford rest and make possible a sufficient feeding. If vaccines are of value then* early use is obviously indicated to ame- liorate this symptom. There is no reason to believe that any of the empirical measures used heretofore shorten the disease; they merely ameliorate the condition of the patient; hence, if the disease is mild and the paroxysms relatively infrequent, no treatment should be given other than that determined by the hygienic and dietetic measures already laid down. If we can avoid drugs we should do so, for it must always be remem- bered that a drug does many things to the organism besides that which we particularly desire and some of these drug effects are deleterious, as for example, the disturbance of digestion in a disease in which so much depends on the stomach. In cases of moderate severity we may, then, with advantage, see what local measures effect before having recourse to medication. LOCAL PROCEDURES Mechanical Support. Few simple devices have been rewarded with more success than the one recommended by Kilmer, the appli- cation of an elastic belt to the abdomen, chest or both. The support given by this contrivance lessens the vomiting in no small measure and modifies the frequency of the paroxysm. It finds its greatest application in infants and weakly children with poor abdom- inal tone, such as obtains in rickets. Kilmer's instructions are as follows : "A stockinette band is placed upon a baby ... in the same manner as is done by orthopedists before applying the plaster-of-Paris jacket. This band extends from the axilla to the pubes and fits the baby snugly. Two shoulder straps are used to prevent the band from slipping down. Upon this stockinette band a single width of elastic bandage is sewn, extending entirely around the body and covering the abdomen. The bandage is sewn on when very slightly on the stretch." If the vomiting is not con- trolled the belt may require a little tightening. The effect is particularly noticeable on the vomiting. A similar elastic bandage may be sewed on PERTUSSIS 527 the stockinette to cover the chest and diminishes the number of par- oxysms. These may be worn separately or together. 1 All forms of excitement and highly emotional states should be avoided ; gentle persuasion in nervous children exerted, which while it cannot abort a true paroxysm, may lessen the cough often suggested to the child which precipitates a paroxysm. Fresh air, avoidance of dust, prevention of chilling by exposure to draughts, cold beds, etc., constitute no mean part of the treatment. Numerous sprays, local applications to the air passages and insuffla- tions have been advised. They are of more than doubtful efficacy, while they often excite and alarm the child and aggravate the condition. Inhalations. Inhalations of medicated steam will sometimes lessen the number and severity of the paroxysms and lessen the cough of bronchitis, occurring between the paroxysms or render more liquid and easy of discharge the mucus of a bronchitis. It must be remembered that fresh air is of first importance in whoop- ing cough and that it should not be sacrificed to long inhalations, which themselves from the heat and dampness may become depressing. Again it must be remembered that one case may find more relief from one agent than from another, or that better results are afforded by occasional change of the medicament employed. One may try the compound tincture of benzoin first, three or four times a day, more especially at night, when the paroxysms are likely to be worse and sacrifice sleep, or the frequency and length of time may be determined by the degree of relief afforded. A dram or two of compound tincture of benzoin is placed upon the surface of hot water; the drug is carried with the steam and inhaled. Simple devices may be used, such as a pitcher, a carafe, or a simple kettle to contain the hot water, a cone of paper arranged over the mouths of the vessels or the spout of the kettle. If the latter is used, it may be kept steaming and a rubber tube attached to the spout may be attached at the other end of a funnel, to facilitate the inhalation. Another simple device that is especially applicable to children is as follows: the child lies on the side of the bed, a pitcher filled with boiling water, to which the medication is added, is placed on the floor on a level lower than the face, a stiff piece of cardboard, previously warmed to lessen condensation of the steam, is bent into the shape of a half cylinder and, as an inverted trough, conducts the steam from the pitcher to the face. Croup kettles of various designs may be used, but one must always 1 "Whooping Cough A New Method of Treatment." Theron W. Kilmer. New York Medical Journal, June 20, 1903. 528 TREATMENT OF ACUTE INFECTIOUS DISEASES be on the sharp lookout for fire when the alcoholjamp is used. Electric heaters are of course to be preferred when accessible. Of the different designs of croup kettle my choice is for one made by Lewis and Conger of New York on designs of Holt. It adds safety to convenience. The inhalations are altogether more efficacious if given under a tent There are numerous ways of contriving this; ropes or bandages about the four posts of the bed, or where posts are lacking improvised posts at the corners of laths or canes, over which a sheet may be thrown. A sheet may be thrown over an open umbrella. It is better that the whole body should not be included in the tent, only the head. This can be done by arranging four improvised posts, two on each side, a little way apart, connected by rope or bandage with a sheet or rubber sheet over them. Next to benzoin try creosote. This may be given in the same way; a dram on the surface of the hot water used in any of the receptacles mentioned, in the way mentioned. In some of the croup kettles, such as Holt's, a sponge carried in the spout receives the creosote and the steam passing through the sponge conveys the vapor of the drug. A mixture of creosote (3ii) (8 c.c) and compound tincture of benzoin (5ii) (60 c.c.) affords a good combination. Chloroform. When the paroxysms are frequent or severe, threat- ening convulsions, or asphyxia, a few drops of chloroform on a handker- chief, sponge, towel or the hand should be given to inhale. Other Measures Advised. Nagele has advocated pulling the jaw down and forwards, after the manner of the anaesthetists, to interrupt the laryngeal spasm. Smith, quoted by Ker, says that prolonged spasm may be broken by plunging the infant's hands into cold water. In the most severe form of spasm, intubation may be necessary and does afford relief. For technique see Diphtheria, Chap. XVIII. For inhalation one may try oil of eucalpytus, in the same propor- tions as the benzoin, or menthol gr. xv in 3i to ii (1 Gm. in 4r-S c.c.) of compound tincture of benzoin as recommended by Holt, or cresolin, two or three times in the twenty-four hours. There is on the market a special form of vaporizer for cresolin. Drugs. No end of drugs have been recommended to relieve the paroxysms of pertussis, which in itself constitutes the proof of their very limited value. The condition to be attacked is a hyperexcitability of the neuromus- cular apparatus of the larynx, as well as a general nerve excitation. It would seem rational, then, to select drugs that have a sedative effect on the nervous system and those are the drugs that have been shown empirically to be the most efficacious. It must be remembered, however, PERTUSSIS 529 that these drugs all have undesirable effects as well, the most of them being depressant to the circulation and so should not be used indefinitely or recklessly. Again it is to be remembered that individuals react differently to the different drugs and if results are not obtained after full dosage, it is better to try another rather than keep on with the first in hopes that the action is merely delayed. My own preference is for the drug especially advocated by Holt and now used very extensively, antipyrin. Antipyrin. This drug is easily soluble in water and has a slightly bitter taste, but hardly enough to make it desirable to disguise the taste. It should be given in liberal quantities. Holt advises for a child six months old gr. i (0.060 Gm.) every three hours and, if there are no untoward symptoms increase the dosage up to every two hours. At a year one may begin with a grain and a half (0.10 Gm.) and at two years gr. ii (0.125 Gm.) every four to six hours, the dosage being increased up to every two hours. As the paroxysms are as a rule worse at night, one can with advantage combine with the antipyrin sodium bromide, in doses of gr. ii (0.125 Gm.) at six months, gr. iii (0.20 Gm.) at one year and gr. iv (0.25 Gm.) at two years to be administered in the latter part of the day and night. By some it is deemed advisable to stop the drug after a week, having recourse to some other drug, as bromide for a few days, alternating by periods with antipyrin. The drug is contraindicated in weakly children with impaired circu- lation or with pneumonia. Bad effects rarely come from such dosage as is advised unless the patient has an idiosyncrasy for the drug. The most common idiosyncrasy is marked by an erythematous erup- tion or localized edema. More rarely one sees evidences of collapse, pallor, weak pulse, low temperature and cyanosis, but this is less common and less marked than after acetanilid. The continuance of the drug must depend on results and the reaction of the child to the drug. Belladonna. No drug has enjoyed a reputation for efficiency in pertussis comparable with belladonna. Belladonna is ranked as an antispasmodic and its pharmacology is sufficiently worked out to justify this classification. Its effects on motor nerve endings supplying smooth muscle structures explains its good effects in many forms of spasm, but will not explain the results obtained in the spasm of the striped muscles of the larynx. Pharmacologists have not adequately explained its clinical results in this disease. Cushny has suggested that perhaps it owes its efficacy to its content 530 TREATMENT OF ACUTE INFECTIOUS DISEASES of hyoscine operating to depress the irritability of ,the respiratory center. If this is true, one would not substitute atropine for the Galenical prep- arations of the drug. It is possible that a depression of sensory, nerve endings in the mucous membrane of the trachea affected may play a role. Two facts must be kept in mind in using the drug to control the paroxysms. (1) That it has to be used to the physiological limit, that is, to the point of the earliest toxic manifestation to get results; and (2) that there are many individuals that have an idiosyncrasy for this drug; hence, the beginning dose must be small, a tentative dose. The most consistent advocate of this treatment was Jacobi, whose definite instructions in the usage of this drug in his editor's note to the article on Pertussis in Modern Clinical Medicine cannot be improved upon and which I quote here. Taking the case of a child of two years, he says, "Give 6 drops of Tr. Belladonna three times a day; unless the drug cause a 'feverish' flush on the cheeks within half an hour, which must last half an hour or more, it has no effect. If 6 drops have no such effect, give 7, 8, 9 or more every time. The effect must be attained every time, three times daily. Give as many drops as are required to accomplish that end. After a few days more drops will be required. After about a week the full dose will prob- ably have to be doubled." I would advise before starting with so large a dose as advised by Jacobi that a small dose of m. i (0.060 c.c.) of the Tincture be used, for in cases of idiosyncrasy the susceptibility is demonstrated to small doses. If there are no untoward effects one may rapidly mount to the dose advised. If there be no idiosyncrasy one feels free to give large doses, for this is one of the drugs that children bear proportionately better than adults, taking as J. Walter Carr says at four or five years as large doses as adults. One may give doses at more frequent intervals, every four hours, if preferred, but when the full dose is attained, to the production of flushing with its attendant disagreeable manifestations, I think the fewer doses are to be preferred. If we are treating an infant of six months, one begins with a dose of m. ss. to i (0.006 c.c.) three times a day or the fluid extract m. 1/10 (0.006 c.c.), at one year double the dose, at two years begin with m. iii (0.20 c.c.) of tincture and increase a minim (0.060 c.c.) a dose every day to "flushing." Beside the flushing one may anticipate dryness of the mouth, some hoarseness and dilated pupils. Idiosyncrasies for the drug are shown both by the symptoms just specified occurring with a minimum dose or by a general erythema, PERTUSSIS 531 suggesting scarlet fever, a talkative delirium and more rarely by vomiting and prostration. If the delirium is wild it may be controlled by morphine, while prostra- tion or collapse may be combated by caffeine, camphor and strychnine. The bladder should be emptied by catheterization, if retention occurs, and in severe cases saline infusions help to encourage diuresis and elimination. Bromides. These drugs are hardly potent enough to be of much avail unless pushed to a point of general depression, but combined with antipyrin may enhance the sedative effect of the latter. They may be used with the antipyrin in the latter part of the day and more especially when there is much insomnia. The dose for a child of two should be gr. iii (0.20 Gm.) with each dose of the antipyrin used. Some authors recommend, however, that they be used alternately a week at a time. Opium and Its Derivatives. The efficiency of opium in lessening cough, and in inducing sleep sorely tempts the physician and the parent to an unwise usage. It must be remembered that the disease is to be long drawn out, that a certain degree of tolerance will be established and that children are highly susceptible to its toxic effects. For all these reasons it should be used sparingly and only when imperative, that is, when the other sedatives specified are without effect and danger threat- ens from the exhaustion induced by the paroxysms. Of opium itself, the best preparations are Dover's powder and pare- goric (Tr. opii camphorata). Of its derivatives, codeine and heroine. Reserve their usage for the severe cases or confine the dosage to night administration. Try first the effect of the least harmful of these preparations, codeine. It may be given in solution as the phosphate or in tablet form to the older children as sulphate, the dose being gr. 1/100 (0.0006 Gm.) at six months, gr. 1/60 (0.001 Gm.) at one year, gr. 1/40 (0.0015 Gm.) at two years up to gr. 1/8 (0.008 Gm.) or gr. 1/4 (0.015 Gm.) in the older chil- dren. Of the paregoric m. iii-iv (0.20-0.25 c.c.) at six months, m. v-x (0.30- 0.60 c.c.) at one year, m. x-xx (0.60-1.30 c.c.) at two years up to 3ss. (2 c.c.) at five years. Of the Dover's powder gr. 1/8 (0.008 Gm.) at six months, gr. ss. (0.030 Gm.) at one year, gr. i at two years and gr. ii (0.125 Gm.) at five years. Talbot with due warning of possible danger entailed, urges the necessity of adequate doses of opium in cases threatened with exhaus- tion, even to the point of producing prolonged sleep. 532 TREATMENT OF ACUTE INFECTIOUS DISEASES These drugs are best administered at bedtime and in severe cases may be administered again during the night. MEASURES RECOMMENDED BY OTHER AUTHORITY Quinine. This drug has long been in use in pertussis. The gen- eral instructions are to administer it late in the disease and then in large doses of gr. i to gr. iss. (0.060-0.10 Gm.) for every year of the child's life, two to four times a day. It is hard to see what benefits can accrue so late in the disease to offset the discomforts or possible toxic effects of so large dosage. Heroine. A derivative of morphine, is preferred by some men to codeine. The dose of the hydrochloride is gr. 1/100 (0.0006 Gm.) at one year, to gr. 1/24 (0.003 Gm.) four to six times a day or to be used at night as codeine or opium. Many other drugs have been recommended, the only excuse for using which lies in the fact that when the more tried measures fail, one feels justified in using any means that holds out any promise whatsoever. Bromoform has had considerable vogue, but it is the consensus of opinion that little is to be expected from it, while toxic manifestations are readily elicited. To children old enough it may be given dropped on a lump of sugar. If not so, it is best given in emulsion, but it must be remembered that it easily settles out of the emulsion; hence, thorough shaking must precede its usage each time, and it is well to have a fresh emulsion made before the bottle is exhausted, to avoid the large dose that is almost sure to result in the bottom of the bottle from this fact. The dose is a 1/2 minim to 5 minims (0.030-0.30 c.c.) three times a day. It must be used with caution. Personally, I prefer not to use it. Fluoform, in 2 per cent, solution in water in doses of 3i (4 c.c.) of the solution every two hours has been recommended. Another fluorine compound is a difluordiphenyl; it is used locally on the chest in the shape of an ointment. This is known as antitussin. I have had no experience with these preparations. Benzyl benzoate is highly recommended by A. W. Bingham of New York in doses of 20 drops of the 20 per cent, solution given in milk at three-hour intervals. This dose is suitable for children as young as two years. Corresponding doses are given in infants. Specific Treatment. Specific treatment by the use of sera and vaccines awaits upon the certain identification of the etiological agent. This certain identification has not come, but the claim of Bordet and Gengou that they have isolated the bacillus responsible for the disease seems so good, that this organism, isolated from the bronchial mucus PERTUSSIS 533 raised by the paroxysm in the earlier stages of the disease, has been utilized for the production of a vaccine. Although vaccines have been used extensively in the past five years since the first edition of this book there is not yet an agreement as to their value; but I think that many excellent pediatricians look with favor upon their use and as no bad results, genreal or local, have attended the treatment so far, I should be inclined to use the treatment. Talbot gives an injection every other day for three or four doses; first dose 1,000,000,000; second dose 1,500,000,000; third dose 2,000,000,000; fourth dose 2,000,000,000. This dose is for children two years or over. For children under two years half that dose. The Department of Health of the city of New York recommends for children under one year an initial dose of 250,000,000 followed by 500,000,000, 1,000,000,000 and 2,000,000,000 and 2,000,000,000 at intervals of two to three days. An autogenous vaccine may be used, if the organism is recovered, but in most instances one has recourse to commercial products. Huenekens emphasizes that the vaccine should be very fresh, not more than a week old and no preservative be used. Various sera have been tried without encouraging results. Insomnia. Sleeplessness is so much the result of the frequency of the paroxysms that measures that relieve the latter improve the former. The doses of bromides advised towards the latter part of the day either in combination with the antipyrin or alone gr. iii (0.20 Gm.) are helpful. Chloral is well borne by the child and it may be administered at night in doses of gr. ii (0.12 Gm.) at six months, gr. iii or gr. iv (0.20- 0.25 Gm.) at one year and if not efficacious the dose may be repeated in two hours. It is somewhat irritating to the stomach; hence, it may be given by the rectum in a couple of ounces of warm milk. Trional has also been used for the purpose, gr. ii to gr. iv (0.12-0.25 Gm.) at two years to be repeated if needed. Threatened exhaustion from loss of sleep may make the use of opium imperative in cases specified above. Complications. Vomiting regularly accompanies the disease, but may become so persistent and severe as to constitute a complication. The first consideration is that of the diet which has already been discussed under that heading. The application of the abdominal support, such as the Kilmer belt, in many instances lessens the severity and frequency of the vomiting in no small measure. (See mechanical support described above.) When the vomiting occurs with the paroxysms, those measures which lessen the attacks of coughing will diminish the vomiting, but at times 534 TREATMENT OF ACUTE INFECTIOUS DISEASES the vomiting may occur apart from the paroxysms, as an expression of gastric irritation. In these cases, small doses of bicarbonate of soda, gr. v (0.30 Gm.) with the food may be helpful, while in the more severe cases cocaine hydrochloride, in doses of gr. 1/6 (0.010 Gm.) twice a day has been recommended. (Eustace Smith quoted by Ker.) Diarrhea is to be treated by a consideration of the diet, an occa- sional dose of calomel in divided doses, gr. 1/10 (0.006 Gm.) every ten minutes for 10 doses or gr. 1/4 (0.015 Gm.) every 1/4 hour for 4 doses, followed by bismuth subnitrate, gr. xx to gr. xxx (1.30-2 Gm.) every three or four hours and by occasional irrigations. The small doses of calomel act, too, as an antiemetic. Ulcer of the Frenurn. An ulcer of the frenum of the tongue occurs now and then in whooping cough. It is usually superficial but may be deep. It is due to the projection of the under surface of the tongue upon the cutting edge of the incisors. Efforts at healing are made by boric acid mouth washes and occasion- ally touching the ulcer with silver nitrate stick. If it resists we may call dental aid to protect the tongue against the teeth or if the process is serious sacrifice the teeth, which, of course, are first teeth. Hemorrhages. These occur in various parts of the body, but require no treatment (or expectant or symptomatic treatment in case of cerebral hemorrhage), except nasal hemorrhages. These at times may be sufficiently severe to require the application of adrenalin, in a spray of 1 to 10,000 or if the bleeding point can be seen, on a pledget of cotton, 1 to 1,000. Very rarely the nares may require plugging. Coakley advises as a hemostatic tannic acid, mixed with water to the consistency of a syrup and applied on a pledget of gauze. Bronchopneumonia. This complication is what makes whooping cough the serious disease it is. It is responsible for the vast majority of the fatal cases, estimated by some authorities at 90 per cent. It is prone to occur after the paroxysmal stage is well established, in the second or third week. The treatment is that of bronchopneumonia under other circum- stances and will be found described under Pneumonia, Chap. IX, and under Measles, Chap. XIX, and Streptococcus Pneumonia, Chap. X. It is necessary to emphasize the importance of the open-air treatment of these cases, the adoption of which has materially lowered the mor- tality of this dread complication. The only contraindication is a laryngitis of severe grade. Such treatment must be carried out with rigid regard for proper PERTUSSIS 535 technique, which will be found described in the chapter on Pneumonia, Chap. IX. Convulsions. Next to bronchopneumonia this is the most fatal of the complications of whooping cough. The nervous system is in such an irritable condition that slight sources of irritation may pre- cipitate a convulsion and, indeed, convulsions may occur in relatively mild cases; they occur in all degrees of severity, from trivial short-lived spasms to prolonged and fatal attacks. The physician is rarely at hand at the beginning of the convulsion and until he arrives great alarm is experienced by the family and for their sakes, as well as for that of the child, some instructions should be given to meet the condition. Perhaps the best measure to be pursued by the* parent is the giving of a hot mustard bath or pack and because of the lesser disturbance and handling of the patient demanded by the latter procedure, the pack is to be preferred. Into a quart of luke-warm water a tablespoonful or handful of mus- tard is thrown, a towel dipped in it and wrung out and wrapped about the baby. The child is then wrapped about with a blanket, an ice-cap put at the head or lacking the ice-bag, cracked ice in a towel, a hot water bottle at the feet, a small fold of a towel tucked in the corner of the mouth to protect the tongue from the teeth, but with care not to ob- struct the breathing and then the child kept as .quiet as possible. The pack is to be continued for ten or fifteen minutes, then the child is wrapped in a dry blanket, heat kept about the body and extremities and cold at the head. The bath is prepared by using mustard, a tablespoonful to the gallon ; use a small part of the water at a tepid temperature to prepare the mustard and then add the rest of the water, raising the temperature of the bath to 100 F. (It is to be remembered that hot water kills the ferment in the mustard and no oil will be generated to effect an irrita- tion.) The bath can later be raised three or four degrees. It is con- tinued some ten minutes and then the child is dabbed dry, wrapped in a blanket and treated as after the pack. The physician's first effort is to promptly interrupt the convulsion and his next to prevent its recurrence. To interrupt the convulsion nothing is better than a few whiffs of chloroform, given with care, not crowded down upon the face. As soon as the desired result is attained, the prevention is sought in the adminis- tration of chloral, a drug toward which a child has considerable tolerance and particularly when convulsed. It is better administered by the rectum to avoid its irritating effects on the stomach. The irritation to the rectum is prevented by the use of an ounce or two of warm milk 536 TREATMENT OF ACUTE INFECTIOUS DISEASES as a solvent. The dose at six months is 3 or 4 grains (0.20-0.25 Gm.), at one year 5 or 6 grains (0.30-0.35 Gm.), and by some given in doses of gr. x (0.60 Gm.). At two years 8 or 10 grains (0.50-0.60 Gm.J. The dosage will depend somewhat upon the severity of the attack. If there is twitching at the end of an hour the dose may be repeated. The drug may be expected to take effect within a half hour. Some practitioners add bromide to the chloral in doses of approxi- mately twice as much bromide as chloral. If, however, after the use of the chloroform and chloral the convulsions recur, morphine should be used. The drug should be used hypodermically and in sufficient doses. At six months the dose of the sulphate usually recommended is gr. 1/48 (0.0015 Gm.), at one year gr. 1/24 (0.003 Gm.), and at two years gr. 1/16 (0.004 Gm.), and this dose, if not effectual may be repeated in a half hour to an hour. Those who are imbued with the traditional fear of morphine in infancy may begin the initial dose with a slightly smaller amount, but satis- factory results will hardly follow in severe cases unless the larger doses are used. In obstinate cases I would recommend a lumbar puncture. I have seen very satisfactory results in a few cases of continued convulsions, in other conditions follow this procedure. Other Measures Recommended. Holt recommends oxygen in- halations as of value in some cases which have resisted other efforts. Still recommends urethane to prevent recurrence of convulsions in doses of gr. 1 3/4 (0.10 Gm.) three times a day for an infant of nine months and in doses of gr. iii to gr. viii (0.2-0.50 Gm.) three times a day for children six to ten years old. Release from Quarantine. There is a great disagreement about the length of time a case may be a source of danger, ranging from six weeks to six months. It seems certain that the most contagious period is the catarrhal and early paroxysmal and a whoop may continue long beyond the infective period. As the infectious stage lasts only about three weeks as a rule, six weeks would seem a liberal period for quaran- tine. Convalescence. Another reason for dread of this disease is it prolonged course. The average duration of the paroxysmal stage is six weeks, but many run a much longer period and especially in the winter, when pulmonary complications always threaten. The par- oxysms often last for months, in many cases long after the infection has surely passed. How much this continued cough and whoop is due to a curious irritability of the laryngeal muscles in the presence PERTUSSIS 537 of what would otherwise be a trivial catarrh of the mucous membranes of the laryngo-tracheal tract or to a mere habit it is difficult in many instances to determine. The continued administration of sedative drugs to subdue this occasional cough is pernicious. In the young children and infants the treatment during convales- cence resolves itself into a dietetic one, for the degree of malnutrition is in many cases grievous and the powers of repair much reduced. Often a change of air is of benefit and these children seem to do par- ticularly well at the shore, in a warm climate and even a sea voyage may be of great benefit. Of tonics, iron in the shape of the bitter wine of iron, vinum ferri amarum, in doses of 3i (4 c.c.) in water three times a day or Vallet's mass or Blaud's pill gr. ii to gr. v (0.20-0.30 Gm.) according to age is indicated and in infants cod-liver oil, best given clear in doses of m. xv to 3i (1-4 c.c.) three times a day. No drugs should be used if they induce gastric disorder or if there is anorexia and a coated tongue. The bowels should be attended to by the use of the milk of magnesia in doses of 3 i to iv (4-15 c.c.) or cascara, best in the form of some elixir or aromatic prep- aration. Fresh air by day, the sleeping porch by night are of vital im- portance in clearing up the residuum of bronchial catarrh and avoiding colds; baths with cool sponges following and progressively becoming colder, exercise in the open to the point of comfortable fatigue, avoidance of wet feet or exposure are the paths to health and these measures are the more important in view of the fact that next to measles no disease is so commonly followed by tuberculosis as pertussis. Removal of large tonsils and adenoids may hasten the disappearance of the paroxysms and the completion of convalescence. Prophylaxis. It is agreed that vaccine used prophylactically is of real value. It should be as fresh as possible. Three subcutaneous in- jections are usually given, one every third day. Amount used Chil- dren, 500 million, 1000 million and 2000 million; adults 1000 million, 2000 million and 3000 million. DEPARTMENT OF HEALTH, THE CITY OF NEW YORK. SUMMARY Distribution of the family. Separate the suspects from other children. Remove infants from the same house, if possible. Contacts should be hi isolation for three weeks. Contacts may receive a prophylactic treatment with vaccine. (See text.) 538 TREATMENT OF ACUTE INFECTIOUS DISEASES Remember modes of conveyance by spraying of coughing, sneezing, laughing and talking, for this can occur in the open air; hence, avoid environment of a case even in the open. During an epidemic keep children from gatherings of children, par- ties, etc. Room. Light and air. Approach to verandah or balcony, or two rooms, for change from one to the other, permitting of thorough ventilation. Occasional formaldehyde disinfection of room. Open air. Milder and uncomplicated cases may be kept up and out of doors but must avoid contact with other children. Change of climate in selected cases. More severe and complicated, open air, if patient can be kept cov- ered. Avoid draughts, high winds and dust. If feasible, temperature of room should be from 65 F. to 70 F. Two children should not be treated in the same room. Clothing. Flannel next the skin. Avoid over-loading. Nurse. Should not be urged to take the case unless she has had pertussis. Avoid contact with other children. Should never leave her patient when on duty if a young child or infant, lest it suffocate in a paroxysm or have a convulsion. Prophylactic vaccination. Physician. Should wear gown. Should wash face and hands on leaving case. Should not go at once to another child. If he has not had pertussis he may wear a small mask, like a chloro- form mask, wet with 1-20 phenol. Should avoid standing in front of a patient during a paroxysm. Prophylactic vaccination. Precautions. Strict isolation to quarters assigned, if in the house. Avoidance of other children if allowed out of doors. Secretions should be received on gauze and burned. Bed-linen, night clothes, handkerchiefs, towels, etc., boil an hour or soak overnight in 1-20 phenol, then launder. Domestic pets may carry the disease and should be excluded. PERTUSSIS 639 Bed. For preparation of bed for open air, see Pneumonia, Chap. IX. Indications for remaining in bed. When there is fever. When there are complications. When there is great nervous irritability. Bath. Cleansing bath of soap and warm water daily, on a blanket or be- tween blankets. Diet. Older patients and mild uncomplicated cases, no change. When vomiting is present and gastro-intestinal symptoms are pres- ent. Feed right after a paroxysm as there is then a period of quiescence and avoid feeding near an anticipated paroxysm, as it precipi- tates it. When paroxysms occur hourly or oftener. Give small quantities of high calorie food frequently. Milk plain or modified. Dilute with water half and half . Use lime water 1-20 of milk. Dilute half and half with barley or arrowroot water. Milk gruels of barley, wheat flour, rice, arrowroot, malted or farinaceous infant foods. Whey, buttermilk, koumys, animal broths thickened with cereals and farinaceous foods, custards, baked or soft, jellies with sugar, junket, soft egg, albumin water, wet toast, milk toast, softened rusks, boiled rice and cereal. Avoid dry foods, they irritate and provoke paroxysms. Dilute infants' milk mixtures. Rectal feeding. Only hi most severe cases. Cannot be utilized for any considerable period. Hygiene. Daily baths. Ordinary oral hygiene. Sprays for nose of 2 per cent, to 4 per cent, boric acid solution or quarter to half strength DobelTs solution. Bowels. Use cascara in older children and milk of magnesia in the younger or other simple and mild cathartics. Fever. In uncomplicated cases needs no treatment. Dictates remaining in bed. 540 TREATMENT OF ACUTE INFECTIOUS DISEASES Cough. May cause suffocation, convulsions, cerebral hemorrhage, exhaustion, frequent vomiting and malnutrition. Avoid excitement or emotional state. Avoid dust, chilling, cold beds, draughts; quiet child's alarm by assurance. Fresh air. Mild cases require no treatment. Drugs only upset. More severe cases. Local procedures. Mechanical support, including Kilmer belt. (See text.) Sprays and local applications to the nose of doubtful value. Inhalations. Medicated steam. Compound tincture of benzoin or creosote, 5i or ii (4-8 c.c.) on hot water, or a combination of creosote 5ii (8 c.c.) and com- pound tincture of benzoin 5ii (60 c.c.). May use pitcher, a carafe, simple kettle, with paper cones or regular croup kettle. Best under tent. (For technique, see text.) May use in place of benzoin, creosote or oil of eucalyptus in same manner. Chloroform. When severe and threatening convulsions or asphyxia. Few drops on handkerchief, sponge or towel. Other measures to interrupt prolonged and dangerous spasm. Pull jaw down and forward as hi giving an anesthetic (Nagele). Plunging hands in cold water (Smith quoted by Ker). Most severe form of spasm. Intubation. (See Diphtheria, Chap. XVIII.) Drugs. Antipyrin. At 6 months gr. i (0.06 Gm.) every three or every two hours. At 1 year gr. iss. (0.1 Gm.). At 2 years gr. ii (0.15 Gm.) every six to four hours (Holt). Towards night combine with bromide of soda. At 6 months gr. ii (0.15 Gm.). At 1 year gr. iii (0.20 Gm.). At 2 years gr. iv (0.30 Gm.). Don't use it in weakly children and in pneumonia. Idiosyncrasies for antipyrin. (See text.) Belladonna. Has to be used to the physiological limit. One should begin with a small dose as idiosyncrasies are not uncommon. Jacobi's dose. Six drops of the tincture of belladonna three times a day. This should cause a feverish flush on the cheeks hi hah* an hour PERTUSSIS 541 and last half an hour; if it does not the dose must be increased up to 7, 8, 9, or more drops. One must get the flush each time. It is better to begin with smaller doses than the above, e. g., At 6 months begin with in. ss.-i (0.030-0.060 c.c.). At 1 year, m. i-ii (0.060-0.150 c.c.). At 2 years, m. iii (0.20 c.c.). Increase a minim a dose a day up to the point of inducing flush- ing. For other signs of full dose and for idiosyncrasies, see text. Bromides. Best combined with antipyrin as above. Opium and its derivatives. Use only when exhaustion threatens and other measures fail. Best used at night. Codeine best. Use phosphate or sulphate. At 6 months, gr. 1/100 (0.0006 Gm.). At 1 year, gr. 1/60 (0.001 Gm.). At 2 years, gr. 1/40 (0.0015 Gm.). Older children, gr. 1/8 to gr. 1/4 (0.01-0.015 Gm.). Paregoric (Tr. opii camphorata). At 6 months m. iii-iv (0 . 20-0 . 30 c.c.) . At 1 year m. v-x (0 . 30-0 . 60 c.c.) . At 2 years m. x-xv (0.60-1 c.c.). At 3 years 3 ss. (2 c.c.). Dover's powders Pulv. ipecac et opii.). At 6 months gr. 1/8 (0.008 Gm.). At 1 year gr. ss. (0.030 Gm.). At 2 years gr. i (0.060 Gm.). At 5 years gr. ii (0. 15 Gm.). Measures recommended by other authority. Quinine. (See text.) Heroine. (See text.) Bromoform. (See text.) Fluroform. (See text.) Antitussin. (See text.) Benzyl benzoate, 20 drops of 20 per cent, solution given in milk every 3 hours (dose for two years of age). Specific treatment. Vaccines. (See text.) Insomnia. Relieved by measures relieving paroxysms, especially bromides and antipyrin. Chloral at night. At 6 months gr. ii (0.15 Gm.). At 1 year gr. iii to iv (0.20-0.30 Gm.). 542 TREATMENT OF ACUTE INFECTIOUS DISEASES May be repeated in two hours. Give by rectum in 2 ounces of warm milk. Trional. At 2 years gr. ii to gr. iv (0.15-0.30 Gm.). With threatened exhaustion give opium in doses as given above. Complications. Vomiting of severe type. Diet. (See above in summary.) Belt. (See above in summary.) When accompanying cough. Measures used to control cough. (See above in summary.) Unaccompanied by cough. Measures to relieve gastric irritation. Sodium bicarbonate gr. v (0.30 Gm.) with the food. Cocaine hydrochloride, gr. 1/6 (0.010 Gm.) twice a day (Eustace Smith by Ker). Diarrhea. Regulation of diet. Calomel occasionally, gr. 1/10 (0.006 Gm.) every ten minutes for ten doses, or gr. 1/4 (0.015 Gm.) every quarter hour for four doses, followed by Bismuth subnitrate, gr. xx to gr. xxx (1.30-2 Gm.) every three or four hours. Occasional irrigations. Ulcer of the frenum. Use boric acid (2 per cent, to 4 per cent, solution) as a mouth wash. Silver nitrate, touch occasionally with the stick. Dental assistance to protect tongue. If severe may extract the incisors responsible, if they are of the first set. Nose bleed (epistaxis). Spray with adrenalin (1-10,000) or apply adrenalin (1-1,000) on cotton to bleeding point. If severe, plug nares. Tannic acid mixed to the consistency of a syrup applied on gauze (Coakley). Bronchopneumonia. (See Pneumonia, Chap. IX.) Open air. (For contraindications, see Pneumonia, Chap. IX); also severe laryngitis. Convulsions. Parent or nurse may initiate treatment with hot mustard bath or pack. (For technique, see text.) PERTUSSIS 543 To interrupt convulsion, Chloroform, give a few whiffs. When the convulsion is interrupted, Prevent recurrence. Chloral. At 6 months gr. iii to gr. iv (0.20-0.30 Gm.). At 1 year gr. v to gr. vi or even gr. x (0.30-0.40-0.60 Gm.). At 2 years gr. viii to gr. x (0.50-0.60 Gm.). Give by the rectum in 1 or 2 ounces (30-60 c.c.) of warm milk. If there is twitching at the end of an hour repeat the dose. Bromides may be added to the chloral in doses of gr. ii (0.15 Gm.) of the bromides to gr. i (0.060 Gm.) of the chloral. If the convulsions recur in spite of this, use Morphine sulphate At 6 months gr. 1/48 (0.00125 Gm.). At 1 year gr. 1/24 (0.0025 Gm.). At 2 years gr. 1/16 (0.004 Gm.). Give hypodermically. If convulsions or twitching persist, repeat dose in one-half to one hour. In obstinate cases. Try lumbar puncture. (For technique, see Cerebro-spinal Meningitis, Chap. XXV.) Other measures recommended. Oxygen inhalations (Holt). Urethane (Still). (See text.) Release from quarantine. When paroxysms cease unless unduly prolonged. (See text.) Usually about six weeks. Convalescence. Diet, especially, in malnutrition of infants and young children im- portant. Change of climate. Especially to sea-shore. Warm climate. Tonics. Iron. Bitter wine of iron (Vinum ferri amarum) 3i-ii (4r-8 c.c.) three times a day. Vallet's mass (Massa ferri carbonatis) gr. i-iii (0.060-0.20 Gm.) three times a day, or Blaud's pill (Pil. ferri carb.) same dose, gr. iii (0.20 Gm.). Cod liver oil m. xv-3i (1-4 c.c.) three times a day. Keep bowels in order. 544 TREATMENT OF ACUTE INFECTIOUS DISEASES Hygiene. Fresh air by day. Sleeping porch at night. Exercise hi the open air. Avoidance of wet feet. Watch constantly for any signs of tuberculosis. Prophylaxis. Vaccines. Fresh as possible. Dosage. (See text.) Intervals. (See text.) CHAPTER XXIII MUMPS (PAROTITIS) THIS disease of uncertain etiology affects characteristically, but not exclusively, the parotid glands. It is rare in infancy, finds its maxi- mum incidence in the second and third lustra, affects many young adults, but is again rare in later life. It is very rarely fatal, but entails much discomfort and in its compli- cations sometimes serious results. There is good reason to believe that the organism isolated and de- scribed by Laveran and Catrin, a diplococcus, is the causative agent of the disease. Symptoms. Usually the enlarging gland is the first symptom. A few, however, will have signs of a general infection with pains variously distributed over the body. The jaws feel stiff and there may be a tem- porary loss of taste. Sour food may provoke a pain in the jaw, but this is not constant. It has often been thought an early and significant symp- tom. The parotid swells, giving rise to a characteristic appearance of the face. Sometimes the sublingual or submaxillary glands may share in the affection or may be exclusively attacked. With the parotitis there may be a sense of fullness in the ears and some degree of deafness. The white blood count ranges from 5000-8000 and there is an actual and relative increase of lymphocytes. Distribution of the Family. I am a firm believer in the pre- vention in every individual of any kind of infection where possible; so, while many look upon mumps as of slight importance, if not as an amusing incident, such serious consequences can, to be sure rarely, ensue that I advise isolation of the patient or removal of the other chil- dren and young adults to other premises. The period of incubation is from twelve to twenty-six days; hence, these contacts should not expose susceptible individuals until the ex- piration of twenty-six days. I am aware that only rarely will such a recommendation be followed by the wage earner and that much protest will be voiced in cases of the school children, but, at least, in the case of the latter, they should not be allowed to go to school longer than ten days after exposure, which period 546 TREATMENT OF ACUTE INFECTIOUS DISEASES trespasses close,, on the appearance of prodromal symptoms if they are infected and during this period of invasion they are highly contagious. These contacts should not return to the environment of the patient until the quarantine has been raised. Room. A well lighted and well ventilated room as free from fur- nishings as possible should be chosen and a bed, preferably of the hospital type. A patient who has any fever or other evidence of constitutional reac- tion to his infection should be confined to bed. Mild cases in children in whom neither the one nor the other obtains may be allowed up, but confined to the room. To male adults, the high incidence (about 30 per cent.) of orchitis as a complication, its distressing symptoms and the possibility of atrophy should be explained with the statement that remaining in bed until the parotid swelling has subsided plus a margin of safety, in all some ten days, is believed to lessen very materially the probability of this complication. The infection comes from the buccal and nasal secretions and "these should be destroyed. Infection through the third person is very rare, because the infecting organism is very short lived, but the physician should wash his hands thoroughly on leaving the patient and avoid an immediate call on another susceptible individual. The nurse should take similar precau- tions in her absence from the sick-room. Baths. A cleansing bath with soap and water should be given every day. Diet. The difficulty of eating makes a fluid diet or a semi-solid diet a necessity. Milk and milk preparations, cereals, milk broths, meat soups, plain or thickened with farinaceous foods, or with cracker soaked in them, custard, soft eggs, soft toast and similar substances may be used, but the quantity should be such as to satisfy the patient's appetite. If there be no fever and the patient's condition will permit the use of his jaws, a more solid food, meat, fish and vegetables may be used. Water or drinks made of fruit juices may be allowed and in febrile cases urged. Acid food or drinks often cause a sharp pain in the jaws and has been looked on by many as characteristic, but this does not always occur and the giving or withholding of such articles depends purely on the absence or presence of pain when taking them. Care of the Patient. Since the infectious material is resident in the secretions of the nose and mouth and since a mixed infection of the parotid gland leading on to suppuration may occur and presum- MUMPS 547 ably by way of Steno's duct, the hygiene of the mouth becomes of importance. One may use boric acid solution 2 per cent, to 4 per cent, as a mouth wash or a DobelPs solution, diluted 1/2 to 3/4. These same solutions may be used in the nose in a spray or applied with a swab on an appli- cator or wooden tooth-pick. Bowels. At the beginning of the treatment the bowels should be effectually moved by calomel or a salt, or both, as gr. 1/4 (0.015 Gm.) calomel every fifteen minutes until gr. iss. (0.10 Gm.) are taken, followed in two hours by gss. (15 Gm.) of Epsom, Rochelle or Glauber's salt. During the illness the bowels may be moved by a mild saline, like a Seidlitz powder, citrate of magnesia or Hunyadi water or its equivalent in one of the many aperients on the market. Fever. Only rarely is the fever of any moment. Its discomforts are to be met by cool sponging. In the early stages, if accompanied by pains or aches acetanilid, gr. iss. (0.10 Gm.) or phenacetin gr. iii (0.20 Gm.) can be given at hourly or two hour intervals. Treatment of the Parotitis. In the majority of cases no treat- ment is required and no discomfort is experienced beyond a stiffness in the muscles of the jaw. It is altogether better not to interfere at all in such cases, as is often done merely because there is a swelling and either the doctor or the patient feels that something ought to be done. The swelling lasts a week to ten days, but the second parotid may be affected so late as to drag the period out. When there is pain and marked discomfort in the glands efforts at relief may be made first by topical application, of heat, cold or drugs. LOCAL TREATMENT Heat. In milder cases heat is afforded by the patient himself by the application of a dry dressing, as of absorbent cotton or of non- absorbent cotton, covering the affected part liberally and held in place by a bandage. Dry heat can also be applied by the use of the hot water bottle or a bag, the size of which is adapted to the swelling, filled with fine scouring sand or salt and heated in the oven. Hot fomentations are often efficacious. Two or three layers of thick flannel are laid in a towel and boiling water poured upon them. The water is wrung out of them by twisting them in the towel by turning the ends of the towel in opposite directions. The degree of heat should first be tested, a flirt in the air made to throw off an excess of steam or hot vapor, the edges turned under to 548 TREATMENT OF ACUTE INFECTIOUS DISEASES prevent any drip of hot water and a dry flannel placed over them. They should be replaced every few minutes before they get cool and this kept up for fifteen to twenty minutes at a time. When taken off the glands should be covered with dry cotton. This may be repeated as often as it affords comfort. Cold. Some patients find more relief from cold than from heat. Cold may be applied in an ice-bag. The circular ice-bag is the best. The pieces of ice should be about the size of the end of one's fingers, only enough water put in to cover the ice and then the air pressed out and the cover screwed on. This makes the bag apply itself closely to the part, which it will not do if it contains air. Under the bag should be a layer of flannel, be- tween it and the face. Instead of the ice-bag an ice poultice may be used. Ice Poultice. "Cut two pieces of oiled muslin the required shape and size, place them together and turn over the edges about an eighth of an inch all round. Bind with adhesive plaster, leaving unbound a small section at the top till the ice has been put in. Fasten the corners securely, strengthening them with extra pieces of adhesive plaster. Mix the ice after breaking it into pieces the size of a walnut, with one-third as much flaxseed or bran, which will absorb the water as the ice melts, and with a small amount of salt, which will intensify the cold. " Cover the poultice with gauze before applying, and hold it in place either with a binder or a four-tailed bandage, as the position requires." Quoted from Practical Nursing by Maxwell and Pope. Salt should be used cautiously. Drugs. It is questionable whether any of the ointments and Uniments applied do actual good. Among those which have been rec- ommended, I will mention camphorated oil (linimentum camphorse), Belladonna ointment of the pharmacopeia, Guiacol, 1 in 20 of vaseline and lanolin equal parts, and ichthyol ointment 10 per cent, to 25 per cent. Now and then a gland goes on to suppuration. In this case it should be incised. While the seat of the infection is peculiarly the parotid glands, other glands may at times be affected, such as the submaxillary, the sub- lingual, the testicle, the ovary, the mammary glands, the pancreas and still more rarely the lachrymal and thyroid glands. Of course, the appreciation of their involvement by this specific infection comes only when the parotid swelling tells the tale or in the presence of an epidemic, when, even in the absence of a parotid swelling the signifi- cance of the glandular swellings is understood. MUMPS 549 The treatment of the submaxillary and sublingual glands is the same as that of the parotid. When the testicle is involved one may speak of Complications. Orchitis. It may be prefaced that testicular pains during mumps are not uncommon even when the organ is not apparently involved. This complication is very rare in boys before puberty, but after that period its frequency is given by some authorities as high as 33 per cent. With the involvement of the testis there is usually an exacerbation or recrudescence of the constitutional symptoms. While in some cases the discomfort is trivial, in many the pain is severe. This may be the earliest and only organ involved. The diagnosis in this case would depend on the presence of an epidemic or exposure. Ker calls attention to the fact that accompanying the orchitis there may be a slight urethral discharge. Even in the presence of the paro- titis this discharge may be misunderstood as gonorrheal or on the other hand an actual gonorrheal discharge might be assumed to be a part of the orchitic involvement. A smear for the detection of the gono- coccus of Neisser should be taken. Remaining in bed during even a trivial attack of mumps lessens the likelihood of an orchitis very materially. If the patient is up and about, he must, of course, be made to go to bed. A proper suspensory, to support the drag of the inflamed organ must be applied as the first and most essential measure and, indeed, in the milder cases little else is required. A ready contrivance for affording support is a pillow stuffed between the thighs well up against the perineum; or the thighs may be brought together and a sheet of adhesive plaster 3 or 4 inches wide spread across the thighs on which the scrotum may rest. The disadvantage of these methods is that they interfere with a freedom of motion in the bed. A "T" bandage, one arm going about the waist and the other between the thighs, to support the scrotum, split just beyond the point of support, each half to be attached above to the part around the waist on either side or, if accessible, one of the many forms of support on the market. A dry poultice may be used, which consists of an abundance of cotton about the scrotum, which retains the heat of the body. A time-honored application is: Lotio Plumbi et Opii; Lead acetate, 128 grains (8.5 Gm.) ; Tincture of opium, 4 drams (15 c. c.) ; and water to make 1 pint (475 c.c.). (Shake before using.) The bowels must be kept freely open with salines during the run of orchitis. The condition is likely to last from three to seven da} r s and resolve without further trouble. The danger lies in the fact that in rare cases atrophy of the testis occurs. In the females either the ovaries or the 550 TREATMENT OF ACUTE INFECTIOUS DISEASES mammary glands may be affected. There is tenderness over the site of the ovaries but the organs are rarely enlarged. Hot applications over the abdomen or over the mammary glands, using the measures advised for the parotid glands, may be used. Vulvitis, too, is an unusual manifestation in the female. It is to be treated by local applications of boric acid solution, Sitz baths and hot compresses. Dr. Joseph Sailer reports 14 cases in 4000 or 3.5 per cent. He found it to occur most commonly on the 5th to 8th day, but it sometimes comes on late in convalescence. Pancreatitis. The vomiting, sometimes severe, the pain and ten- derness in the epigastrium and left hypochondrium, might be readily attributed to a gastric disturbance, if one did not have in mind the pos- sible involvement of the pancreas. Jaundice may occur. My friend, Dr. Geo. Blumer, tells me he has seen a case go to operation, disclosing an extensive fat necrosis. The treatment consists in the application of heat or cold over the site of pain and tenderness and a limitation of diet and especially on fat, both to afford the gland a relief from excitation of food taken and the dyspeptic disturbances that might ensue from insufficiency of the pancreatic ferments. The trouble is short-lived and the dimi- nution in food will have no significance. Thymus gland. Dr. Sailer reports the rare involvement of this gland, 0.1 per cent, of his cases. There was localized edema over the manubrium, pitting on pressure. This may extend from the cricoid cartilage to the middle of the gladiolus and on either side of the mid-clavicular line, with a circular or oval outline. There is no tenderness to pressure nor nausea. The X-ray detects the enlarged outline of the gland. Meningo-encephalitis. The large number of cases of mumps occurring in our camps during the late war bore in upon us the fre- quency and importance of this complication. Probably it is with rare exception, the sole cause of death. Haden reported 9 cases in a series of 476 of mumps, nearly 2 per cent. There is headache, nausea and vomit- ing which may be severe, slight rigidity of the neck, perhaps Kernig's signs, but not well marked, drowsiness and high fever. The spinal cord fluid is clear, under an increase of pressure, shows a pleocytosis, lymphocytosis usually predominating, and Fehling reducing bodies in 60 per cent, of the cases. It may be the earliest manifestation of the infection and simulate very closely a tubercular meningitis. In one such case I made the diagnosis on the basis of its occurring during an epidemic of mumps and confirmed by a tender testicle, developing later an orchitis. MUMPS 551 It is assumed that one is dealing with a meningoencephalitis. I am not conversant with pathological reports on such cases. One wonders if the pituitary or pineal glands might not be involved to account for the symptom complex. Lumbar Puncture is a valuable therapeutic measure, as it af- fords much relief to the headache. An ice-bag applied to the head may be efficacious to relieve headache. In severe cases morphine may be indicated in doses depending on age. (See Cerebro-spinal Meningitis, Chap. XXV.) Nephritis, arthritis, have both been mentioned in the literature as having complicated this disease, but they are of extreme rarity and are to be treated, when they occur as under other circumstances. No other treatment of the condition is needed, except bromides for nervousness, trional for sleeplessness, small doses of phenacetin for pain and in the very severe cases small doses of morphine. Release from Quarantine. Isolation should continue about ten days after the swelling has ceased, but in prolonged cases it may be cut down to a week after the disappearance of the local trouble. Convalescence. Is usually rapid and needs little else than fresh air and good food. If a tonic is desirable, one may use iron, the bitter wine in children in doses of 3i (4 c.c.) three times a day and the B laud's pill in the older cases in doses of gr. iii (0.20 Gm.) to gr. v (0.30 Gm.) three times a day. Disinfection. The infective material is easily destroyed on ex- posure to light and air and many men think it unnecessary to do more than clean and ventilate the sick-room. If, however, one wishes to take extreme precautions it may be disin- fected and the clothes treated as described under Scarlet Fever. (See Chap. XVII.) SUMMARY Distribution of the family. Contacts should not expose susceptible individuals until incubation period of three to four weeks has passed. Patient Should be confined to room. If there is fever or complications, to the bed. Remaining in bed lessens the incidence of orchitis. Room. Good light and ventilation. 552 TREATMENT OF ACUTE INFECTIOUS DISEASES Physician. Should wash his hands carefully on leaving patient and not go directly to a susceptible person. Nurse. Should take similar precautions. Baths. Daily cleansing bath of soap and water. Diet. Fluid or semi-solid on account of difficulty of eating. (For suitable articles, see text.) Acid foods or drinks often cause sharp pain in jaws. Care of mouth. Remember the danger of mixed infection of the parotid and its sup- puration. Boric acid solution 2 per cent, to 4 per cent. Dobell's solution half to quarter strength. Nose. Use sprays or cotton swabs on wooden toothpicks wet with same solutions. Bowels. At the beginning use calomel or salt or both. Calomel gr. % (0.015 Gm.) every fifteen minutes until six doses are taken and follow in two hours by Rochelle or Epsom salt 5 ss. (15 Gm.). During illness use milder salines, such as citrate of magnesia, Seid- litz powder, Hunyadi or similar water. Fever. Rarely marked. Cool sponges. If accompanied by pains and aches, Acetanilid gr. iss. (0.10 Gm.) or phenacetin gr. iii (0.20 Gm.) every three hours or until relieved. Treatment of the Parotitis. Often no treatment indicated. Pain and discomfort. Topical treatment. Heat. Hot-water bag. Bags of hot salt or scouring sand of suitable shape. Dry poultice. Thick applications of absorbent or non-absorbent cotton, held in place by a bandage. MUMPS 553 Hot fomentations. (For technique, see text.) Cold. Ice bag. (For technique of application, see text.) Ice poultice. (For technique, see text.) Drugs. Ointments and liniments of doubtful value. Camphorated oil (Linimentum camphorae). Belladonna ointment official, or 3 Guaiacol, 1 part. Vaseline, 10 parts. Lanolin, 10 parts. M. Ichthyol ointment (in vaseline) 10 per cent, to 25 per cent. Suppurating glands. Should be incised. Complications. Orchitis. Suspension. Pillow stuffed between thighs. Sheet of adhesive plaster across the thighs, on which scrotum may rest. A "T" bandage. Dry poultice. Abundance of non-absorbent cotton. Hot lead and opium lotion on gauze or absorbent cotton. Lead acetate, gr. cxx (8 Gm.). Tincture of opium, 3ii (8 c.c.). Water to make 1 pint (500 c.c.). Keep bowels open. Ovaries. Hot applications to abdomen. Mammary glands. Much such measures as in orchitis. Vulvitis. Boric acid solutions 2 per cent, to 4 per cent. Hot compresses. Hot sitz baths. Pancreatitis. Limit fat in diet. Apply heat or cold over site of pain. 554 TREATMENT OF ACUTE INFECTIOUS DISEASES Nephritis. (See Scarlet Fever, Chap. XVII.) , Arthritis. (See Scarlet Fever, Chap. XVII.) Nervous system. Bromides gr. x to gr. xv (0.60-1 Gm.) in water three times a day, gr. xv to gr. xxx (1-2 Gm.) at night. Meningo-encephalitis. Lumbar Puncture. (For technique, see Cerebro-spinal meningitis, Chap. XXV.) Ice-bag. Severe headache or delirium. Morphine according to age. (See Cerebro-spinal Meningitis, Chap. XXV.) Sleeplessness. Bromides gr. xv to gr. xxx (1-2 Gm.) in water at night. Trional gr. x to gr. xv (0.60-1 Gm".). Pain. Phenacetin gr. iii-v (0.20-0.30 Gm.). Morphine gr. 1/10 to gr. 1/8 (0.006-0.008 Gm.). Release from quarantine. Ten days after disappearance of local trouble. Convalescence. Fresh air. Good food. Iron if tonic is needed. Disinfection. Clean and ventilate room. CHAPTER XXIV GLANDULAR FEVER THIS is essentially a disease of childhood, occurring only occasionally in adult life, and is characterized by glandular swelling especially of the neck. It begins as a rule on the left side. Axillary and inguinal glands may be involved and possibly some of the deeper sets. Liver and spleen have been found enlarged in some cases. The adenitis is a result of an acute infection but the nature of the infecting agent is not known. Isolation. The disease is undoubtedly contagious, hence, the child affected should be kept from contact with the other children. Suspects and children who have been exposed should be kept from susceptible individuals for a week or ten days, for the incubation period while still undetermined is believed to be about a week. Room and Bed. If the patient be confined to the bed, and that is only when fever or complications are present, they should be selected as in other contagious diseases. Diet. If there is anorexia or vomiting the food is not pressed until these symptoms have subsided, then the ordinary diet for febrile cases is allowed. See Chap. II. Water is given freely. Bowels. Calomel, a salt or castor oil should be given at first. If there is much nausea or vomiting calomel in divided doses may be used, e. g., gr. 1/10 (0.006 Gm.) every ten minutes for ten doses, fol- lowed in two hours by milk of magnesia 3ss. to i (15-30 c.c.) or liq. magnesii citratis 5iv to viii (120-240 c.c.) or if there is no nausea the salt alone or castor oil in doses of 3ii to 5ss. (8-15 Gm. or c.c.) according to age may be given. Throughout this disease the bowels should have attention, an enema or mild saline like liq. magnesii citratis being given every other day. Care of Mouth and Nose. Mild alkaline sprays and mouth- washes such as quarter strength DobelTs solution or 2 per cent, boric acid solution, or warm physiological salt solution may be used. 556 TREATMENT OF ACUTE INFECTIOUS DISEASES There is likely to be a mild grade inflammation of the tonsils or phar- ynx, but bearing no relation to the adenitis. That the glands sometimes suppurate and that otitis, parotitis, ne- phritis has been known to occur, accentuates the necessity for care of the mouth, the possible source of such complications. Toxemia. At the onset the usual malaise, headaches, pains and fever of an infection may occur. If these are marked small doses of acetphenetidin (phenacetin) gr. i to gr. ii (0.060-0.12 Gm.) every two to three hours or aspirin gr. ii to gr. v (0.12-0.30 Gm.) or salicin gr. iii to gr. x (0.20-0.65 Gm.) at the same intervals may be used to relieve discomfort. Fever. The temperature is not high as a rule but may reach 104 F. or 105 F. Sponging with cool water may make the patient more comfortable. Adenitis. The large tender glands are the "hall-marks" of the disease. They become obvious after twenty-four to forty-eight hours and increase to the si^ze of pecan nuts, remaining discreet. As a rule they begin high up under the sterno-cleido mastoid of the left side spreading later to the right side. They cause the patient to hold the neck stiff and at times to experience some pain on swallowing; moreover, these glands are very sensitive to the touch. All the glands of the neck are likely to become involved, even "a fine network of glands about 1 c.c. in diameter, like the spots placed at the intersection of the strands of a large mesh veil, covers the entire lateral and posterior aspects of the neck," as Haas picturesquely puts it. Beside the superficial glands, cervical, axillary, inguinal, epitrochlear, the mesenteric causing pain in the region of umbilicus, bronchial and mediastinal perhaps causing the croupy cough, may be involved. Relief of pain and discomfort may be sought in the measures appli- cable to adenitis from other causes, namely, heat, in the shape of hot fomentations (see Scarlet Fever, Chap. XVII) or poultices, or hot-water bag or cold in the shape of the ice-bag or cold compresses. (See Scarlet Fever, Chap. XVII.) Ichthyol is a favorite application in 25 per cent, to 50 per cent, in vaseline. Very rarely a gland may suppurate, when it is to be treated surgically by incision and evacuation of pus. For glands which are slow in receding Haas recommends Fowler's solution (liq. potassii arsenitis) m. ii to x (0.12-0.65 Gm.) in water three times a day. Complications. Beside the occurrence of suppuration in an af- fected gland, otitis media and nephritis are the only serious compli- GLANDULAR FEVER 557 cations, fortunately rare. They are treated as under circumstances. (For nephritis, see Scarlet Fever, Chap. XVII; for otitis, see Scarlet Fever, Chap. XVII.) The course is usually mild and although the glands do not resolve for two to four weeks the malaise and fever disappear after a few days, though slight recrudescences may occur with involvements of other glands or recrudescences of the process in the same glands or set of glands with febrile manifestation may be repeated several times. The case impresses one at times as a streptococcus invasion and certain bacterial findings in the throat and suppurating glands strengthen the impression. Again the condition is at times difficult to differentiate from mild scarlet fever for erythematous rashes in glandular fever are occasional happen- ings. The late glandular relapses and nephritis increase the perplexity of the diagnostician. Convalescence. Severe secondary anemia may occur and in severe cases may be quite striking. Iron may be administered for this. In the younger children the bitter wine of iron (Vinum ferri amarum) 3i to 3ii (4-8 c.c.) three times a day, or in older children Vallet's mass (Massa ferri carb.) gr. ii to gr. v (0.12-0.30 Gm.) three times a day, or Blaud's pill (Pil. ferri carb.) in same doses. As a general tonic small doses of the tincture of nux vomica, m. ii to m. x (0.12-0.65 c.c.) or strychnine sulphate gr. 1/150 to gr. 1/60 (0.00045-0.001 Gm.) three times a day according to age. Fresh air and good food are the best tonics. Prognosis is good. The only cases to be dreaded are those compli- cated by Nephritis. Prophylaxis. We know so little about the mode of conveyance of this disease and indeed of its true nature that we are unable to effect efficient prophylactic measures beyond isolation of the sick child in the family. SUMMARY Treatment Isolation. The child should be kept from contact with other children. Suspects and children who have been exposed should be kept from susceptible individuals, a week or ten days. Room. Light and airy. Diet. Do not force feeding during period of anorexia. Later follow rules in Chap. II. Give water freely. 558 TREATMENT OF ACUTE INFECTIOUS DISEASES Bowels. Calomel gr. 1/10 (0.006 Gm.) every ten minutes for ten doses, fol- lowed by Milk of magnesia 5ss.-i (15-30 c.c.) or Liquor magnesii citratis 5iv-viii (120-240 c.c.) or if there is no nausea A salt alone, or Castor oil 3ji-iv (8-15 c.c.). Enema or mild saline every other day. Mouth and throat. Washes and sprays of Two per cent, to 4 per cent, boric acid solution. DobelPs solution, quarter strength. Warm physiological salt solution (3i of common salt to 1 pint, 4 Gm. to 500 c.c.). Toxemia. Pains and aches of sthenic period. Phenacetin gr. i-gr. ii (0.060-0.12 Gm.) every two or three hours or Aspirin gr. ii to gr. v (0.12-0.30 Gm.) at same intervals or Salicin gr. iii to gr. x (0.20-0.65 Gm.). Fever. Sponging with cold water. Adenitis. Heat. Fomentations. Poultices. Hot-water bottle (See Scarlet Fever, Chap.XVII.) Cold. Ice-bag. Cold compress. Ichthyol 25 per cent, to 50 per cent, ointment over the affected glands. Surgery. Incision of suppurating glands. Delayed resolution. Fowler's solution (Liq. potassi arsenitis) m. ii to m. x (0.12-0.65 Gm.) three times a day. Complications. Rare. Nejhritis. } (See Scarlet Fever > Chap ' XVIL) GLANDULAR FEVER 559 Convalescence. Anemia. Iron. Vinum ferri amarum (Bitter wine of iron) 3i to 3ii (4^8 c.c.) three times a day for young children. Vallet's mass (Massa ferri carbonatis) gr. ii to gr. v (0.12-0.30 Gm.) or Pil. ferri carbonatis (Blaud's) same doses. Tr. nucis vomicse m. ii to m. x (0.12-0.65 c.c.) three times a day or Strychnine sulphate gr. 1/150 to gr. 1/60 (0.00045-0.001 Gm.) three times a day. Fresh air. Good food. Prophylaxis. Isolation of sick child. CHAPTER XXV CEREBRO-SPINAL MENINGITIS A GENERAL infection, due to a definite organism, the diplococcus of Weichselbaum (diplococcus intracellularis meningitidis), the char- acteristic symptomatology of which is referred to the site of its greatest local activity, the meninges of the brain and spinal cord. It is one of the few diseases for which a specific treatment has been achieved and for this reason an etiological diagnosis is important, that is, the recognition of the causal organism, which may be recovered from the blood before it appears in the spinal cord or in some instances before there are cerebro-spinal symptoms. Indeed, in the presence of an epi- demic, cases of meningococcic septicemia have been determined which never developed cerebro-spinal symptoms even though no intraspinal therapy had been used. It is now recognized that there are three groups of meningococci, the normal or regular, the para or irregular and the intermediary group which cross agglutinates with the other two. The importance of this lies in the appreciation of the fact that unsatisfactory serum therapy may be due to an insufficient representation of the immune bodies produced by a certain group in the polyvalent serum which is used. Distribution of the Family. One has to consider the possibility of infection of other members of the family and the danger which other members of the family may be, in the capacity of carriers, to those outside. So rarely did fresh cases break out in the wards of hospitals admitting these cases and so rarely did physician or nurse acquire the disease from the patient, that for a long time it was assumed that the disease was not contagious and even to-day such facts as these and that in large epidemics, in the vast majority of instances, only one member of a family is affected is hard to understand, but more careful study and experimentation has demonstrated the contagiousness of the disease and the important role of the carrier. It is because of the high mortality of the disease and the dread possibilities even in case of survival, that Public Health authorities have included it among the contagious and reportable diseases and it becomes incumbent upon us to pursue every means to prevent our patient from being the source of yet another case. The insistence on that isolation that has become habitual in the case CEREBRO-SPINAL MENINGITIS 561 of scarlet fever has not yet been voiced by writers on the subject, but it seems to me such isolation is as imperative in the case of the one as the other, for the high mortality and the wretched sequences of the one balance the high incidence of the other. The patient, then, should be insolated with nurse or attendant. Other children should be removed, if possible, and to quarters where they shall not come in contact with children, for though they may not develop the disease they may still be carriers of the infection capable of infecting others. How long these "contacts" should be isolated is a difficult matter to decide. The incubation period has not been very well determined, but the average time seems to be 7-14 days. However, some of the observations suggest that in some cases, at least, it may last a month, though usually it is a much shorter period. If laboratory facilities are at hand suspects should have their nasal secretions examined to determine whether or no they harbor the dip- lococcus in the nasal passages. If the children cannot be removed, communication direct or indirect with the patient must be carefully avoided. Adults, though still susceptible, are far less so than children, but, with the exception of those members of the family whose presence in the sick-room is necessary to the patients, no contact with the patient should be allowed. Adults in the family must remember that infection of fresh cases has occurred curiously frequently through a third person; hence, they should avoid contact with children. If the adults come in contact with children in the course of their daily duty, they should remove from the environment of the patient and observe a period of isolation, as in the case of the children cited above. In all cases where possible these "contacts" should have their nasal secretions examined to determine whether they are "carriers" or no, and, if so, should avoid children at least as long as the epidemic lasts. Indeed with knowledge that the carrier is a menace to whomsoever he comes in contact with, it would seem reasonable to insist on an isola- tion of such carriers until they are free from the infection. This was the rule insisted on in camps during the recent war. The number of people who in contact with the sick become "carriers" is surprisingly large, Elser and Huntoon, during an epidemic, deter- mined that at least 70 per cent, were in this class. Apart from the epidemic the "carriers" were rare, but occasionally a person becomes a permanent "carrier" and can convey the disease. That so few of the persons harboring the organisms in this manner become themselves the victim of the disease would bespeak the prob- 562 TREATMENT OF ACUTE INFECTIOUS DISEASES ability of some 'Other factor in the determination of the infection and with our present views of infection, we seek it in the lowering of the individual's resistance. For this reason, it becomes doubly important to avoid during an epidemic minor infections, such as rhinitis, tonsil- litis, etc., at other times trivial, lest it afford the opportunity for the diploccus of Weichselbaum to gain entrance into the blood. " Contacts" should use a mild spray for the throat and nose, such as 2 per cent, boric acid or Dobell's solution, quarter strength, or one of the mild equivalents on the market. Under no circumstances should strong astringents or strong bactericidal solutions be used, lest the irritation set up in the mucous membrane lessen the resistance of the structures to the invasion of the infecting organism. Nurse. The nurse from her intimate contact with the patient is very likely to become a carrier. For this reason she should avoid coming into contact with children during her hours off duty and remem- ber that coughing, sneezing and kissing are means by which the organ- ism may readily be conveyed to another. She should clean her hands and face with soap and water and alcohol or bichloride 1 to 1,000 and spray her nose and throat before going out. As a precautionary measure she should use one of the mild sprays advised above from time to time while on duty. Physician. The physician has always to think about the possi- bility of carrying the disease; but, fortunately, it is rarely that he can be shown to have done so. The organism is readily killed by drying and exposure to sunlight and the physician's contact with the patient is brief. He should, however, carefully cleanse his face and hands with soap and water and alcohol or 1 to 1,000 bichloride and spray his throat and nose before leaving the case for another call and should make his stay with the patient as brief as is compatible with the performance of his duties. He should, moreover, spend some period in the open air before another visit is made and endeavor not to make his next call upon a child. Room. A large well ventilated room, free of furnishings, with bare floors or floors covered with some cheap material which may be destroyed after the patient has been removed, such as carpet lining covered with unbleached muslin, should be chosen. A verandah lead- ing from the room and a bath room immediately contiguous are ad- vantages. Light and air are potent allies in destroying the infection. If the light hurts the eyes, suitable screens may be arranged to protect the patient. Avoidance of noise, jars, irritations of all kinds are to be observed on account of the marked hypersensitiveness of the patient. CEREBRO-SPINAL MENINGITIS 563 Precautions in the Sick-Room. Since the infective material is known to reside in the nasal and oral secretions, all these should be received on rags or muslin that may be destroyed or into vessels in which they may be disinfected with carbolic 1 in 20 or bichloride of mercury 1 in 500. The thermometer should be left in the sick-room and kept in carbolic 2 per cent, to 5 per cent, or in formalin. Eating utensils should be boiled, but if sent out of the sick-room for that purpose should be previously soaked in 1 to 20 carbolic acid for twenty minutes to a half hour. Urinals, bed-pans, etc., should be disinfected with 1 to 20 carbolic (phenol) or 1 to 500 bichloride, while clothes should be soaked overnight in 1 to 50 to 1 to 20 phenol and then boiled a hah" hour to an hour before being put in the family wash. Bed. The bed is to be prepared in the usual way. It is doubly imperative to avoid wrinkles, crumbs, dampness of the sheets from secretions, because of the tendency to form bed-sores in this condition. If the emaciation is marked, the nutrition of the skin badly impaired or any hint of a bed-sore observed, it is well to have a water-bed or air mattress. The extreme sensitiveness of the patient to cold makes a demand on more clothing than in other febrile conditions. The Patient. Much depends on the skill, fidelity and patience of the nurse in attendance. The demands are often continuous and in- sistent, the pains and discomforts sacrifice rest and sleep and so strength. For this reason and because of the long course many of the cases take, all should be done to economize the strength and health of the nurse, in the choice of a room, the nearness of the bath room, the quiet and seclusion of her own rest hours. Two nurses should be on the case, one for night and the other for day. The patient should wear a nightgown of light flannel or if this is irritating, cotton. It should be open all the way down in front, to make the necessary examinations possible with the least disturbance to the patient. Diet. During the early hours or days of the infection when the fever is high and the evidences of intoxication acute, the feeding is not to be urged against the anorexia, but as the disease is peculiarly associated with emaciation and is likely to be long drawn out, the feed- ing after the first few days, even in the presence of fever or stupor is to be increased, given at regular two and three hour intervals. Often at a later stage the appetite is keen, if not ravenous, and it should be indulged abundantly. At first the food should be liquid, milk or one of the milk prepara- 564 TREATMENT OF ACUTE INFECTIOUS DISEASES tions, such as buttermilk, koumys or if there is any gastric disturbance, skim milk, whey or peptonized milk. Cereal gruels or well cooked cereals and farinaceous foods, such as arrowroot, barley, rice, cornstarch, farina, imperial granum, cornmeal, oatmeal, if it occasions no gas formation, jellies of barley flour, tapioca, sago, milk toast, veal, mutton, chicken or beef broths, may be used. These may be thickened with barley or other flour. Later, ice cream, eggs, custard, potatoes, oysters, scraped meat, pureed peas, small string beans or spinach and asparagus tips. In infancy the modification of the milk is to be changed to a somewhat greater dilution. In stupor or in case the patient cannot swallow, the feeding must be by gavage or nasal feeding; it is well to change occasionally from one to the other. As a rule in the older patients the oral route is prefer- able, while in children the nasal is the better. Drinks. Water, fruit juices in water, carrying sugar, not merely to sweeten but to add materially to the food ingested, are administered. It cannot be too much emphasized that the drinks should be pushed. The demands of the tissues are great and the apathy of the patient defeats these demands unless the nurse offers fluids frequently and urges the patient to drink. The feeding should be at intervals of two to three hours and as the case becomes subacute, some definite idea of the actual amounts of heat units ingested and energy needs of the case must be kept in mind. (See Chap. II.) Skin. A cleansing bath of warm water and soap should be given each day. Bed-sores are prone to occur. The emaciation accentuat- ing the bony prominences makes it imperative to relieve the pressure upon these points by frequent change of position, mechanical devices such as rings and cushions, by keeping these parts scrupulously clean and dry and by frequent rubbing to keep the circulation active in the skin and by the use of alcohol rubs and talcum powder, by avoiding wrinkles in the sheets, crumbs in the bed and by most gentle handling. If sores are imminent the air mattress or water-bed should be used and increasing care given the threatened parts. Mouth and Nose. In the care of the mouth and nose in this disease two things are to be kept in mind: first, the comfort and welfare of the patient; second, the danger his secretions entail to others. The mouth should be cleansed by having the patient rinse his mouth with plain water, followed by 2 per cent, to 4 per cent, boric acid solu- tion or DobelPs solution, half to quarter strength, used as a mouth wash or spray. After eating, the nurse should see that all dead spaces in CEREBRO-SPINAL MENINGITIS 565 the mouth and interstices of the teeth are freed from food particles by the use of small cotton swabs on wooden tooth picks or other simple applicator, wet with the same solution. If there is sordes on lips and teeth or the tongue is heavily coated, half strength official hydrogen peroxide may be applied to soften the deposit and in case of the tongue the edge of a whalebone or equivalent instrument may be used as a scraper, then followed by the solutions mentioned. For a dry mouth equal parts of 2 per cent, boric acid solu- tion and albolene with a little lemon juice is excellent. The nose may be sprayed by the same solutions. All secretions should be destroyed, preferably by burning, and danger in handling these secretions should be kept in mind by the nurse, who should carefully wash her hands and have recourse to an antiseptic, such as alcohol or 1 to 1,000 bichloride after the ministrations. Eyes. There is likely to be a conjunctivitis of mild or moderate grade. It is believed that these secretions, too, are infectious and for that reason they should be destroyed with the same care as in the case of nasal secretions. For the eyes nothing is better than mild boric acid washes of 2 per cent, strength. Bowels. The bowels should be freely opened at the beginning of the illness and attention given them throughout the course. For an initial catharsis, calomel in doses of gr. 1/4 (0.015 Gm.) every quarter hour for four or five doses, followed in two or three hours by milk of magnesia in dose of 3ss. (15 c.c.) is suitable and is especially good in cases of vomiting, in which the divided doses of calomel is credited with an antiemetic action and the milk of magnesia acts as a gastric sedative. If there is no vomiting, castor oil 3 ii to iv (8-15 c.c.) or Rochelle salt, 3ii to iv (8-15 Gm.) may be used. Later, milk of magnesia, 3ss. (15 c.c.), Liquor Magnesii Citratis, Siv to viii (180-240 c.c.), Hunyadi water, 3iii to vi (90-180 c.c.), or cascara preparations may be given, or an enema may effect the purpose. If there is much vomiting during the course, the enema will be the better choice of methods. If hyperaesthesia is very marked, the oral adminis- tration may be less annoying. Treatment of Nausea. Almost invariably vomiting occurs with the onset of the disease. Sometimes it continues for days. It is also a feature of the long-standing cases. Not only is the vomiting exhausting in itself, but it makes feeding difficult. The vomiting is probably central and may occur without nausea. Measures directed at the stomach itself would seem then to promise little unless some gastric irritability in addition existed. We may, however, try such expedients as cracked ice, a mustard paste, one 566 TREATMENT OF ACUTE INFECTIOUS DISEASES of mustard to four of flour, to the pit of the, stomach, sodium bicar- bonate gr. x-xv (0.60-1 Gm.) in a little water, bismuth subnitrate gr. x-xv (0.60-1 Gm.) stirred in a little water, or cerium oxalate gr. iii to v (0.20-0.30 Gm.) in the same way, or all in combination, bromides in 5-15 grain (0.33-1 Gm.) doses. Feeding is sometimes possible by the stomach tube, when other- wise rejected. Treatment of symptoms. As one might anticipate from the nature of the lesion, symptoms referable to cerebral irritation are dominant. Restlessness, delirium and sleeplessness demand attention. The application of the ice-cap or ice-coil is a helpful measure and the sedative effects of warm sponge baths are to be kept in mind. Of the drugs in the milder cases one has recourse to bromides, for the more severe, codeine and morphine or even hyoscine hydrobromide in doses determined by age and severity, e. g., bromides gr. iii-v (0.20- 0.30 Gm.) three times a day at one year; gr. v-x (0.30-0.60 Gm.) at five years; for adults gr. 15-20 (grams 1-1.3). Codeine sulphate gr. 1/60-1/30 (0.001-0.002 Gm.) at one year and gr. 1/10-1/5 (0.006-0.012 Gm.) at five years; for adults gr. 1/8-1 (0.008- 0.060 gram) or in severe cases morphine gr. 1/200-1/100 (0.0003-0.0006 Gm.) at one year to gr. 1/30-1/20 (0.002-0.003 Gm.) at five years. For adults gr. 1/8-1/4 (0.008-0.004 grams). Hyoscine hydrobromide to a child of five years may be given if above drugs faH, in doses of gr. 1/800-gr. 1/400 (0.000075-0.00015 Gm.) ; gr. 1/200-1/100 (0.0003-0.0006 gram) to an adult. Convulsions. Slight twitchings may be controlled by the use of chloral, best given by the rectum in small amounts of warm milk reinforced by bromides by mouth or rectum. Severe convulsions require morphine. The circulation, attacked by the toxins of the disease and feeling the effects of their action and that of intracranial pressure on the medul- lary centres, needs support and yet its impairment is not, as a rule, as great as one might anticipate. For continuous support we rely on digitalis or strophanthin or for immediate demands on caffeine. Do not use strychnine on account of its exciting effects on motor centres. Dose. In adults digitalis is given in the form of the infusion 3ss. (15 c.c.) or m. xxx of the tincture (2 c.c.) three times a day for three or four days, or in emergency strophanthin gr. 1/120-1/90 (0.0005-0.00075 Gm.) into vein or muscle, followed by digitalis as mentioned. Caffeine CEREBRO-SPINAL MENINGITIS 567 in the form of a soluble salt gr. v (0.30 Gm.) every four to two hours. Children are given smaller doses according to age or weight. It is believed by certain investigators that brain volume may be lessened by the use of hypertonic glucose solution. If this be true those symptoms referable to increased intracranial pressure, such as restless- ness, delirium, sleeplessness and to a certain extent circulatory distur- bances should be relieved by the measure. They advise giving intraven- ously a 25 per cent, glucose in the amount of 250 c.c. taking one hour for the administration. The solution should be sterilized in an autoclave. This injection is to be repeated at 12-hour intervals until evidence of reduction of intracranial pressure is observed. Bladder. Distension is likely to occur in the stuporous and incontinence is likely to mean an overflow. Evidence of such a state of affairs is to be sought for by palpation and percussion and efforts at relief afforded by the application of hot stupes over the hypogastrium or if this fails by the use of the catheter. Drug Treatment. There is no drug that can be called specific; though urotropin has been greatly recommended with the hope that its presence in the cerebro-spinal fluid (which is demonstrable) might prove bactericidal. Our knowledge of the action of urotropin, however, points to its efficiency as a bactericide only in the presence of an acid medium. It probably has no action whatsoever in the alkaline cerebro-spinal fluid. It is still recommended but with diminishing fervor. Specific Treatment. Upon the determination of the diplococcus intracellularis meningitidis as the causative agent of the disease, there followed efforts to find a specific substance to combat it and its effects. The fact that the toxic substance of the organism was found to belong to that class of poisons known as endotoxins, i. e., toxins bound up in the body of the organism itself and not excreted by it as is the case with the diphtheria bacillus, and the fact that antitoxins to this kind of toxin have not been determined made the outlook for success in this direction no better than in the case of other diseases due to endotoxin-bearing bacteria, such as pneumonia, streptococcsemia, etc. The effort was made, however, to obtain an active serum by the im- munization of animals with the meningococcus and as the first efforts at treatment followed the usual lines of subcutaneous or intravenous injections, disappointing results ensued, until the suggestion to inject the serum into the spinal canal reaped a rich reward. In spite of theoretical considerations the serum does seem to have some antitoxic power, but in no sense owes the total of its efficacy to this. What it does seem to do is to inhibit the growth, induce the death 568 TREATMENT OF ACUTE INFECTIOUS DISEASES and initiate the disintegration of the diplococcus, while at the same time it has opsonic qualities, encouraging phagocytic activity. Mode of Preparation. The serum is obtained by injecting into animals (the horse is the animal now preferred) at weekly intervals, increasing quantities of the meningococcus. At first dead bodies are used and it is found that better results ensue if the autolysate (products of self-digestion) of the organism is used alternately with the diplococci themselves. The whole course takes from four to six months. Later the live diplococci take the place of dead ones. Blood is then withdrawn from a vein, the cells separated from the serum and the latter preserved for use. Dosage. The dosage is limited only by the capacity of the spinal canal. The dose may be taken at 30 c.c. with these modifications: (1) That if more than this amount of cerebro-spinal fluid can be with- drawn from the spinal canal, an equal amount of the serum should re- place it. (2) That if less than 30 c.c. is withidrawn from the canal, the dose should approximate 30 c.c. as near as possible without inducing pressure symptoms or rather without forcing against rapidly increasing resistance. Doses less than 30 c.c. are much less efficacious. Sophian as a result of his studies lays great stress on the blood press- ure. He takes a fall of 20 mm. as an indication for halting the injection. Then he waits a few minutes and tries again; if further fall occurs he stops, as he has noted that after a fall of 20 mm. a further fall is apt to be precipitate and dangerous. He gives the average dose as controlled by blood pressure to be 1 5 years 2 12 c.c. serum 5 10 years 5 15 c.c. serum 10 15 years 10 20 c.c. serum 15 20 years 15 30 c.c. serum 20 years and over 20 40 c.c. serum occasionally more (Forchheimer's Therapeusis of Internal Diseases.) This precaution of Sophian 's is rarely observed in practice and experience does not emphasize the necessity. Frequency. The dose should be repeated each day for three or four days or longer; longer if the diplococci are found on the stained spread of the cerebro-spinal fluid withdrawn to be still persistent or if active symptoms of the disease continue, even if the fluid seems free from diplococci. It is only in the exceptional case, whose symptoms yield promptly and in which the diplococci have disappeared that fewer doses are permissible. Normal cerebro-spinal fluid reduces Fehling's solution. In cerebro- CEREBRO-SPINAL MENINGITIS 569 spinal meningitis this reduction does not occur. With an amelioration of the condition this reduction gradually returns and excellent observers have come to look upon its return as one of the indications for discon- tinuing the administrations of the serum. It may be added that this loss of reduction of Fehl ing's solution occurs in some of the other acute inflammations of the spinal cord. Results. The results are seen both in the amelioration of symp- toms and in the change wrought in the cerebro-spinal fluid. In the latter the diplococci free in the fluid disappear, then the intra- cellular organisms undergo change, that retard or prevent their growth on ordinary media, interfere with their staining properties, then dis- integration and autolysis take place with diasppearance of the bacteria. The cerebro-spinal fluid, itself, becomes clearer; the pus cells disappear, Fehling's solution is again reduced, while in the blood the leucocytosis makes way for a normal count. The general symptoms show improvement in the lessening of the nervous manifestations, such as delirium, in a lowering of temperature and better circulation and respiration. The improvement is more often gradual, the temperature going down by lysis, but a large per cent, of the cases show a true crisis in the fever and a precipitate improvement in the other symptoms. The disease is shortened by the use of the serum, complications are less frequent and serious sequelae are lessened. Bad Results. A disagreeable rather than a dangerous result is serum sickness which occurs much as after diphtheria antitoxin is administered. (See Diphtheria, Chap. XVIII.) The more dangerous accidents enumerated above, including collapse, have been attributed to anaphylaxis, rapid lysis of the cocci, the effect of the preservative trikresol and increased intracranial pressure. Worth Hale's studies attributed the dangerous results to the trikresol used to preserve the serum as well as to intracranial pressure, but Flexner believes the accidents in the use of serum cannot be attributed to ana- phylaxis nor to the preservatives and would attribute them all to the increased intracranial pressure. Lumbar Puncture. This procedure is absolutely essential to the diagnosis and to the serum therapy and in addition affords no small measure of relief from certain of the symptoms. It is an exceedingly simple procedure and practically free from danger, but is often approached by him who undertakes it for the first time with trepidation and seems to the parent who witnesses it an heroic under- taking, both of which facts make for delay in this urgent measure. Site. The site of puncture is determined by a line drawn across the spine at a level with the highest points of the crests of the ilia; a tape 570 TREATMENT OF ACUTE INFECTIOUS DISEASES or a string stretched between these points gives the point on the spine. The spine of the vertebra nearest this point is the fourth. The point of insertion of the needle is between it and the vertebra above, that is, between the third and fourth or between it and the vertebra below, that is, between the fourth and fifth. In children choose the exact mid-line; in adults choose a point 3/8 to 3/2 inch to the right or left of the mid-line, directing the point of the needle inward, i. e., towards the mid-line, going in between the laminae. This rule is often violated, the mid-line being chosen, but the likelihood of breaking off the needle and danger of not getting into the canal is enhanced by so doing. Position of the Patient. The patient should lie on his side at the edge of the bed or table with his back towards the operator. An assistant then bends the child forward, by gently pressing the head down and the knees up so that the spine curves boldly outwards, thus separating the spines of the vertebrae from each other and making the puncture easier. This position is preferable to the sitting posture chosen by some operators. Preparation of the Patient. The skin all about the site of punc- ture should be cleansed with soap and water and then with alcohol, or one may paint the site of puncture with tincture of iodine after a preliminary cleaning with alcohol. Preparation of the Operator. The hands should be cleansed with the same precautions as for a more considerable operation; thoroughly with soap and water, followed by alcohol or one may use sterile gloves. Preparation of the Apparatus. All the apparatus used should be rendered sterile by boiling. Appropriate needles or trochars and canulas, a syringe and test-tubes constitute the paraphernalia. Anaesthetic. It is better to do without an anaesthetic. The pain is but slight, as patients have testified, and the use of an anaesthetic complicates the procedure. If an older child or adult is fearful of pain or the parents insist, a local anaesthetic in the shape of ethyl chloride to freeze the site of puncture, or cocainization with 1 per cent, to 2 per cent, cocaine is to be preferred to general anaesthesia; if this may not be employed, a few whiffs of chloroform may be given. Deep anaesthesia is entirely unnecessary and adds discomforts and dangers. Needle. One may use a needle or a trochar and canula. The needle should be stiff of a fairly good calibre. The exploratory needles used for paracentesis of the thorax or other cavity or antitoxin needles, the bore and length depending on the age of the patient, may be used, or a trochar and canula or a special lumbar puncture needle, after the pattern of Quincke. CEREBRO-SPINAL MENINGITIS 571 Needles are now supplied that bend but do not break, which avoids an embarrassing accident. Needles of large calibre leave a wound from which the fluid continues to leak and increases the danger of infection. I have found the explor- atory needles more satisfactory than trochar and canula. The Tap. When the point of entrance has been determined, it is well to use the thumb of the left hand, with the edge of the nail on the upper border of the lower vertebra bounding the space as a guide and push the needle along the back of the nail firmly and slowly until a lessened resistance tells of entrance into the space, of which the flow of fluid is corroborative, when the open end of the needle is released or the trochar is withdrawn. Care should be taken not to rudely push the needle across the cerebro-spinal cavity against the body of the vertebra as bleeding ensues and interferes with an examination of the fluid. The depth to which the needle is carried is in children about an inch. In adults it is considerably more and the needle should be at least 4 inches long. The flow may be drop by drop, but is usually continuous or may spurt in a stream, depending on the pressure and the bore of the needle. The amount varies from a few c.c. to 50 or 60 c.c. or more. Twenty to 30 c.c. are common figures. (Normal infants 10 to 20; older children 15 to 25. Pfaundler.) Collecting the Fluid. One should have test-tubes 15 to 20 c.c. at hand, sterile or rendered sterile by boiling with the needles and syr- inge. The open end of the tube is put under the flow and filled three- quarters full, leaving room to introduce a sterile cotton plug without touching the fluid. If the fluid runs a little bloody at first this tube as soon as the fluid runs clear, makes way for another tube to catch the clearer fluid. Let all run that will, catching in several tubes. Sophian takes the blood pressure during the tapping and if it falls. 10 mm. Hg. he discontinues the flow. After plugging the tubes they should be set upright and left undis- turbed until examined. Appearance of the Fluid. The fluid' should be purulent or turbid r but the rule is not invariable. When the case is one of meningitis clinically, a fluid which is purulent or turbid indicates serum at once without awaiting the examination of the fluid. Again if the fluid is bloody and obscures the appearance of the fluid the serum should be given. Only in case the fluid is watery clear should one await for the results 572 TREATMENT OF ACUTE INFECTIOUS DISEASES of an examination, for in this case it is in all probability a case of tuber- cular meningitis, serous meningitis or poliomyelitis. In other words always give the patient the benefit of every doubt in giving him the serum, for it is in itself harmless. Injection. The injection should be by the gravity method. It should be made very slowly. The container is filled with serum, which should be warmed to about the temperature of the blood, the air expelled, and then connected with the needle; the patient watched carefully for evidences of collapse, poor pulse, cyanosis, embarrassed breathing, upon the appearance of which some of the serum should be allowed to flow back into the apparatus until improvement occurs. It is a wise precau- tion to wait a few minutes after the injection of the serum before the needle is withdrawn so as to make unnecessary another puncture if signs should develop. After the needle is withdrawn, remove the iodine from the skin with alcohol, apply sterile gauze to the puncture, affixing it by adhesive strips. Some clinicians deem they facilitate the diffusion of the serum in the cord by raising the foot of the bed. Special gravity apparatus is on the market or one may use the barrel of a 15-25 c.c. syringe as a funnel, to which is attached a 12-14 inch long rubber tube about 1/4 inch in diameter with metal end piece to fit end of needle (Sophian). This method has replaced the older syringe method, as it is difficult to produce a trauma of the cord by it as the inflow is more even and slower and if bad symptoms arise, the fluid can be drawn off by simply lowering the container. If breathing is bad, artificial respiration may be instituted. Atropin sulphate in doses gr. 1/80 to gr. 1/50 (0.00075-0.0012 Gm.) and cocaine hydrochloride gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) is ad- vised (Sophian). Reaction. Headache or pain in the back and limbs may ensue or on the other hand the patient may be rendered more quiet, but as a rule no bad reaction follows. Headache may be relieved sometimes by raising the pillow. If it is very severe morphine may be used. Dry Tap. Dry taps are usually due to failure in technique. For this reason all preparations for puncture should be carried out with precision; the patient held firmly in the position desired, the land- marks carefully determined and the thrust made firmly with constant regard to the direction. With repeated punctures the patient becomes more alarmed and the whole procedure made more difficult. It means in the great majority of cases that the canal was not entered. If one CEREBRO-SPINAL MENINGITIS 573 feels sure that he has entered the space and no fluid is obtained, he may introduce a sterile wire through the needle to clear it from a plug of tissue that may be occluding it and if not successful in this manoeuvre, withdraw the needle and go in a space above or below. The dry tap may be due to inspissation of the fluid. Raising the patient to a sitting position may initiate the flow ; gentle suction of the syringe may be tried or a little salt solution or a little serum may be gently forced in or the use of two needles in adjacent spaces with saline irrigation between them has been advised. In true dry tap one may force much smaller amounts in at more frequent intervals. No great pressure should be used. In this city the serum is now prepared by the Board of Health (New York). Tfc Possible Bad Results. The statement made that the proce- dure practically entails no danger it is thought by some should not be taken too literally. Wegeforth and Latham contend that a puncture should not be lightly undertaken as they say "The two cases just re- corded indicate the possibility of the removal of cerebro -spinal fluid acting as a factor facilitating the infection of the meninges from the blood stream." They contend that in cases of septicemia suspected of being meningococcic, an .examination of the blood should be made to determine the nature of the infecting organism and if the invading organism be found to be a meningococcus that an effort should first be made to sterilize the blood stream by the use of the antimeningococcic serum before the cerebro-spinal system is involved. This has been done on several occasions and by different workers. They would delay lumbar puncture, then, until the clinical symptoms of invasion of cerebro-spinal system is sufficiently definite before going into the cord. If the blood stream shows no infection at all the risks of puncture are diminished. Even then they advise that minimal quantities of fluid be withdrawn for laboratory tests with small bore needles so that the pressure relations within the cerebro-spinal cavity be disturbed as little as possible. Another unhappy result that follows, especially on too frequent tappings, comes from traumatism done by the needle and serum to the cord and meninges, setting up a myelitis and involvement of the nerve roots, which affords an explanation of the pain and stiffness of the back and legs, so often felt, atrophy of certain muscles and vasomotor dis- turbance. Early Usage. There is no one fact more emphasized by statis- tics than that every hour of delay in the usage of the serum adds an appreciable percentage to the mortality. Flexner and Jobling, ana- lyzing over 350 cases, show that when the serum was administered 574 TREATMENT OF ACUTE INFECTIOUS DISEASES on the first to 4he third day, in 123 cases the mortality was 16.5 per cent., on the fourth to the seventh day in 126 cases the mortality was 23.8 per cent., and later than the seventh day of 112 cases the mortality was 35 per cent. Intravenous Treatment. The intensive study of cases in camps during the late war has made it more and more probable that the disease instead of localizing itself in the brain and cord primarily is a septicemia in the beginning, localizing itself secondarily in the cerebro-spinal system. Herrick was able to get positive blood cultures in about 1/3 of his cases and claims that when the best laboratory technique is available these figures rise to 50 per cent, and even to 80 per cent. In 45 per cent, of his cases he was able to recognize the infection before the meningitis occurred and this stage of premeningitic general- ized infection he found to vary between a few hours and several daj^s, the average 48 hours. The diagnosis of these early cases is, of course, materially aided by the presence of an epidemic. The patient looks and feels ill, not infre- quently there is an early tonsillitis or laryngitis of varying degrees of severity; there is a moderate fever and the patient complains of a severe headache; this, however, is not constant. More significant is the apathy and emotionless expression of the patient. The conjunctivas are red- dened, often strikingly inflamed, and the organism may be recovered from the secretions. Of diagnostic significance is the petechial rash, coming out rapidly in crops. This is seen on the trunk and less con- stantly on the extremities, face, conjunctivas and in the mucous mem- brane of the mouth. These may be few and discrete and give the ap- pearance of an extensive purpura. There may be at this early stage of the infection none of the signs of brain and cord involvement other than may be attributed to any severe infection and some inequality and irregularity of reflexes and the spinal cord fluid shows no more than one finds in other acute infections. Blood cultures yield the specific organisms in the proportions cited. Herrick's plea for the prompt and efficient use of the serum by the intravenous route is logical and the following is largely abstracted from his article in the Journal of the A. M. A., Vol. 71, No 8, Aug. 24th, 1918, p. 612. The patient is first given a desensitizing dose of 1 c.c. of the serum subcutaneously; an hour later an intravenous injection of antimenin- gococcus serum is given. As a further precaution to avoid anaphy lactic reactions the first 15 c.c. are given very slowly at the rate of 1 c.c. a minute, the rest more rapidly. The dose is 80 to 150 c.c. serum, depend- ing on the degree of toxicity, but the larger doses are always the safer. If during the injection any untoward symptoms appear the injection CEREBRO-SPINAL MENINGITIS 575 is immediately intermitted. These symptoms are pallor or cyanosis, weak, rapid and irregular pulse or dyspnoea or vomiting. After two or three hours it is perfectly safe to make another effort and success rarely fails. Even patients sensitized by previous serum may be so handled. Herrick advises atropine and morphine before the administration or at any rate if symptoms cited occur. Epinephrin, too, is of value. (See serum treatment of Pneumonia, Chap. IX.) Frequency. In severe cases the serum should be repeated every 8 to 12 hours throughout the acute stage of 2 to 4 days, in milder cases every 24 hours. In Herrick's experience the average number of injections given were between 4 and 5 and the total serum 400 c.c. He gave one patient 12 doses, totalling 1050 c.c. Success may in a measure be checked up by blood cultures, due allowance being made for imperfections of technique. If on the evidences of septicemia a puncture of the spinal cord is made, which is the rule, it seems to me that a small needle should be used and only such amounts withdrawn as will establish diagnosis. Wegeforth and Latham would have us puncture the cord only when signs of meningitis have developed and after intravenous injections of serum. Herrick puncturing early and finding clear fluid lets the cord alone; when signs of meningitis occur he would withdraw only enough fluid from the canal to lessen its pressure to normal and that only about a half hour after intravenous injection (italics mine) and then introduce not more than 30 c.c. into the cord. After this he would drain the cord freely on the occasion of further intraspinal therapy, utilizing the effects of such drainage on the choroid plexus to increase the perme- ability to the antibodies in the blood stream. His average intraspinal injections numbered four. The efficacy of the intravenous treatment undoubtedly lessens the number of spinal injections needed. If 8 or 10 intraspinal injections are not efficacious, it is wise to interrupt the treatment, draining only so often as to relieve pressure symptoms. Some men (Olitsky) believe drainage quite as effectual as serum. The lack of success in any given case may be due to the serum. It is well, then, when meningococci are recovered by culture to determine by them the agglutization power of the serum used. Even when this cannot be done, it is well to try a serum from another source as possibly derived from similar strains. Fulminating Cases. The overwhelming rapidity of these cases does not permit of timely intervention on the part of the physician. The patients are profoundly affected when seen. These are cases in which intravenous injections as advised are urgent. 576 TREATMENT OF ACUTE INFECTIOUS DISEASES With meningeal involvement more frequent, dosage by the spinal route, as Dunn urges, seems rational. He advises a dose at once and another as soon as the beneficial effects begin to wane, which may be in a few hours, or to give the dose at twelve-hour intervals. The best result I have ever obtained was after intraspinal injections of 6 to 8 hour intervals, gradually lengthened as improvement followed. This was before intravenous treatment was urged. The frequent drainage of pus may have contributed materially to the fortunate issue. Chronic Cases. In the prolonged cases, as long as there are diplococci in the fluid or fever or pain or symptoms of activity of the process in any terms, except a rigidity of the neck and Kernig's sign, which are apt to persist for some time after complete disappearance of other symptoms, the treatment should be continued. Dunn has advised as a routine that after four doses on consecutive days, a wait of a few days follow and then again a course of four treatments be given and again a wait and so on until all signs disappear. It would seem advisable to change the serum used in the cases or to try the effects of drainage alone for a time. Sophian has used in the chronic cases meningococcic vaccine as an adjuvant to the serum treatment. The doses are 50,000,000, up to 1,000,000,000 or 1,500,000,000 every three to five days. Hydrocephalus in the chronic cases demands taps at daily in- tervals or once in two, three, or four days, depending on symptoms. Relapses. Relapses occur in a small per cent, of the cases, though Ker found that 15 to 20 per cent, of his cases relapsed. A relapse is to be treated like a fresh case, in all the details specified. Exacerbations in the course of a case are to be treated in the same vigorous manner. When the spinal fluid is too thick to run through the needle, it has been advised to use a sterile physiological salt solution to irrigate the cord and then inject the serum. When for other reasons the tap is dry and particularly in infants a puncture into the ventricles has been made, the cerebro-spinal fluid withdrawn and the serum given into the ventricles. Puncture of the Ventricles. In posterior basal meningitis, the use of serum by the intradural method is hazardous and useless. The hydrocephalus demands puncture of the ventricles daily or less often according to the severity of symptoms. If the fluid is infected, serum is injected into the ventricles as into the cord. This procedure is not difficult in infants. The anterior-fontanelle CEREBRO-SPINAL MENINGITIS 577 is used. One enters at the lateral border, pushes the needle down, back and in to the depth of 2 to 4 cm. Use the same needle as in lumbar puncture. In older individuals the puncture must follow a trephining. Results. The mortality in different epidemics in different local- ities showed about 75 per cent. The analysis of the first 400 cases after the introduction and use of the antitoxin reversed the figures; 75 per cent, recovered and 25 per cent. died. Of infants under one year, before the introduction of antitoxin the mortality was approximately 100 per cent.; a recovery a rarity. After the introduction of antitoxin, of the first twenty-two treated 50 per cent, recovered. In 1914 Flexner reported on 1,294 cases treated with his serum. The mortality was 31 per cent. For those treated on the first to the third day the mortality was 18 per cent., on the fourth to the seventh day 27 per cent. Later than the seventh day 36.5 per cent. The highest mortality was under one year, 49.6 per cent.; the lowest from five to ten years, 15.1 per cent. Thirty per cent, of the cases reported by Flexner ended by crises. In a few cases, he says, the meningococci seem to be serum fast ; and in a number of relapses the cocci seem to have acquired serum fastness and defeat the effort of the serum. Complications. Changes in mentality, varying from irritability and changes in disposition to profound damage together with different paralyses may ensue. Relief of intracranial pressure must be afforded by frequent tappings, by the use of the vaccine and serum. Eye complications are varied in type, in part due to effects on cen- tres from pressure or meningo-en cephalitis and to be treated by tap- ping and the use of serum and vaccines; and in part local, such as severe conjunctivitis or even suppurative processes, panopthalmitis with blindness. These are to be treated as under other circumstances, but the use of the serum locally may help materially. The ocular muscles may be involved. Ear. Otitis is very common, occurring in over 10 per cent, of the cases and is to be treated by paracentesis. For treatment of Otitis Media see Scarlet Fever, Chap. XVII. Deafness is another unfortunate issue. Joints. An involvement of the joints takes place in 15 per cent, of the cases and may be a polyarthritis, lasting weeks or months. 578 TREATMENT OF ACUTE INFECTIOUS DISEASES Vaccines (see text) are indicated. Fluid may be removed from a joint and serum injected (e. g., 10- 15 c.c. into knee) with great benefit. Pains may be relieved by the use of salicylates or local measures. (See Rheumatism, Chap. III.) During the acute stages pneumonia is fairly common, pleurisy, peri- tonitis, pericarditis, endocarditis less so. With intravenous treatment the complications are less frequent. For measures directed at relief of symptoms and support of circulation, see Pneumonia and Rheumatism, Chaps. IX and III.) Pyelitis is fairly common. Meningococci may be found in the urine even before they are deter- mined in the cerebro-spinal fluid. Urotropin should be used. (See Typhoid Fever, Chap. XIV.) In severe cases, subcutaneous or intravenous use of serum and the use of vaccines would be indicated. Convalescence. This period varies greatly. It may be fairly prompt, long delayed from weakness and poor nutrition or complicated with permanent damage to some centres in brain or cord or with some of the conditions mentioned. Air, sunlight, an abundance of good food and good nursing are the main indications. It has been advised (Herrick) to use vaccine during convalescence to prevent recurrences, e. g., 3 to 5 injections at 6-day intervals of 50 to 200 millions of killed autogenous meningococci; for some prolonged convalescences or recurrences would seem to be due to organisms pro- tected by exudates undergoing mucoid transformations or perhaps derived from nose, accessory sinuses, eye, ear or pericardium. This would seem to be a wise measure. Orchitis and epididymitis are other rare complications. For local treatment see Mumps (Chap. XXIII). Prophylaxis. Protection of the individual. Serum may be used subcutaneously, just as diphtheria antitoxin, to afford passive immunity and it has been claimed that it affords such immunity over a period of two to three weeks. It would be indicated for those who find themselves in immediate contact with a patient; doctors, nurses, and members of the patient's family. What is believed to afford a more lasting and effectual protection is afforded by vaccines. These vaccines have been given in the same doses and at the same intervals (weekly) as the antityphoid vaccine; namely, 500,000,000- CEREBRO-SPINAL MENINGITIS 579 1,000,000,000; but Sophian, because of the rather striking pain in the neck, which alarmingly suggests the real disease, after the initial injec- tion, recommends as a first dose, 100,000,000, followed in a week by 500,000,000 and in another week by 1,000,000,000. Carriers. Fifty per cent, and in some epidemics even a much higher per cent, of contacts become carriers, and infection through the third person is common ; 95 per cent, of these carriers do not suffer them- selves. All contacts should be examined and those found to be " carriers" should be quarantined until their nasal discharges are negative for the meningococci on two occasions, and Sophian advises that those contacts be quarantined a week even when the discharges are negative. As the incubation period is nearly two weeks it would seem wise to quarantine for this period. As Major Russell has remarked, it is the chronic carrier with large number of meningococci always present that constitutes the real danger rather than a man with a few organisms. He must be kept under ob- servation. In quarantine they should use the mild antiseptic sprays, such as 2 per cent, boric acid solution or quarter strength Dobell's solution. Sophian lays great stress on the use of saline douches three times a day, followed by a spray of peroxide of hydrogen 1/2-1 per cent. Others recommend the blander silver preparations, but astringents that irritate the mucous membrane and so lower its resistance should never be used. SUMMARY Distribution of the family. The disease is contagious and isolation should be obligatory. The children of the family and other "contacts" should be kept from other children, as possible carriers. The children of the family should be isolated over a period that probably covers the illy defined incubation period, i. e., three to four weeks. The nasal passages of the suspects should be examined for diplococci. Adults, too, should be kept from the sick-room unless their duty keeps them there. Adults of the family should not come in contact with other children and if their duty brings them in contact with children, they should remove from the environment of the patient and submit to the isolation period before seeing children again. Contacts should have their nasal secretions examined. If they are positive, they should keep from children during the epidemic and if possible, isolate themselves until the cultures are negative. 580 TREATMENT OF ACUTE INFECTIOUS DISEASES Avoid infections of nasal passages, especially during epidemics of colds and sore throats. " Contacts" should use a mild spray for the throat and nose, 2 per cent, boric acid solution or quarter strength DobelFs Solution Never use strong astringents. Nurse. Some cases a night and day nurse. Very likely to become a " carrier." Avoid contact with children. Remember the ease of conveyance by kissing, coughing and sneezing. Before going out clea'n hands and face with soap and water followed by alcohol or 1-1,000 bichloride and Spray throat and nose with the mild solutions mentioned. Should spray throat and nose from time to time while on duty. Physician. Should make his visits as short as is compatible with his full duty. On leaving, wash face and hands with soap and water followed by alcohol or bichloride 1-1,000. He should not see another child at once. Room. Choose with reference to light. Air. Verandah or porch approach. Bath room near by. Should be stripped of furnishings. Carpet lining or unbleached muslin on the floor. Screens for the eyes, if sensitive to the light. Avoid jars, noise and other sources of irritation. Precautions in the sick-room. Nasal and oral secretions should be received on rags and burned or disinfected in 1-20 phenol or 1-500 bichloride. Thermometer. Should be left in sick-room and kept in 2 per cent, phenol or in formalin. Eating utensils. Boil in sick-room, or if sent out of sick-room soak in phenol 1-20 for twenty minutes to half-hour, then send out to be boiled. Clothes. Soak overnight in 1-20 or 1-50 phenol, then boil half-hour before sending to the family wash or laundry. Urinals, bed-pans, etc. 1-20 carbolic or 1-500 bichloride. Bed. (For technique of bed making, see Pneumonia, Chap. IX.) Especial care should be taken on account of bed-sores. CEREBRO-SPINAL MENINGITIS 581 With any threat of bed-sores Air mattresses or Water-bed. Clothing somewhat more abundant than usual on account of ex- treme sensitiveness to cold. Patient. Isolation. Nightgown should be of light flannel or, if irritating, cotton. Should be open all the way down the front to facilitate exami- nations. Diet. Early days do not force. Later consider the body needs. Articles of diet. (See text.) In infancy modified milk is to be further diluted. In stupor or dysphagia. Nasal or oral gavage. Nasal better in children; oral in infancy. Drinks should be forced. Water, alkaline waters, fruit juice, as lemonade, etc. Care of body. Skin. Cleansing bath of soap and water daily. Bed-sores. Prevention. Change of position. Scrupulous dryness; use of rings and cushions. Rubbing of skin with hands. Use of alcohol and talcum powder. Care of bed in avoidance of wrinkles and crumbs of food. When sores threaten, use air mattresses or water-beds. Sores should be handled on surgical principles. Mouth and nose. Remember that the secretions are infectious. Rinse mouth with plain water, then with Boric acid solution 2 per cent, to 4 per cent, or with Dobell's solution quarter to half strength. Teeth. Brushed with soft brush or cotton swabs, wet with above solu- tions, care being taken to free interstices from particles of food. Remove particles between gums and cheeks. Sordes and coated tongue. Soften with half strength official peroxide of hydrogen, then scrape tongue with edge of whalebone. Follow with the boric acid or Dobell's solution. Dry mouth and tongue. Use 2 percent, boric acid solution. Albolene aa. Flavor with lemon-juice. 5S2 TREATMENT OF ACUTE INFECTIOUS DISEASES Nose. Soften hard secretions with olive oil. Spray with boric acid or Dobell's solutions. Burn all secretions as infectious. Nurse should carefully wash hands and use alcohol or 1-1,000 bichloride as an antiseptic after these ministrations. Eyes. Mild conjunctivitis is common. Secretions are probably infectious and should be burned. Cleanse eyes with 2 per cent, boric acid solution. Care of bowels. Open freely at the beginning. Calomel, gr. 1/4 (0.015 Gm.) every quarter hour for four or five doses, or gr. 1/10 (0.006 Gm.) every ten minutes for ten doses. Follow in two to three hours by milk of magnesia gss. (15 Gm.) if there is vomiting, Castor oil 3ii-iv (8-15 Gm.) if there is no vomiting; or Sal Rochelle 5ji-5ss. (8-15 Gm.) or Epsom salt 3ii~5ss. (8-15 Gm.) in half to three-quarter glass of water. Throughout the illness use, Milk of magnesii 5iH5ss. (8-15 Gm.) or Liquor magnesias citratis giv-viii (120-240 Gm.), Hunyadi or similar water. Enemata, especially if there is vomiting, though hyperesthesia may make it a too distressing procedure. Nausea. A feature of the onset is vomiting, and it may continue for some time. One may try- Cracked ice. Mustard paste, 1 in 3, 4, 5, or 6 of flour to pit of stomach. (For technique, see Pneumonia, Chap. IX), or Sodium Bicarbonate gr. x-gr. xv (0.60-1 Gm.) or Bismuth Subnitrate gr. x-gr. xv (0.60-1 Gm.) or Cerium Oxalate gr. iii to gr. v (0.20-0.30 Gm.) or a combination of the three. Lavage. Treatment of symptoms. Restlessness, delirium, sleeplessness. Ice-cap or ice-coil. Warm sponge baths. Bromides, in doses gr. x to gr. xxx (0.60-2 Gm.) according to age. More severe. Codeine phosphate in doses of gr. 1/48-gr. ss. (0.0015-0.030 Gm.) according to age. CEREBRO-SPINAL MENINGITIS 583 Very severe. Morphine sulphate in doses of gr. 1/48-gr. 1/4 (0.0015- 0.015 Gm.). Hyoscine hydrobromide in doses of gr. 1/300-gr. 1/100 (0.0002- 0.0006 Gm.) in adults. Convulsions. Slight twitchings. Chloral best given by the rectum in warm milk. Dose, gr. v to gr. xxx (0.30-2 Gm.) according to age. Bromides may be added to the chloral in double the dose of the latter, and may be given by mouth or rectum. Severe convulsions. Morphine sulphate, doses of gr. 1/24 to gr. 1/3 (0.003-0.020 Gm.). For details of treatment of convulsions in children, see index. Circulation. So far as influenced by the intracranial pressure, do a lumbar punc- ture. For continuous support use digitalis in doses of gr. ss. to gr. iii (0.030-0.20 Gm.) three times a day (3ss. to 5ss. of infusion (2-8 c.c.). or m. v to m. xxx (0.30-2 c.c.) of the tincture. Strophanthin in emergency in doses of gr. 1/120 to gr. 1/60 (0.0005-0.001 Gm.). For immediate demands. Caffeine in doses of gr. ss. to gr. v (0.0>30-0.30 Gm.) every two hours as a soluble salt of caffeine sodium salicylate or sodium benzoate. Intravenous injection of glucose. (See text.) Bladder. Watch for distension. Apply hot stupes over the epigastrium. Catheterize. Urotropin. Doubtful value. Dose, gr. v (0.30) two to four times a day well diluted. Specific treatment For preparation of serum and the theory of its action, see text. Administration of serum. Intravenous treatment. As the infection is probably in the beginning a septicemia intravenous treatment is indicated. (For discussion, see text.) Diagnosis may be made before cerebro-spinal symptoms develop. (See text.) Determine sensitization by intradermal method. (See Pneumonia. Chap. IX.) 584 TREATMENT OF ACUTE INFECTIOUS DISEASES If this cannot be done, in cases of known sensitization or best in any case, give desensitizing dose of 1 c.c. subcutaneously, one hour later give full dose; first 15 c.c. at rate of 1 c.c. per minute. Give rest more rapidly. Dose 150 c.c. If untoward symptoms appear: cyanosis, pallor, dyspnoea, vomit- ing cease injection for one hour and then try again. Atropine sulphate gr. 1/150-1/100 (0.0044-0.0066 Gm.) or morphine sul- phate gr. 1/4-1/8 (0.015-0.008 Gm.). Epinephrin (adrenalin) 1:1000 m. xv intravenously. Frequency. Eight to twelve hours in severer cases; 24 hours in less severe during the acute stage. Usually takes 4-5 doses. Mode of administration. (See Pneumonia, Chap. IX.) Intraspinal treatment. Unless cerebro-spinal symptoms occur it is best not to puncture the cord, or to use small needle and withdraw small amounts. On the appearance of cerebro-spinal symptoms puncture the cord preferably about a half hour after an intravenous injection, re- moving enough to relieve pressure and introducing not more than 30 c.c. of serum into the canal; if further spinal therapy is neces- sary, drain cord and follow procedure below. Dosage. Only limited by the capacity of the spinal canal. Rule, 30 c.c. or if more than this amount of cerebro-spinal fluid is with- drawn from the canal, replace an equal amount of serum. If less than 30 c.c. of cerebro-spinal fluid is withdrawn, approxi- mate the dosage of serum to 30 c.c. but without forcing against resistance. Sophian is guided by blood pressure readings. (See text.) For Sophian's table of dosage at different ages, see text. Frequency of dosage. Once a day for three or four days or longer if meningococci per- sist in the cerebro-spinal fluid or the symptoms are active. Favorable results are shown by amelioration of symptoms and change in cerebro-spinal fluid. (For details, see text.) Lumbar puncture. Site. In a line with the iliac crests. Crosses spine nearest to fourth lumbar. Go in between fourth and third lumbar or between fourth and fifth lumbar. In children enter needle in exact mid-line of vertebral column. CEREBRO-SPINAL MENINGITIS 585 In adults enter 3/8"-l/2" to right or left of mid-line and direct needle inward toward the middle line. The mid-line, however, is preferred by many operators. Position of the patient. On his side with back toward the edge of the bed or table, head and knees approximated. Preparation of patient. Wash site with soap and water and alcohol or Paint the site with tincture of iodine. Preparation of the operator. Prepare as for a surgical operation. Soap and water and alcohol or sterile gloves. Preparation of the apparatus. All should be sterilized by boiling; needles, trochars and canulas, syringe and test tubes. Anaesthetic. Better none; pain is trivial. If fear makes it advisable freeze site with ethyl chloride or use 1 per cent, to 2 per cent, cocaine solution or give a whiff of chloroform. Needle. Should be stiff and of fairly good calibre, such as is used for thora- centesis or diphtheria antitoxin administration. Trochar and canula. Quincke needle. The Tap. Guide needle along upper thumb-nail pressed against upper border of lower vertebra bounding the space to be entered. Lessened resistance tells of entrance of needle into canal. Flow through needle corroborates entrance. Don't push needle across space into body of vertebra, lest bleeding ensue and spoil fluid for examination. Depth of entrance. In children about 1", in adults more. Needle should be 4" long at least. The flow. May be drop by drop; but is usually continuous or in a spurt. The amount. Normal infants, 10 to 20 c.c. Older children, 15 to 25 c.c. Adults, 20 to 30 c.c. May vary in meningitis from a few c.c. to 50-60-100 c.c. Collecting fluid. -Sterile test-tubes 15 to 20 c.c. Fill not more than three-quarters, so that plug of cotton will not touch. If fluid runs bloody, catch this in one tube and the clearer in the other. Let all flow that will, or 586 TREATMENT OF ACUTE INFECTIOUS DISEASES If blood pressure falls 10 mm. during the tapping it is well to discontinue. (Sophian). Plug and set upright. Appearance of fluid. Usually turbid or purulent. Don't wait for examination, but give the serum. If blood obscures it, don't wait, give serum. If watery clear, wait and examine. May be tuberculous or serous meningitis or poliomyelitis. Give patient benefit of any doubt by administering the serum. The injection. Fill the container with serum warmed to blood heat; expel all air. Inject slowly by gravity method. ,. . Some advise raising foot of the bed to facilitate diffusion. Watch for poor pulse, cyanosis, embarrassed breathing, collapse and let serum flow back until improvement occurs. Keep the needle hi situ for a few minutes to avoid necessity for another puncture, if symptoms develop (Dunn). Remove excess iodine with alcohol. Seal puncture with sterile gauze pad. If bad symptoms develop as above, Do artificial respiration. Cocaine hydrochloride, gr. 1/8-1/4 (0.008-0.015 Gm.) hypoder- mically (Sophian). Atropine sulphate, gr. 1/80-gr. 1/50 (0.00075-0.001 Gm.). Adult dose. Children, dose gr. 1/800 to gr. 1/100 (0.00008-0.0006 Gm.). Reaction. As a rule none of consequence. May be headache, pain in back and limbs. Raise the pillow. Morphine sulphate, dose, smallest that will relieve pain, gr. 1/48 to gr. 1/4 (0.0015-0.015 Gm.). Dry tap. Usually due to failure in technique. Canal is not entered. Needle is plugged with tissue. Try a space above or below. Fluid may be inspissated. Sitting patient up may initiate the flow; gentle aspiration with syringe may be effectual. Saline irrigation or serum under slight pressure, two needles in adjacent spaces with saline irrigation. True dry tap. Use small amount of serum under gentle pressure at shorter intervals. Early usage of first importance. (For statistics, see text.) Possible bad results. (See text.) CEREBRQ-SPINAL MENINGITIS 587 Intravenous treatment Simultaneous intraspinal therapy if signs of meningitis occur. Begin as soon as diagnosis can be made by symptoms and positive blood culture. Method. Desensitize patient by subcutaneous injection of 1 c.c. of horse serum. After one hour an intravenous injection of 80-150 c.c. of anti- meningococcic serum. (See text for details.) Frequency. Every 8-12 hours until desired reaction occurs. Average 4-5 injec- tions. Fulminating cases. More frequent doses, twelve hours or less (Dunn). Also intravenously in doses of 75-100 c.c. are urgent early. Chronic cases. Continue treatment as long as diplococci persist, or there are active symptoms, such as fever and pain. Change the serum used as possibly elaborated from different strains. Stiff neck and Kernig's sign may outlast the infection. Give a dose four days in succession, then wait a few days, another series and so on, until signs disappear (Dunn) . Try effect of drain- age alone for a few days. Sophian uses Meningococci vaccine in addition to the serum. Begin with 50,000,000 and increase up to 1,000,000,000 or 1,500,000,000. Give at three to five day intervals. Hydrocephalus. Tap every day or once in two, three or four days according to symp- toms. Posterior basic meningitis. Tap ventricles daily or less often according to symptoms. Intradural injection of serum dangerous. If ventricular fluid is infected inject serum into ventricles as into cord. Tapping ventricles. Infants. Enter by anterior fontanelle at lateral border, push needle down, back and in 2 to 4 c.m. Use same needle as in lumbar puncture. Older individuals. Trephine. Complications. Mental disturbances. Frequent tapping. 588 TREATMENT OF ACUTE INFECTIOUS DISEASES Serum. Vaccines. Eye. Special treatment. Serum applied locally. Panopthalmitis with blindness. Oculo-motors may be involved. Ear. Otitis. (For treatment, see Scarlet Fever, Chap. XVII.) Joints. Vaccines. Remove fluid and inject serum. Arthritis (Salicylates, see Chap. Ill, Rheumatic Fever). Pneumonia. (See Pneumonia, Chap. IX.) Serum under skin or into vein. Vaccines. Endocarditis. As under other circumstances. Serum into vein or under skin. Vaccines. Pyelitis. Urotropin. Vaccines. When severe. Serum under skin or into vein. Relapses. Treat as a fresh case. Exacerbations. Treat vigorously as a fresh case. Prophylaxis. Individual. Passive immunity. Serum subcutaneously. Lasts two to three weeks. More lasting immunity. Vaccines. One hundred million, a week later CEREBRO-SPINAL MENINGITIS 589 Five hundred million, and then a week later One billion. Carriers. Quarantine until discharges are twice negative. Convalescence. Period varies greatly depending on damage done. Fresh air, sunlight, good food, careful nursing. Herrick advises vaccines to prevent recurrences, giving 50 to 200 millions of killed meningococci, 3-5 injections at 6-day intervals. CHAPTER XXVI POLIOMYELITIS (INFANTILE PARALYSIS) THIS disease, so dreaded because of its frightfully crippling effects, is undoubtedly of microbic origin. A minute globular organism, so minute as to pass through the pores of a Berkfeld filter, has been detected in the central nervous system, cultivated and made to reproduce the disease in monkeys by Flexner. The virus is conveyed by individuals infected or commonly by "car- riers"; that is, those who having been in contact with the sick, though not themselves infected, can carry the virus to a susceptible person and infect him. The r61e played by insects in transmitting the disease is questionable. The portal of entry seems to be the upper air passages, especially the nose, and the virus passes from here to the olfactory lobes, spinal cord fluid and thence to the nervous tissue for which it has a special affinity. Protection of the Community. The focus from which all epi- demics radiate is the patient sick with the disease in question. Pro- tection begins then with sufficient isolation of this individual, so that there shall be no immediate contact between him and a susceptible individual and this can be readily accomplished when understanding and willingness on the part of those concerned cooperate. But another source of infection beside the patient frankly sick is the abortive and ambulatory case and only a sufficiency of skill in diagnosis of this group of cases can be of avail in eliminating him as a source of infection. Another source of infection is the " carrier." The carriers may be divided into two groups; first, those who have been in contact with the sick and though uninfected themselves carry a virulent organism about with them and those who have had the disease, have recovered and yet carry about virulent organisms, like the diphtheria and typhoid carriers. Flexner has called attention to these four groups. Flexner and Amos have concluded that healthy and chronic carriers are rare. Isolation. Those in contact with the patient should be kept iso- lated, so far as possible for three weeks and if this is not possible POLIOMYELITIS 591 should at least avoid contact with children; children should not be allowed to go to school or to public gatherings. It is believed that the nasal mucous membrane has a distinct protec- tive action against infecting organisms. If this be so any antiseptics used in the shape of sprays or local applications which in any measure injure the innate protective mechanism may lessen this protection. For this reason the use of sprays is of a doubtful value. The abortive cases are to be especially looked for in epidemics. A diagnosis of an abortive case of poliomyelitis is at best conjectural and when occurring as a sporadic case scarcely possible, but in an epi- demic symptoms of an acute infection, in which the febrile reaction is accompanied by excessive irritability and hypersesthesia, should arouse suspicion; sweating, stiffness of the neck or gastro-intestinal symptoms may be accompanying features. When such a diagnosis is suspected the spinal cord fluid should be examined. This is clear and shows a ground glass or opalescent appear- ance due to an increase of the number of leucocytes. If shaken up a foam forms that lasts from one-half to one hour due to an increase of the globulin content. These tests are of value only if positive and in the absence of blood. The cytology varies with the stage of the disease. There is always a pleocytosis. As a rule in the first week there is a lymphocytosis, though rarely in the very early days there may be a polynucleosis. The globulin is scant during the first week, but increases steadily and is in excess even 8 to 10 weeks after the onset. Later in the second and third weeks, the cells decrease, the proportion of polymorphonuclears decrease and the proportion of lymphocytes and mononuclears increase. The globulin reaction becomes more striking. Rarely do the cells reach a thousand ; more commonly a few hundred or only 10 to 100. The reduction of Fehling's solution unlike that of cerebro-spinal meningitis persists. The fluid may appear normal. This picture may be given by tuberculous meningitis and syphilitic myelitis, so there is absolutely no diagnostic feature in the symptoma- tology or findings, but such a spinal fluid added to the general symptoms given above, occurring during an epidemic makes a diagnosis of poliomy- elitis fairly certain and from the practical standpoint imperative. The blood shows a leucocytosis; sometimes as high as 30,000, and an increase of 10 per cent, to 15 per cent, in the polymorphonuclears. These cases are to be isolated in the same way as the frank cases and those exposed to such a case treated as those exposed to a frank case. 592 TREATMENT OF ACUTE INFECTIOUS DISEASES More difficult is the problem of chronic carriers. We know that the infection resides in the secretions of the nose and in the saliva and has been found in the tonsils and pharynx. The organism has been found, described and cultivated by Flexner and his workers and the infectivity of secretions determined by inocula- tion into monkeys, but a ready method of determining the infectivity of the secretions of suspected " con tacts" and of patients recovered from the disease awaits elaboration. In the meantime, such contacts and convalescents should be kept especially from children. Isolation of the Patient. I feel that sufficient emphasis has not been laid on complete isolation of these cases. In the last New York epidemic I saw and treated a great many cases in the open wards and did not see a spread of the disease within the ward, but I believe that the rarity of cases among contacts gives us a false sense of security. Hill's studies in Minnesota (quoted by Lovett and Richardson) on the relative transmissibility of this disease with other well known contagious diseases showed that 22 per cent, of those exposed to Scarlet Fever contracted the disease, to Diphtheria 17 per cent., to Infantile Paralysis 6 per cent. Studying exposures in single families, 40 per cent, contracted Scarlet Fever, 30 per cent. Typhoid Fever, 29 per cent. Diphtheria and 17 per cent. Infantile Paralysis; moreover, in some epidemics as high as 40 per cent, of houses or families affected showed more than one case. These figures as well as the knowledge of the infectivity of the dust from infected rooms (Thro), the conveyance of the disease by healthy individuals, all seem to me to demand as strict an isolation for these cases as for Scarlet Fever and I recommend the rules laid down in that chapter as applicable here. See Scarlet Fever, Chap. XVII. Rules for Disinfection in the Patient's Room. All secretions and excretions should be destroyed, those from the nose and mouth best received on rags or gauze and burned. For the mode of disinfection of secretions, articles in use about the patient, clothes and bedclothes, see Typhoid Fever, Chap. XIV. Doctors and Nurses. It should be remembered that cases have appeared in or through individuals only once in contact with a patient and that a short time. The physician and nurse should take the same precautions, then, as when treating a scarlet fever case and the precautions to be taken in the sick-room and on leaving the sick-room should be the same. See Scarlet Fever, Chap. XVII. Room. A light, well-ventilated room should be chosen, stripped of furniture, carpets, rugs, hangings, etc., leaving bare floors or linoleum, so that the floors and wall may be wiped with damp cloths occasionally POLIOMYELITIS 593 and these destroyed; for it has been shown that the dust of a room harboring a case is infective and capable of transmitting the disease. Such a room should be screened, for it is possible that insects may convey the disease, as they probably do typhoid fever by becoming contaminated with secretions; for virus passes through the gastro- intestinal canal of man and remains active; but that the disease is regularly conveyed by an insect, e. g., the fly, as was once suspected, is not proven. A convenient bath room and a separate exit from the house are to be considered in the choice. Bed. The bed should be of the hospital type, a half or at the most three-quarter bed, of iron with woven wire springs and a firm mattress. The bed should be made with care (see index), and the sheets drawn smooth and free from wrinkles. One must remember the great hypersesthesia and paralysis and how much a well made bed makes for comfort. Moreover, numerous me- chanical contrivances will be used if paralysis and contractures develop and this type of bed facilitates such efforts. Care of the Body. Cleansing baths of warm soap and water should be given each day and oftener if the sweating is severe. These are to be followed by sterile talcum powders in abundance. The mouth is cared for as in any of the acute infections and the same measures applied to the care of the nose and genitals. See Pneumonia, Chap. IX. It must be remembered, however, that the virus is present in the secretions of the mouth and nose and that all secretions should be burned or otherwise destroyed. The nurse remembering the danger to herself in handling these secre- tions should wear gloves and sterilize her hands. Diet. During the acute stage the diet should consist of milk or milk preparations, cereals, bread, broths, plain or fortified with cereal or farinaceous flours, eggs, custard, rice, ice-cream. Water or lemonade, orangeade, or other drinks flavored with fruit juices and fortified with sugar may be used. Later a liberal diet may be allowed and the appetite satisfied. Treatment of Symptoms. When the diagnosis is made or sus- pected, the patient should be put to bed for the most important part of his treatment, rest. When one recalls that the essence of the disease is an inflammatory and degenerative process in the motor centres of the cord and bulb it should go without saying that they should rest; and that means that the muscles they subserve must rest; hence, the whole body. A clue to the 594 TREATMENT OF ACUTE INFECTIOUS DISEASES continuance of this activity of the process is given by the persistence of the hypersesthesia. When this disappears, it may be assumed that repair has begun in the centres. Until this time the patient should not be persuaded to try the para- lyzed or paretic limbs; but rather forbidden to do so. Even when there are no constitutional symptoms or hypersesthesia accompanying the paralysis it is better to keep the patient in bed for a couple of weeks. Bowels. When first seen a cathartic should be given. Castor oil 3ii-5i (8-30 c.c.) a salt, Rochelle or Epsom 3j~5i (4-30 Gm.) accord- ing to age or calomel gr. i to gr. ii (0.060-0.120 Gm.) in divided doses, followed by a salt. Later cascara, compound licorice powder or aloin in doses suited to the age may be given or milder salines such as liquor magnesii ci- tratis, Hunyadi water, milk of magnesia or occasionally stronger salts as above or castor oil. Enemata are usually necessary even when cathartics are given, for constipation is a rather striking feature and more marked when the abdominal muscles are paretic. Urine. In the early days retention may occur. It is necessary then to be on the lookout, as catheterization may be necessary. One should try, first, however, the simple device of running water, water sprinkled on the hypogastrium or heat or cold applied to the hypogas- trium. PREPARALYTIC PERIOD Specific Treatment. Efforts to accomplish a cure by specific therapy has been made along two different routes. First by the use of immune sera derived from a horse by the injection of the organism responsible for the disease and second by the use of serum from a patient convalescent from the disease. It has not yet been definitely settled what is the etiological agent concerned in this disease. Claims are made by Flexner and his co-workers at the Rockefeller Institute for globoid organisms which pass a Berfeld filter and by Rosenow of Chicago for a pleomorphic streptococcus. Both these workers, using the organisms they have isolated, have produced an immune serum which each has used in the treatment of the disease with, what has seemed, satisfactory results. The serum is given intraspinally, intravenously and intra- muscularly. Nuzum and Willy using the serum obtained with the Rose- now organism have reduced the mortality to 11.9 per cent, of 159 cases as contrasted with 38 per cent, in 100 cases untreated during the same period. Their method is to use the serum as early as possible, giving 15-30 POLIOMYELITIS 595 c.c. intravenously very slowly, repeating it every 12 hours if neces- sary; at the same time they give 5-15 c.c. intraspinally after removing about the same volume of spinal fluid. The injection should be made slowly and without pressure as the lumen of the blood vessels is dimin- ished by the perivascular infiltration. They claim that in 12 to 24 hours there is a critical fall of temperature, a slowing of the pulse and a general improvement in the patient. If given early paralysis may be prevented. They have seen paralysis clear up under late serum treatment. Sera from patients recovered from or convalescent from acute poliomyelitis was used in the epidemic of 1916. Opinions differed as to the efficacy of this measure, but the majority agree that results were similar to those described above after the administration of immune horse sera. It seems to me to offer greater promise than the horse serum and I should always use it in preference to the immune horse serum when it is available. The method consists of drawing blood under aseptic conditions from donors convalescent as recently as possible, and who are shown to be free from syphilitic taint or other infection. After the blood is allowed to clot at room temperature it is placed in the ice box to await separation of the serum. The serum is then decanted and, if possible, centrifuged to obtain a product free from corpuscles and hemoglobin. It may then be given fresh or inactivated by the addition of sufficient tricresol to produce a final product, containing 0.2 per cent, of tricresol, i. e., 2 c.c. of tricresol to 998 c.c. of serum, or it can be inactivated by heating in a water bath to 56 C. for half an hour. The method of administration is the same as outlined above for immune horse serum. The size of the intraspinal dose should not be more than 15 c.c. and introduced only after the removal of an equal or greater quantity of fluid. The size of the dose, too, is modified by the knowledge that sera obtained from patients recovered years before rather than months is apt to be less potent. The serum should be given intravenously at the same time. The dose is limited only by the diffi- culty of obtaining the serum. One would give 40-60 c.c. or even more if the quantity at hand is abundant. The repetition of the dose depends on the severity of the toxemia and the reaction of the patient to the serum and upon the degree of pleocytosis in the spinal fluid. The serum must be administered early in the disease to prevent paralysis. It is still a question what effects the serum may have upon paralysis already established. Draper says that " generally speaking patients who show counts below 100 in the first twelve to eighteen hours are less apt to develop paralysis then those who show 500 or more." 596 TREATMENT OF ACUTE INFECTIOUS DISEASES Fever occurs in this period and disappears soon after the on- set of paralysis. It is not a feature of the disease and requires no treatment. Hyperaesthesia, pain and sensitiveness of muscles or limbs to pressure or handling are characteristic if not constant. Hyperaesthesia and fear of pain on handling lead to striking irri- tability to which undoubtedly meningeal involvement adds. The pain may be spontaneous or elicited only on handling. These discomforts are usually more marked in paralyzed limbs, but may occur in limbs which are not paralyzed and, indeed, during the paralytic period. The discomfort induced by movements often causes the child to hold the part so quiet that it simulates paralysis. Even the weight of the bed-clothes may cause distress and in such cases cradles over the limb to support the clothes are helpful. At times the application of a light splint to immobilize a limb is grateful to the patient. Heat is especially soothing and may be applied as fomentations or with the hot- water bag ; wrapping the part affected in a thick layer of cotton batten subserves the same purpose. Drugs. When irritability is the preponderating feature, bromides, either the potassium salt or triple bromides may be given with benefit. When pain is dominant a member of the coal-tar group, phenacetin, antipyrin or acetanilid is indicated. (See Summary for doses.) Salicylates, such as the sodium salts or acetyl salicylic acid (aspirin) are less depressing than the aniline derivatives and sometimes as effectual. For more severe pain codeine or even morphine may be necessary. (See Summary.) Sometimes drowsiness and apathy are present instead of irritability, but even then wakefulness may be a feature. Insomnia which makes such inroads on strength is met by bromides or a mild hypnotic such as trional sulphonethylmethane or by codeine. Stiffness and pain in the muscles of the neck, especially on bending the head forward is common and demands care in handling and intelligent arrangement of the pillows. Applications of heat should be useful. Convulsions are very rare and should indicate warm packs and morphine to control the convulsion and bromides to prevent recurrence. Gastro-intestinal symptoms are so common as to attract atten- tion and during an epidemic a febrile attack accompanied by vomiting should elicit suspicion and concern. POLIOMYELITIS 597 The vomiting and anorexia demand rest for the stomach. The food is stopped entirely or cut down to small amounts. Sodium bicarbonate or bismuth may be used but it is not commonly persistent nor requires much interference. Diarrhea may occur, but constipation is the rule. Severe diar- rhea indicates regulation of food; castor oil and bismuth subnitrate. Tonsillitis and pharyngitis are sometimes present and the virus has been recovered from the tonsils. Hot saline irrigations may be used. (See Scarlet Fever, Chap. XVII.) Sprays of mild antiseptics and argyrol 15 per cent, to 25 per cent, may be applied. Use of Urotropin (Hexamethylenamine). Because, when adminis- tered by the mouth, this drug was found in the spinal cord fluid and because when given to monkeys it was thought that the subsequent infection was modified in severity, it came to be quite extensively used; but careful observations of clinical results following its use holds out no hope from its use and, moreover, the efficacy of urotropin (hex- amethylenamine) depends upon its breaking up to set free formalde- hyde. This occurs only in acid and not in alkaline media such as the cerebro-spinal fluid. Pathology. The disease has been called a meningo-encephalo- poliomyelitis, and this term will explain the types of the disease we observe. But it is even more than this for it affects both the white and gray matter of the brain, the cord and the intervertebral ganglia and the abdominal ganglia. Flexner*s studies lead him to this con- clusion: that the route of infection is in the vast majority of instances, practically always, by the nasal mucous membrane to the lymphatic channels of the olfactory lobes, to the cerebro-spinal fluid, by this to be distributed to the nerve tissues of the cerebro-spinal axis, for which the virus has a special affinity. Conveyance by the blood must be exceedingly rare in human beings and curiously enough the avidity of nerve tissue for the virus is not sufficient to derive it from the blood vessels unless damage has pre- viously been done to them or to the choroid plexus. Types of the Disease. Wickman, in his monograph on the dis- ease, which to avoid the common name connoting the pathology, he calls in honor of the two great students of the condition the Heine- Medin's Disease, divides the clinical pictures into eight types, 1. Spinal (the most common) poliomyelitis. 2. Landry's paralysis (ascending or descending paralysis). 3. Bulbar type. 4. Encephalic or cerebral type. 598 TREATMENT OF ACUTE INFECTIOUS DISEASES 5. Ataxic type. 6. Polyneuritic type. 7. Meningitic type. 8. Abortive type. These types are not clear cut and merge into one another. For this reason fewer and more inclusive groupings have been ad- vocated, such as 1. Spinal type. 2. Bulbar type. 3. Cerebral type. 4. Abortive type. (Miiller.) or 1. Upper motor neurone type. 2. Lower motor neurone type. 3. Abortive type. (Peabody, Draper and Dochez.) The abortive type, whose symptoms are those of a preparalytic period has been discussed. Wickman has divided this Type into four groups, 1. A group showing symptoms of any general infection. 2. A group showing much meningeal irritation (meningism). 3. A group in which pain is a feature (influenza-like) . 4. A group with predominant gastro-intestinal disturbance. These serve to fix the attention on poliomyelitis during an epi- demic. The ascending and descending spinal types, Landry's paralyses, are rare and highly dangerous types. The polyneuritic and ataxic types are among the rarer manifestations of the disease. Meningo-encephalitic Type. As has been said sharp differen- tiation between the types of Wickman does not obtain; hence, it is better to consider the meningeal and encephalitic cases together. The symptoms are such as one might expect from involvement of the brain and its covering; headache, irritability, restlessness and some- times convulsions. In some, apathy or stupor predominate; vomiting is likely to occur. There are pain and stiffness of the neck, disturbances in the rhythm of pulse and respiration; tache cere*brale and there may be Kernig's sign. As the hydrocephalus develops Macewen's sign may be noted and in infants the fontanelles bulge. The involvement of the centres causes palsies, facial, monoplegias or hemiplegias, opthalmoplegia, increased reflexes and, later, spasticity. POLIOMYELITIS 599 These symptoms are to be met as described under the section on the preparalytic period and under cerebro-spinal meningitis, Chap. XXV. Bulbo Spinal Type. Again a sharp differentiation between the bulbar and spinal types is useless, if possible, and they will be con- sidered together. This is the common well-known type of the disease that gave to us the term anterior poliomyelitis. Most authorities recognize distinct stages that have decided signifi- cance from the standpoint of therapeutics. 1. The acute stage; from the onset to and through the spread of paralysis. 2. The stage of recovery in those muscles capable of recovery. 3. The stage of residual and permanent paralysis. The Acute Stage. All that pertains to the general symptoms of this stage, aside from the paralysis has been dealt with above under the pre-paralytic period. The essence of the therapy is rest of function of the affected parts and hence, the inflamed cord centres supplying those parts. Rest means not only a comfortable bed, careful nursing, devices to find comfortable positions for the painful members, but also freedom from excitement, entertainment and visitors and, particularly, avoidance of pernicious measures of mechanico- or electro-therapeutics, often insisted on by the parents in an eagerness to see something done for the condition. Beside affording rest we ameliorate the discomforts. Lovett calls attention to the importance of recognizing the tendency to contracture in these first two or three weeks and taking measures to prevent it. This is especially likely to occur in the Achilles tendon. Lovett advises gentle stretching of the muscles and, as a prevention, a box covered with a blanket placed at the bottom of the bed against which the soles of the feet may rest and preserve for the feet a right angle to the legs. The weight of the bed-clothes, which, pressing on a paralyzed part, exaggerates the deformity and encourages contracture, must be taken off by wire cages, stretching clothes across the crib or similar devices. Light splints may be applied to correct the position; pillows and folded blankets may be used for the same purpose and the position of a joint should be changed from time to time. The best guide to the length of the period of the active cord involve- ment is the continuance of tenderness in the muscles and joints. It may last two or three months and during this time no active measures should be applied to the affected muscles. When the bulb is affected one may see ocular palsies, facial palsy and involvement of the tongue, the pharynx and muscles of deglutition. These latter may compel feeding 600 TREATMENT OF ACUTE INFECTIOUS DISEASES by nasal or stomach tube and entail constant care to keep the mouth and pharynx free from secretions and food particles that may induce a foreign body pneumonia. Involvement of Muscles of Trunk and Diaphragm. Paralysis of the respiratory muscles is the usual cause of death. The intercostal muscles are almost always affected before the diaphragm. Death due to this cause may be direct or due to pulmonary com- plications sequential to the paralysis. Either set of muscles are capable of carrying on the respiration. It is the involvement of both that is fatal. In what seems extensive involvement of these muscles hope lies in the fact that improvement may be rapid and substantial because the depression of centres often overflows the site of actual damage. When the dyspnoea becomes accentuated oxygen may be administered and respiratory stimulants such as atropine, caffeine and strychnine may be given hypodermically and, these failing, artificial respiration tried, but when one bears in mind the pathological basis of this failure in function he realizes how futile these measures must necessarily be. The paralysis of the abdominal muscles greatly aggravate constipa- tion and makes the patient more dependent on cathartics and enemata. Retention of urine must be borne in mind and the measures described above undertaken. Paralysis of the Extremities. The distribution of the paralysis is weird, often affording combinations topographically and functionally remote from each other. The legs are involved more commonly than the arms and one leg more commonly than both. The onset of the paralysis is lawless; it being the first manifest symptom in some cases or occurring any day after the onset, though the majority of cases show paralysis within three days. However, the onset of the paralysis may be delayed a week or two. Again it is difficult to forecast the extent of the ultimate paralysis by the extent in the early days, for the early paralysis may be due to other causes than actual cell destruction such as edema and pressure of exudate on centres, depressing effects of toxins on centres, or only partial and not necessarily an eventual crippling involvement of a group of cells , in the cord, so that in a very extensive early paralysis complete recovery or slight damage only may follow. Unhappily there is the obverse of the shield and prognosis waits on time. What is to be done in the acute stage and even more important what is not to be done has been detailed above. When the acute process has subsided (see above) one should POLIOMYELITIS 601 begin the treatment with massage. Massage must be begun gently and for short periods of time at first; gradually increasing up to fifteen to twenty minutes two or three times a day. Heat in the shape of hot applications or baking is a useful ad- juvant to the massage. Electric light bulb suspended from a cradle makes a simple hot air bath. Care must be taken lest excessive heat damage the tissues. In this way the nutrition and tone of the muscle is subserved. Electricity probably has a very limited value. Its use has un- doubtedly been greatly abused and led to the neglect of more valuable measures, less striking in their exposition and requiring more skill and perseverance. Galvanism is applied to the nerve trunks and faradism to the muscles, if they will respond to faradism. Galvanism is supposed to affect the nutrition of the muscles the more, but the contraction under the faradic current constitutes a more distinct exercise. Passive Movements. Passive movements play an important part in the prevention of contractions, as has been noted above. They also, like massage, have a favorable effect upon the contraction in the affected part. Active Movements. There is no doubt that the best exercise is that developed along normal lines; that is voluntary movements. It must be remembered that the extensive distribution of motor cen- tres governing any group of muscles is in a longitudinal direction and that some centres are very likely to escape and that these centres may be educated to take on the function of the destroyed centres in no small degree. Persistency is all important. In intelligent adults an under- standing of the problem is of great assistance, but the vast majority of the patients are children and very many of them little children, so that cooperation on their part has to be elicited by indirect methods. The warm bath, affording both heat and buoyancy, has been advised, in which the child is persuaded to effort by a desire to play with floating toys, or similar devices by which strong desire is made to elicit voluntary effort may be resorted to. In older children efforts may be systematized. At first, assistance must be given by the operator to effect the pro- posed movements, but as the patient's ability is increased less and less help is given, then resistance exercises are begun in which the operator makes gentle and then increasing opposition to the patient's movements. How long these exercises shall be persisted in before recourse to mechanical expedients is had is a nice question, but it should be months. Good authority puts it at a year and a half to two years, and even 602 TREATMENT OF ACUTE INFECTIOUS DISEASES then one is not sure that improvement may not go on, even when it has been discouragingly slow. If the patient has achieved all he can with the impaired muscles he still may so educate other groups 01 muscles that they may take over the function, in some measure, of those rendered helpless by the lesion. In the case of the legs, the effort to walk should be made, but in a severe case this is obviously impossible without mechanical appliances to afford help. Apparatus. The apparatus may take the form of crutches, corsets, jackets, braces or splints and is distinctly an orthopedic problem and competent authority should be sought. At last the problem may become a distinctly surgical one and, Operative Treatment Is Indicated. Lovett in a masterly article outlines the indications as follows: 1. To correct fixed deformity. 2. To improve muscular function. 3. To secure stability of useless joints. Such operations are instanced by transplantation of a tendon of an active muscle to the insertion of a paralyzed muscle to take over the function of the latter. This should not be an early operation but undertaken only when failure to improve in the paralyzed muscle is without question. Efforts to stabilize flail joints by arthrodesis, or an chy losing of joints by removing their articular cartilages and getting bony union between the members of the joints. This is especially applicable in the ankle, but such operations should not be undertaken without first carefully acquainting oneself with the indications and contraindications in individual joints. Other devices may take the place of arthrodesis, such as the use of silk ligaments mentioned by Lovett. Contractures may require cutting and stretching; especially about the ankle and knee. Prognosis. The mortality runs about 15 per cent., but varies in different epidemics and at different ages. The percentage of recoveries investigated in one series of 234 cases (quoted by Lovett) showed 25 per cent, to be complete and in another series of fifty-seven cases 28 per cent, completely recovered and 31 per cent, more recovered function, but showed some atrophy. The mor- tality varies in different epidemics and in one considerable series showed less than 10 per cent. It seems to be higher in infancy and after ten years than between these periods. POLIOMYELITIS 603 Prognosis of extent of damage. This is difficult to determine in the acute stage, for as has been said, what seems like an extensive damage involving trunk muscles may clear up entirely or the apparent damage may persist and spread and in rare cases the lesion may light up again after subsidence of acute manifestations. Muscles which contract at all after the acute symptoms subside hold out hope of recovery in part or whole and efforts to improve the power of such muscles should be persisted in for many, many months. A single muscle in a group functionating in common is more likely to recover than when associated in its paralysis with more members of the group or the group as a whole, in its paralysis. SUMMARY Isolation. Of "contacts" for three weeks. Use of mild antiseptic sprays for the nose and throat by "con- tacts," e. g., 1 per cent, official peroxide of hydrogen, of doubtful value. Look for abortive and ambulatory cases. (See text.) Of patients. (See summary of Scarlet Fever, Chap. XVII.) Disinfection of patient's room. (See summary of Typhoid Fever, Chap. XIV.) Doctors and nurses. (See summary, Scarlet Fever, Chap. XVII.) Room. High and well ventilated. Near bath room. Strip of furniture and furnishings. Screen. Bed. Half or three-quarters. Hospital type preferred. Woven wire springs; firm mattress. Care of body. Cleansing baths of soap and warm water. Sterile talcum powders. Mouth. (See Pneumonia summary, Chap. IX.) Burn secretions. They contain the virus. Nurse should wear gloves in handling them. 604 TREATMENT OF ACUTE INFECTIOUS DISEASES Diet. Acute stage. Milk, milk preparations, cereals, bread, broths thickened with cereal or farinaceous flours, eggs, Custard, rice, ice-cream. Water, fruit juice drinks, such as lemonade, orangeade. May fortify with sugar. After acute stage. Liberal diet. Satisfy appetite. Treatment of symptoms. Rest, of body and especially the limbs and muscles impaired; the latter until all hyperaesthesia has disappeared. Do not urge patient to move muscles, j Do not massage. | During the acute stage. Do not use electricity. Bowels. Castor oil Sti-gi (8-30 c.c.). Salts (Epsom, Rochelle) 3i~5i (4-30 Gm.). Calomel, gr. i to gr. ii (0.060-0.120 Gm.), followed by a salt. All these in dose according to age. Later. Cascara, compound licorice powder, aloin, liquor magnesii citratis, milk of magnesia, Hunyadi water; dose according to age. Occasionally a stronger salt or castor oil. Enemata. Required especially when abdominal muscles are paretic. Urine. Watch for retention. Try running water. Sprinkle water on hypogastrium. Heat to bladder. Cold over bladder. Catheterize. Preparalytic period. Convalescent serum. More valuable than immune horse serum. (For method of obtaining, see text.) Administered both intravenously and intraspinally. Method of administration. (See Cerebro-spinal Fever, Chap. XXV.) Dose by vein 20, 40, 60 c.c., depending on quantity of serum available. Intraspinally not more than 15 c.c. after the removal of an equal or greater amount of spinal fluid. Frequency depends on toxemia, reaction and pleocytosis of the spinal fluid. Must be administered early. POLIOMYELITIS 605 Immune horse serum. Time of administration early as possible. Dosage 15-30 c.c. intravenously very slowly. Repetition every 12 hours until favorable reaction obtained. Simultaneously give 5^-15 c.c. intraspinally after removing an equal volume of spinal fluid. Fever. Rarely requires attention. Luke-warm water sponges. Hyperaesthesia, pain, sensitiveness of muscles. Remove weight of bedclothes, by cradles and similar devices. Light splints to painful limbs. Heat. Fomentations. Hot-water bag. Wrap part in thick layer of cotton batten. Drugs. Bromides, especially when there is much irritability, gr. v to gr. xv (0.35-1.0 Gm.) three or four times a day, according to age. Phenacetin, gr. iss. to gr. xv (0.1-1.0 Gm.), according to age. Antipyrin, gr. i to gr. x (0.060-0.65 Gm.), according to age. Acetanilid, gr. ss. to gr. v (0.030-0.35 Gm.), according to age. Lesser doses, say one-third, may be repeated at two, three or five hour intervals. Salicylates. Sodium salicylate or aspirin (acetyl salicylic acid), gr. i to gr. xx (0.060-1.35 Gm.), according to age. These doses may be repeated at two, three or four hour intervals if pain continues. Codeine phosphate or sulphate. For more severe pain. gr. 1/48 to gr. 1/4 (0.0015-0.015 Gm.), according to age. Morphine in most severe cases. gr. 1/120 to gr. 1/4 (0.0005-0.015 Gm.), according to age. Insomnia. Bromides, gr. v to gr. xxx (0.35-2 Gm.), according to age. Trional, gr. i to gr. x (0.060-0.65 Gm.). according to age. Codeine sulphate or phosphate, gr. 1/48 to gr. 1/4 (0.0015-0.015 Gm.), according to age. Stiffness and pain in, muscles of the neck. Heat. Fomentations. Convulsions. Rare. Warm packs. Morphine sulphate to control, gr. 1/48 to gr. 1/4 (0.0015-0.015 Gm.), according to age. Bromides to prevent occurrence, gr. v to gr. xv (0.35-1.0 Gm.) every three to four hours. 606 TREATMENT OF ACUTE INFECTIOUS DISEASES Gastro-intestinal. Vomiting. Stop food. Sodium bicarbonate, gr. v to gr. xv (0.35-1.0) in water.' Bismuth subnitrate or subcarbonate, gr. v. to gr. xv (0.35- 1.0 Gm.) suspended in water. Diarrhea. Regulate food, cut down cream and sugar in milk. Give castor oil Sii-gss. (8-15 c.c.). Follow with Bismuth subnitrate, gr. xv to gr. xxx (1-2 Gm.) every two hours. Tonsillitis and pharyngitis. Hot saline irrigations, argyrol 15 per cent, to 20 per cent. (See summary in Scarlet Fever, Chap. XVII.) Urotropin. (Hexamethylenamine.) (See text.) Paralytic period. Rest to paralyzed limbs. Avoiding contractions. Gentle stretching of muscles. Rest at bottom of bed for soles of feet in drop of foot. A box covered with a blanket sufficient. Take weight of clothes from paralyzed parts with cradles and sim- ilar devices. Light splints to correct position. Pillows, folded blankets, for same purpose. Change position of joint from time to time. Bulbar type. Muscles of deglutition involved. Keep mouth free from secretions and food particles. May have to feed with stomach or nasal tube. Involvement of respiratory muscles. Dyspnoea. Oxygen inhalations. Atropine sulphate hypodermically, gr. 1/1000 to gr. 1/60 (0.00006- 0.001 Gm.), according to age. Caffeine sodio-salicylate or benzoate, gr. 1/4 to gr. v (0.015-0.35 Gm.) or Strychnine sulphate, gr. 1/500 to gr. 1/30 (0.00012-0.002 Gm.) hypodermically, according to age. Artificial respiration. Paralysis of extremities. After acute stage subsides. Massage. Gentle at first for very short time. Increase up to 15-20 min- utes two or three times a day. POLIOMYELITIS 607 Heat. Fomentations. Baking. Electricity. Galvanism to nerve trunks. Faradism to muscles that respond. Passive movements. To prevent contractions. To improve circulation in affected structures. Active movements. Best method to develop impaired centres and muscles. Keynote of success is persistency. Warm bath a valuable adjuvant. (See text.) Resistance exercises. Apparatus. Crutches, corsets, jackets, braces, splints. Operative treatment. Transplantation of tendons. Arthrodesis. Silk ligaments. Operation for contractures. Prophylaxis. Avoidance of contacts. Isolation of patient. Destruction of secretions. Members of affected families to avoid contact with children and crowded places. Children to avoid gatherings of children during an epidemic. Schools are common centres of the spread of the disease. Avoid taking children to affected localities, especially in summer. CHAPTER XXVII SMALL POX (VARIOLA) SMALL pox still jealously guards the secret of its origin. A parasite, the Cytorrhyctes variolse, first described by Councilman, bids fair, however, to elucidate the mystery. And yet, many of the symptoms of the disease must be attributed to the concomitant action of pyogenic organisms and in all probability it is to these that most of the fatal issues are due. Jenner's observation that individuals who had suffered from cow pox became by virtue of that fact protected from small pox and his applica- tion of that knowledge in terms of vaccination constitutes one of the most dramatic episodes in medical history and is too familiar to want reiteration here. Jenner furnished the means of eliminating the disease forever and only ignorance and criminal carelessness or wilful neglect has prevented the passing of what once was a scourge to the human race. There seems to be among physicians a wide-spread belief that the infectious organism or virus may be conveyed through the air as well as by contact, which makes isolation more imperative and more difficult; but so good an authority as Rosenau doubts any other mode of convey- ance than a direct one, through discharges, secretions or objects, includ- ing insects, in contact with such. In any case efficient treatment begins with isolation as soon as the diagnosis is made or even suspected. Hospital treatment of the patient is preferable both from his stand- point and that of the community, but if the treatment must be carried out in the home, the physician must realize that a greater obligation rests upon him to establish and maintain isolation and teach the family their part in carrying it out. Skillful nurses can hardly be dispensed with. Room. The room should be as remote from the rest of the house- hold as possible with a separate approach from the outside to avoid unnecessary contact of nurses and attendants with other parts of the house or members of the family. It should be light, well ventilated, kept at 65 F. to 70 F. and screened against insects, whose access SMALL POX 609 to the discharges and secretions affords a highly probable mode of con- veyance. The room should be stripped of all unnecessary furnishings and its treatment and separation from the rest of the house carried out as in Scarlet Fever, see Chap. XVII. Ready approach to a bath room, itself under isolation, facilitates the work about the patient. An open hearth, making possible destruc- tion of discharges on the spot by fire, is a desideratum. The discharges should always be burned. Rules for disinfection of bedding, towels, bed clothes, utensils, etc., may be found under Typhoid Fever, Chap. XIV, and be considered as applicable here. Nurses. If the nurse has not had the disease, she or he should be vaccinated afresh. The nurse should consider herself as isolated, so far as compatible with her duties. A separate kitchen should be afforded her and, if this is not possible, all dishes and utensils should be treated like those used by the patient. If she goes out at all she should take every precaution not to convey the disease and follow the rules laid down for a nurse attending a Scarlet Fever case. See Chap. XVII. Treatment of Other Members of the Family or Exposed In- dividuals. These should all be vaccinated with virus from more than one source to insure a "take." It is certainly desirable to quaran- tine those exposed, but not always possible. Those who show a suc- cessful vaccination may be released when this is obvious; others kept in quarantine for six to eighteen days; but if this is not possible they should be kept under the closest surveillance for the incubation period of sixteen to eighteen days, and isolated on the slightest suspicion of infection. The apartments vacated by a small pox case must be thoroughly disinfected (see Summary) together with their clothes, toilet articles, utensils, tools or articles with which they may have come in contact since their infection. Physicians should look upon themselves as potential sources of danger to the community. Except in emergencies they should make their visit to the patient the last one in the day and in any case spend some time in the open air before calling on another patient. They should take every precaution on the occasion of a visit to avoid contamination, should make their visit no longer than is necessary to do their full duty to the patient and then disinfect themselves as thoroughly as possible on leaving. For full details of precautions to be observed by the physician on his visit, see Scarlet Fever, Chap. XVII. Visitors should not be allowed unless circumstances arise that make it imperative and then should observe all those precautions specified for the physician. 610 TREATMENT OF ACUTE INFECTIOUS DISEASES Bed. The best bed is of the hospital type, an iron half or three- quarters bed with woven wire spring and a firm mattress. For the details of bed-making, see Chap. IX. In very severe cases, especially with skin complications such as boils, abscesses, bed-sores, an air bed or water bed may add greatly to the patient's comfort. Diet. With the onset there may be decided anorexia and during this period no effort should be made to force the feeding. The diet should be preferably milk or milk preparations or if patients cannot take milk, and the vast majority of those who say they cannot are found to bear it well on trial, one may use cereal waters, cereal "pre- pared foods" used extensively in infant feeding, then broths fortified with cereals or farinaceous flours and egg albumin water. Later, how- ever, consideration must be had for the theoretical demands of the patient and a fairly high caloric diet may be aimed at. The rules laid down in Typhoid Fever, Chap. XIV, are applicable here. The condition of the mouth in Small Pox makes the ingestion of food more difficult than in Typhoid and the patient must not be nagged and fatigued to ingest definite quantities fixed upon by these theoretical considerations. Water should be given in abundance. Definite orders should be given the nurse not only to supply the patient's demands but considering the sicker patients too sick to appreciate their needs or to ask for water to offer it to them every hour when awake. Fruit drinks, lemonade, orangeade, etc., may be used and afford an excellent vehicle to carry sugar, the food value of which contributes materially to the patient's needs. Alkaline waters, such as Vichy or carbonated waters, if grateful, may be used. Care of the Body. One has but to visualize the lesion to real- ize the great discomfort the patient must suffer and the amount of nursing skill and fidelity required to contribute to his comfort. Mouth. During the pre-emptive period the mouth should receive the attention usually given it in acute infections. It should be rinsed after each feeding with water and then with 2 per cent, boric acid solution or half to quarter strength DobelTs solution or the equivalent in one of the many milder antiseptics on the market, the use of which may be more grateful to the patient. The teeth may be cleansed with a very soft brush and a good tooth paste or with a cotton swab on a toothpick saturated with one of the above solutions, particular care being taken to free from food the interstices of the teeth and the dead spaces between the gums and cheek. Dry coating on the tongue may be softened by half strength official peroxide of hydrogen and SMALL POX 611 scraped with edge of a whalebone. When, however, the eruption ap- pears, the painful vesicles in the mouth and throat add much to the difficulty of affording proper care. No harsh instrument such as the toothbrush or whalebone can be used. The same solution may be used but irrigations will afford comfort; indeed, much the same measures may be used as in Scarlet Fever. (See Chap. XVII.) When the mouth is foul, permanganate of potash, a claret colored solution, 1 to 4,000, may be used as an irrigation or this may be preceded by half strength peroxide of hydrogen. Chlorate of potash gargles may be used, 1 per cent., or less if painful. Ulcers may be touched with silver nitrate solution, 5 per cent, to 10 per cent. When the throat is painful, ice applied to the neck as in tonsillitis may afford relief. Nose. The nose should be kept free from secretions, by the gentle use of such solutions as have been mentioned in the care of the mouth, as sprays and by cotton swabs, on wooden toothpicks as applicators, dipped in the same solutions. Dried secretions may be moistened first by the application of sweet oil or vaseline. Eyes. The need of careful attention to the eyes cannot be too much emphasized. At the height of the eruption, it and the attendant edema make proper care of the eyes no easy task. Boric acid solution, 2 per cent, to 4 per cent., should be applied on wipes to keep the lids clean and be dropped in the eyes. When the eyes close from the edema a warm boric acid solution must be used as an irrigation, the point of a glass irrigating nozzle being gently forced between the lids. To prevent the lids from sticking together an applica- tion may be made to their edges of vaseline or gr. i (0.06 Gm.) of yellow oxide of mercury to 3 i (4 Gm.) vaseline. Frequent and prolonged applications of cold compresses dipped in a 2 per cent, to 4 per cent, boric acid solution or physiological salt solution tend to lessen the edema and discomfort. When the conjunctivitis is very severe, 5 to 20 per cent, argyroi solutions are useful applications. When corneal ulcerations occur a 1 per cent solution of atropine sul- phate should be used. Skin. One can imagine the task imposed on the skill of the nurse and the ingenuity of the physician to keep the skin, the site of a multitude of pustules, hot, painful and itching, in even relative com- fort. In the pre-emptive period, sponge baths of soap and warm water are proper and desirable, but during the height of the eruption sponge bathing is no longer feasible. Some authors urge, however, the use of prolonged warm baths, keeping the patients immersed for hours at a time. It is claimed for these warm baths, that they reduce the fever, 612 TREATMENT OF ACUTE INFECTIOUS DISEASES lessen the nervous excitation, are a sedative to the skin and macerate the pustules, thus effecting an earlier discharge of their contents. Certainly the procedure seems a rational one and the criterion of its success is the response of the patient. The temperature of the water should be about 95 F. It is best carried out in a long bath-tub at the bed side with a comfortable hammock arrangement attached to the sides of the tub to suspend the patient and facilitate moving him. Burning and Itching. This may be delayed by prolonged warm baths at 95 F. or the efficacy of the baths may be enhanced by the addition of carbonate of soda, 2 to 10 ounces of soda to a bath-tub of water (30 gallons). As the itching and burning is most intense in the face and hands, cold compresses may be applied to them with comfort. Hot compresses, especially to the extremities, are sometimes found more grateful. Ruhrah has mentioned the efficacy of alum solutions 1 per cent, to 2 per cent., or baths in a 1 to 1,000 solution (1 pound of the alum in a bath-tub of 500 liters). When watery solutions are not applied oily substances find favor, for they both alleviate the discomforts and keep the pustules soft and facilitate their discharge. Opening these pustules to relieve the patient of the effects of absorption from them appeals to me. Of course, all applications must be frequently changed, especially in the pustular stage, as the dressings soon become drenched with discharges. Ointments are especially applicable when the crusts begin to form. Simple vaseline or sweet oil may be applied to the skin or to dress- ings, but the itching is more quickly ameliorated if 3 per cent, to 5 per cent, carbolic (phenol) is added to the one or the other. Some clinicians advocate glycerin one part to two of water as an excellent application. The itching is sometimes intolerable; yielding to it lacerates the skin and invites such secondary infections as abscesses and erysipelas. In children mechanical restraint may be necessary to prevent the scratch- ing, such as splints at the elbows and thick "boxing-glove" like ban- dages to the hands. Innumerable applications have been advocated, their very number declaring the difficulty of the problem. Hubbard uses on the face white precipitate ointment (ointment of ammoniated mercury) linen mask. Appreciating the possibility of absorption he changes occasionally to ordinary zinc oxide ointment. He also uses cold watery solutions of glycerin 3i to 5i (4-30 c.c.) applied on absorb- ent cotton. Ruhrah advocates spraying with alcohol to relieve the itching and sometimes adds 1/2 per cent, to 1 per cent, menthol to this. He further SMALL POX 613 speaks of the value of spraying with carbolic acid (phenol) in water solution 1 to 40. Schamberg advocates warmly the use of undiluted tincture of iodine. He begins this early and applies it to the face once or twice a day, if the skin is not too sensitive. In some cases a dilution of one-half may be used. He claims not only increased comfort under the application but a modification in the severity of the eruption, a decrease in the secondary infections and a relief from offensive odors. (Practical Treatment, Musser and Kelly.) If the face becomes dry and uncomfortable under the treatment, they apply such ointments as cold cream. Powders, too, have been used to allay the itching. Hubbard (Hare's Modern Treatment) speaks highly of one made of equal parts of boric acid, lycopodium, corn-starch and subgallate of bismuth. He applies this freely. The offensive odor demands the physician's attention. The application of iodine lessens this. Schamberg uses iodofonn 2 parts, boric acid 10 parts, and talcum 28 parts, dusting it on freely after a bath. Aristol (thymol iodide) may be used instead of iodoform. To Separate the Scabs. Warm sponge or tub baths facilitate the separation as do ointments or plain vaseline. Care of the Skin. When the scabs fall off the skin is often very tender and the application of bland and sterile toilet powders are grateful. Complications such as furuncles, abscesses and erysipelas are to be treated on surgical principles. If the head is shaved at the beginning of the disease local treatment of the eruption on the scalp will be greatly facilitated. SYMPTOMATIC TREATMENT Bowels. When first seen the patient should be given an initial catharsis of a salt, Rochelle, Epsom, or Glauber's, 5ss.-i (15-30 Gm.) in three-fourths glass of water or this may be preceded by calomel in divided doses gr. 1/4 (0.015 Gm.) every quarter hour for six doses and two or three hours later followed by the salt. Later the bowels should be moved daily or every other day by enemata or milder salines, such as Hunyadi water, milk of magnesia or one of the milder salines on the market. The initial stage, which marks the period between the onset and the eruption, usually lasts three days. It is rife with discomforts. The onset is sudden and characterized by the severity of pains in the 614 TREATMENT OF ACUTE INFECTIOUS DISEASES head and back, the nervous manifestations of the toxemia and the fever. A chill usually precedes the febrile impulse, but requires no espe- cial consideration. The fever as a rule is maintained during the initial stage at about 104 F. Such a degree of temperature requires no interference. Cool sponges, however, afford the patient comfort. At the end of the initial stage the temperature goes down to normal or .to but a little above and stays down until the stage of suppuration, when it goes up again. Excessive high temperatures are best controlled by the cold pack or prolonged tepid baths at 95 F. Headache is severe, often intense. It is best treated by the application of the ice-bag or ice-coil. In the early stages, the sthenic period of the fever, small doses of phenacetin, gr. iii to gr. v (0.2-0.3 Gm.) at half-hour intervals for three or four doses, or acetanilid in doses of gr. iss. to gr. ii (0.10-0.120 Gm.) at the same intervals for three or four doses may be safely administered if the patient has not cardiac trouble. Later when the circulatory ap- paratus has felt the effects of the toxins of the disease all members of the coal-tar series should be avoided, because they are themselves depressing. If the headaches are agonizing, as they sometimes are, morphine may be imperative. The same drugs may be used to relieve the backaches. Delirium, may occur in the initial stage, but is more common and violent in the suppurative stage. Fresh air and the ice-bag applied to the head may give some measure of relief. Prolonged tepid baths are probably more efficacious. The patients must be very carefully guarded lest they leave the bed and do themselves harm. Sometimes mechanical restraint is necessary. Sheets drawn fairly snugly and firmly secured with the hands held under them is the most humane method. If delirium becomes so decided as to require drugs, morphine is the best to use, in doses of gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) of the sulphate hypodermically and this may have to be given three times in the day. Insomnia, when continued night after night becomes a serious con- sideration, as it takes a mighty toll of the patient's strength. Well- ventilated rooms, good nursing, enough water to drink, all conduce to good sleep. The ice-bag is a help, the prolonged warm baths contribute; but in spite of these measures drug assistance may be needed. The mild hypnotics may be tried at first, such as trional gr. x to gr. xx (0.65-1.30 Gm.) in a little whiskey or in powder form, washed down with water, or SMALL POX 615 in a little warm fluid like barley water or milk; or chloralamid may be used, gr. xv to gr. xxx (1-2 Gm.) in whiskey or as a powder, but not in warm menstrua, which decompose it. Either of these drugs may be repeated in the same dose in two or three hours if necessary. Bromides in doses of gr. xxx (2 Gm.) may be given in the early evening or this dose may be given in the late afternoon and repeated in the even- ing. One may use the potassium salt or the mixed or "triple" bromides, potassium, sodium and ammonium gr. x (0.65 Gm.) each. Administer in water. Chloral in gr. x doses (0.65 Gm.) may be tried in the initial stage. It is given in water or dilute whiskey, brandy or wine. It should not be given later when the centers are depressed. Too many attempts with these milder hypnotics should not be made to the sacrifice of the patient's strength, but morphine should be used in doses of gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) of the sulphate hypoder- mically. Gastro-intestinal symptoms are not striking, but there may be nausea and vomiting at the onset. This rarely requires treatment, but if retch- ing continues copious draughts of warm water may afford relief or small doses of sodium bicarbonate gr. x to gr. xx (0.65-1.20 Gm.) or bismuth subnitrate gr. x to gr. xv (0.65-1 Gm.). Respiratory Symptoms. There may be some laryngitis and this is best treated by inhalations of steam or medicated steam, using com- pound tincture of benzoin, oil of eucalyptus, menthol or oil of pine; but the effort to inhale and the discomfort of the heat attending the ad- ministration may outweigh the benefit accruing to their use. Some bronchial involvement is common", if not constant. In some cases bronchopneumonia may occur. For the treatment of these con- ditions, so far as the eruption will permit, see Pneumonia, Chap. IX. Edema of the glottis is a much severer complication and should this intervene demands intubation (see Diphtheria, Chap. XVIII) or tracheotomy. Circulation. When evidences of a failing circulation occur, all those measures applicable to the same condition in other acute infections are indicated. For detail, see Pneumonia, Chap. IX. Release from Quarantine. Tlu> should be permitted only when the desquamation is completed, and this occurs last in the thick skin of the hands and feet. Warm baths and the use of soap facilitates the desquamation. Sweet oil or vaseline softens the dry skin and hastens its separation. Finally the patient should have an antiseptic bath of 1 to 10,000 bichloride after a thorough soap and water bath and a shampoo. 616 TREATMENT OF ACUTE INFECTIOUS DISEASES He should then be removed to a clean room and given clean clothes or his old clothes only after a thorough disinfection. Disinfection. All those articles that have come in contact with the patient and which can readily be spared should be burned when possible. Such articles as clothing, bedding, mattresses, carpets, should be disinfected by superheated steam. If this is not possible, mattresses and pillows had better be burned, washable bedding boiled thoroughly and carpets be submitted to the disinfecting vapors used to disinfect the room. Formaldehyde vapor gas is the best as it is not injurious to any fabric or color. Sulphur dioxide is also efficacious but its injurious effects on metals and fabrics must be remembered. For details of disinfection, see Scarlet Fever, Chap. XVII. The dead should be cremated or the body wrapped in sheets saturated in strong antiseptics and buried deep. VACCINATION That after more than one hundred years of the beneficent results of vaccination there should still be found bitter opponents to the proce- dure, forces us to accept them as psychological aberrants, in no way amenable to facts or reason. Were vaccination universally and properly carried out there would be no small pox to treat, for the sporadic case and the poorly protected community that furnish the factors necessary for an epidemic would cease to exist and a disease whose mortality is 45 per cent, to 50 per cent, and in individual epidemics even higher would become of historic in- terest only. Time for Vaccination. The first vaccination should be in early infancy. Before the fifth month the reaction is less than later. As an accoucheur it was my custom to vaccinate the infant before the lying-in period was completed. The results were most satisfactory both with reference to the character of the "takes" and the absence of constitu- tional reactions. Revaccination should be done between the ages of ten and fourteen and again and as often as the individual is directly exposed or an epidemic prevails in his community, unless a previous vaccination dates back to only one or two years. Vaccination or revaccination is to be insisted on in every member of the patient's family exposed and revaccination should be practiced by the physician and nurse on the occasion of every small pox patient seen, unless the interval is less than a year. A failure to "take" on SMALL POX 617 revaccination may be due to many other causes than lack of suscepti- bility, so that in case of marked exposure, a surety of technique and freshness and activity of virus must be had and a repetition of the inoculation is the better part of wisdom. The average period of protection is usually accepted as seven years, but this period must not be accepted as an excuse for not revaccinating after exposure. All persons who have been exposed should be revaccinated, nor should the length of time after exposure enter into the question of whether the exposed individual should be revaccinated or not, for even if the protec- tion afforded be not complete it may be relatively so. Early in the incubation period a vaccination will prevent the disease. In these cases the typical vaccination pustule has time to develop before the febrile period is due. In the middle of the incubation period vaccination will serve to modify the severity of the disease; late it will have no effect. Previous vaccinations enhance the efficiency of the last done dur- ing the incubation period. This period is ten to twelve days. Technique. The virus must be active and secured from recognized sources. Virus furnished in capillary tubes, each a single inoculation, is pref- erable to the dried virus on points. If kept, it must be kept cold, as high temperature destroys it or lessens its strength. The site of inoculation is best rendered clean by soap and water, best by green soap and boiled water, and this followed by alcohol. When dried it is ready for the inoculation. The site preferred is the arm, usually the left, at the insertion of the deltoid. The resulting scar, which in a woman is deemed undesirable at this site, may lead one to choose the leg. The place commonly chosen is on the outer aspect of the leg (not thigh) just below the head of the fibula. The inoculation. A slight wound is made at the chosen site. Some prefer scraping with the edge of a scalpel, others a scarification by cross-hatching, and others incisions. Incisions are insisted on in Ger- many and recommended in England. They are made with the edge of a scalpel or point of a needle in Germany, 1 cm. long and 2 cm. apart, 4 in number. I prefer a small cross-hatch of about 1/8 inch square made with a needle sterilized in a flame. If there has been exposure three or four of these 3/4 inch apart. Blood should not be drawn by any method to a greater extent than to produce bloody serum. The virus is then applied to the abrasion and rubbed gently in with a sterile needle, using the eye-end or a sterile wooden toothpick, using the blunt end. The serum and virus is then 618 TREATMENT OF ACUTE INFECTIOUS DISEASES allowed to dry in the air. The only protection necessary is several layers of clean gauze sewed into the sleeve of the undervest, drawers-leg or stocking over the site of the inoculation. Once thoroughly dry, a folded clean handkerchief may be used. If the child cannot be trusted to avoid scratching, this gauze should be secured to the part by adhesive strap- ping, but should be loose over the inoculation. Shields, pads and other protective contrivances do very much more harm than good. After the first day bathing, including the site of the inoculation, need not.be avoided. If the vesicle ruptures it is to be cleansed with saturated boric acid solution and 10 per cent, boric acid ointment (made with vaseline) may be applied. If it becomes infected it is to be treated exactly like any infected wound, on surgical principles. If the vaccination "takes," on the third or fourth day a papule ap- pears, and on the fourth or fifth day a vesicle with umbilication, showing an infiltration. The vesicle becomes mature on the seventh, shows the pustule on the eighth with a second umbilication. An areola has formed about the developing vesicle and on the ninth day this begins to fade, on the eleventh or twelfth day the scab forms and slowly separates in the third or fourth week, leaving a pit which heals with a scar showing the char- acteristic pits or foveations which are the sign of a successful vaccination. General Symptoms. With the appearance of the vesicle and during its development there may be, but not necessarily, a febrile reaction with attendant discomforts such as headache, backache, etc., simulating a mild attack of grip. The part inoculated may itch or burn or a considerable inflammatory reaction with a resulting sore arm may ensue. The regional lymph glands are usually swollen and often tender. Immunity is established about the time of the pustule formation, on the eighth day. Complications of Vaccinations. These are percentually small, but in one or other form must be met by every active practitioner. The most common result from infection of the wound by pyogenic organisms. All too frequently one sees deep and broad ulcerations; less com- monly, abscesses, cellulitis, lymphangitis, phlebitis, suppurating glands, gangrene, erysipelas and pyaemia. As a less serious complication we see occasionally an impetigo contagiosa. When one considers the careless and often filthy habits of many who are compulsorily vaccinated, the numbers of serious infections seem incredibly small. SMALL POX 619 These complications are nearly all surgical problems and to be treated on surgical principles. Another serious but fortunately rare complication, which from its dramatic course always attracts public attention, is Tetanus. It is true that this unfortunate infection, which has been traced more than once to the virus (and then several such cases, directly trace- able to the same supply of virus), does occur; but I am convinced that in the vast majority of instances and in all sporadic cases it is due to infection of the wound by the patient. A case seen recently by me in consultation was such an one, for no other case from this virus had been reported to the Board of Health and the technique of the practitioner was irreproachable. The child was saved by prompt intraspinal administration of tetanus antitoxin. (See Tetanus, Chap. XL.) Generalized vaccinia occasionally occurs as a result of vaccination. It appears usually during the development of the vesicle to a pustule, comes out in crops and may last some time, in rare instances three to four weeks. The same thing may occur as the result of auto-inoculation. This is due to conveyance of the virus from the ruptured pustule to other slight abrasions on the body, most commonly by scratching. Contraindications. During illness or if recently exposed to the exanthemata; if there is any suppurative process in the body or of the skin; in illy nourished infants or in adults suffering from severe constitutional or organic disease. It is contraindicated in bleeders for obvious reasons. It is better not to vaccinate during menstruation, unless the need is urgent. Revaccination. The course is not always the same as in the first vaccination. It may be in those cases in whom the immunity has disappeared; but those in whom a partial immunity persists, an anaphylactic state or "allergic", show what the students of anaphylaxis entitle "an ac- celerated reaction"; that is, a shortened incubation period and pustule formation (the sixth day); or "an immediate reaction" with an incu- bation period of less than twenty-four hours and the formation of a papule or erythematous halo about the site of the inoculation, the equivalent of the now familiar Von Pirquet's tubercular reaction. Conviction, vision, courage, persistency in advocacy, were all needed to establish this amazing contribution to human welfare one hundred years before the birth of immunilogical studies and all these were found in Jenner. 620 TREATMENT OF ACUTE INFECTIOUS DISEASES SUMMARY Isolation. Hospital treatment preferred. Home treatment. Room. (For choice andttreatment of room, see Pneumonia and Scarlet Fever. Chaps. IX, XVII.) Disinfection during illness of discharges, clothes, objects. (See Typhoid Fever, Chap. XIV.) Nurses. Should be revaccinated. Isolated from rest of household. (See Scarlet Fever, Chap. XVII.) Treatment of other members of the family or exposed individuals. Vaccinate with a virus from more than one source. Quarantine if possible. Release when vaccination is successful. If vaccination does not "take", quarantine or keep under closest observation sixteen to eighteen days. Physicians. Revaccinate. Make case last call of day if possible. Stay only long enough to fulfil duties. Do not call on a susceptible person at once, but keep in open air for a time. (For rules of visit and disinfection on leaving see Scarlet Fever, Chap. XVII.) Bed. (For choice and technique of making bed, see Chap. IX.) Diet. Don't force during early stages when there is much anorexia; milk, milk preparations, cereal waters, cereal foods (infant foods), broths fortified with cereals or farinaceous flours, egg albumin. Later, try to approximate food needs. (See Typhoid Fever, Chap. XIV.) Condition of mouth makes it difficult. Water, offer freely, every hour. Fruit drinks, lemonade, orangeade, etc., fortified with sugar. Alkaline waters. Care of the body. Mouth. Pre-emptive period. Rinse after each feeding with water, then with SMALL POX 621 Boric acid solution 2 per cent, to 4 per cent, or Dobell's solution half to quarter strength. Teeth cleansed with soft toothbrush and good paste or with cot- ton swabs on wooden toothpicks, wet with above solution. Free interstices of teeth and dead spaces between cheeks and gums from food. Soften coating on tongue with half strength official peroxide of hydrogen. Scrape with edge of whalebone. Eruptive period. Cannot use toothbrush or whalebone. Irrigations of above solutions. When mouth is foul. Permanganate of potash solution, claret colored (1-4,000). Chlorate of potash gargles 1 per cent, or less. Ulcers. Touch with silver nitrate solution 5 per cent, to 10 per cent. Nose. Dried secretions softened with sweet oil or vaseline. Cleansed with above solutions applied with swabs on toothpicks or as Sprays. Eyes. Cleansed with 2 per cent, to 4 per cent, boric acid solution. When closed with edema Gentle irrigation of conjunctival sacks with warm boric acid solutions 2 per cent, to 4 per cent. Cold compresses of boric acid solution, frequent and prolonged. Prevent lids sticking by applying vaseline to edges or 1 part of yellow oxide of mercury to 60 of vaseline. Severe conjunctivitis. Five per cent, to 20 per cent, argyrol solution once or twice a day. Corneal ulcerations. Apply atropine sulphate solution 1 per cent. Skin. Pre-emptive period. Sponge baths of soap and warm water. Eruptive period. Prolonged warm baths, at 95 F. in tub. Burning and itching. Warm baths at 95 F. Bicarbonate of soda may be added to the bath. Cold compresses. Alum solutions 1 per cent, to 2 per cent. Alum baths 1 to 1,000 solution. Simple vaseline. Sweet oil. Three per cent, to 5 per cent, phenol in oil or vaseline. Glycerin 33 per cent, solution in water. 622 TREATMENT OF ACUTE INFECTIOUS DISEASES To prevent scratching in children. ^ Mechanical appliances. Splints to elbows. Bandages to hands. (For other appliances, see text.) Cold cream. Powders. Sterile toilet powders. Boric Acid, Lycopodium, Corn Starch. Subgallate of Bismuth, equal parts. Offensive odors. Hubbard. lodoform, 2 parts, 1 Boric Acid, 10 parts, [ Schamberg. Talcum, 28 parts. J Aristol (Thymol Iodide). To separate scabs. Warm baths. Vaseline. Apply sterile toilet powders to tender skin after scabs fall off. Furuncles, ^ Abscesses, I Apply surgical principles. Erysipelas, j Symptomatic treatment. Bowels. Calomel, gr. 1/4 (0.015 Gm.) every quarter hour for four doses, then in two hours, A salt, Epsom, Rochelle or Glauber's 5ss. to i (15-30 Gm.) or a salt alone. Later. Milder salines. Milk of magnesia. Citrate of magnesia. Hunyadi water or Enemata. Fever. Cool sponges. Prolonged warm baths at 95 F. Excessive fever. Cold packs. Headache. Ice-bag or ice-coil. Early stages. Phenacetin gr. iii to gr. v (0.20-0.30 Gm.) every half hour for three to four doses. SMALL POX 623 Acetanilid, gr. iss. to gr. ii (0.10-0.12 Gm.) at same intervals. Do not use these when circulation is depressed. When very severe. Morphine sulphate, gr. 1/12 to gr. 1/4 (0.005-0.015 Gm.). Backache. Same drugs as for headache. Delirium. Fresh air. Ice-bag. Prolonged warm baths at 95 F. Mechanical restraint, best with tightly drawn sheets. Morphine sulphate hypodermically, gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.). Insomnia. Air. Ice-bag to head. Prolonged warm baths at 95 F. Trional gr. x to gr. xx (0.65-1.30 Gm.) in whiskey or in powder. May repeat in two hours if needed. Chloralamid, gr. xv to gr. xxx (1-2 Gm.) in whiskey or in powder. (Do not give in warm drink.) May repeat in two hours. Bromides, gr. xxx in evening or late afternoon and repeat in even- ing, either potassium bromide or the mixed, " triple," bromides of potassium, sodium and ammonium. Chloral, gr. x (0.65 Gm.) in water, whiskey or wine. Do not use except in sthenic period. Morphine sulphate hypodermically, gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.). Gastro-intestinal symptoms. Not marked. (See text.) Respiratory symptoms. Laryngitis. Inhalations of steam, plain or medicated with Compound tincture of benzoin. Oil of eucalyptus. Oil of pine, a teaspoonful or two in the hot water, or Menthol, a few drops of saturated alcoholic solution in the hot water of the inhaler. Cold compresses to neck. Bronchopneumonia. (See Pneumonia, Chap. IX.) Edema of glottis. Intubation. (See Diphtheria, Chap. XVIII.) Tracheotomy. Circulation. (See Pneumonia, Chap. IX.) 624 TREATMENT OF ACUTE INFECTIOUS DISEASES Release from quarantine. When desquamation is complete. Soap and water bath and shampoo, then Give antiseptic bath of 1-10,000 bichloride of mercury. Remove to clean room and put on clean clothes. Disinfection. (See Scarlet Fever, Chap. XVII.) CHAPTER XXVIII TYPHUS FEVER THE infecting agent in typhus fever has not been definitely deter- mined, but the isolation by Plotz of New York of a Gram positive pleomorphic bacillus, termed bacillus typhi exanthematici from the blood of typhus patients, which fixes complement in the serum of con- valescents from the disease, makes a fair claim to the solution of the problem. The mode of conveyance has been discovered, thanks to the brilliant work of Nicolle and Conseil, Anderson and Goldberger, Ricketts and Wilder, and Gavino and Girard. To this work Ricketts yielded his life, a martyr. Again, as in Malaria, an insect plays the role of the intermediary; this time the louse, Pediculus vestimenti, conveying the organism by its bite from the infected patient to a susceptible individual. This constitutes the most important contribution to our knowledge of the disease ever made and explains many observations on its epidemicity; its association with crowding, wretchedness, its "short striking dis- tance/' its prevalence in cold climates and in cold season, etc. It also renders precise efforts to prevent its spread or its occurrence. In these latter years typhus fever had been considered a rarity in the Northern States. Recently a symptom complex which had many features in common with mild typhus fever was reported by Brill of New York. A considerable number of these cases was observed in New York, Chicago and other Northern cities, and, for a time, was considered as possibly a new disease. It has been shown, however, experimentally, that this disease is identical with Mexican (Tabardillo) and European Typhus and that it is conveyed by the same means. The incubation period of typhus lasts as a rule from eight to twelve days; exceptionally as short as four or as long as fourteen. The invasion is abrupt and the duration lasts from twelve days in a child to twenty- one to twenty-four in an adult. In the monkey the period has been observed to be twelve days. The onset of the disease is rapid, characterized by the sharp rise of temperature which reaches its maximum on the second or third day and is accompanied by very severe headache. The temperature is sustained throughout the disease and falls by crisis or rapid lysis on the 12th to 14th day. The characteristic erup- 626 TREATMENT OF ACUTE INFECTIOUS DISEASES tion appears on the third to the fifth day, first on the abdomen, then on the chest, the shoulders, the back and the extremities. It takes two to three days to reach its full development and there are no second crops. The rash suggests measles, but later becomes petechial. Nervous manifestations, delirium or stupor and progressive and severe toxemia are the striking features of the disease. Cardiac weakness may appear early, but is much more pronounced with the appearance of the rash. The blood count shows a slight leu- cocytosis of about 10,000 and a polymorphonucleosis of 80 per cent, to 85 per cent. The mortality varies in different epidemics from 15 per cent, to 60 per cent. The sporadic cases as seen in New York and termed Brill's Disease are relatively benign, the mortality not reaching more than 1 per cent, to 2 per cent. TREATMENT Isolation. The knowledge of the mode of conveyance makes our efforts at prevention of spread more successful than in the days when it was supposed to be conveyed by fomites or more mysterious agents. The keynote to prevention of the spread lies in the destruction of the body louse. The patient should have a room chosen with reference to an abundance of light and air and convenience for nursing. In epidemics, treatment in tents is preferable to the more poorly ventilated wards. The choice of the bed and the manner of its preparation should be exactly the same as in Typhoid. (See Typhoid Fever, Chap. XIV.) As soon as the diagnosis of typhus fever is made, the patient should be undressed and the clothes disinfected. The hah- of the head, pubes, axilla and chest should be shaved and the hair burned. The patient is then scrubbed with soap and water and bathed with dilute (1 per cent.) carbolic acid or 50 per cent, alcohol. After the skin is dry the entire body is sprayed with crude petroleum to destroy lice and ova. The patient is put to bed in an environment free from vermin. The hair on the pubes and in the axilla or in hairy individuals that on the chest, back or elsewhere should have mercurial ointment applied to these parts. If the head is not shaven but the hah* merely clipped, the eggs may be loosened from the hair by soaking the head in vinegar overnight and wiping off the eggs with a towel wet with bichloride. It must be remembered that it is the body louse found in the clothing that is the transmitting agent. TYPHUS FEVER 627 The clothes worn by the patient should either be destroyed by burn- ing or the lice killed by immersion in boiling water. Boiling five minutes is said to kill both lice and eggs; a good measure of time increases the assurance. Live steam is an excellent measure applicable to extensive disinfection as practiced in delousing plants during the war. The bed where the patient has been sleeping should be scrubbed with soap and water and treated with 5 per cent, solution of carbolic acid; the mattress and the blankets subjected to steam, the sheets and spreads boiled; the room is disinfected with sulphur dioxide (use 5-8 pounds per 1,000 cubic feet and leave the room sealed 12-24 hours), or the walls and floors may be sponged thoroughly with crude petroleum and after 12 hours scrubbed with soap and water. Nurses and attendants should wear a one-piece garment which can be tucked into high boots, rubber gloves and close-fitting head gear to prevent pediculi gaining access to the skin. Dr. A. C. Burnham of the American Red Cross writes us of the follow- ing simple device for disinfecting clothes: " In an ash can or boiler place several bricks, add sufficient water to half cover them. Loosely pack clothes in a wire cage (of chicken or other similar wire) and suspend it by hooks to the rim of the can so that it rests on the bricks, but swings free of the water. Close the can tightly and place ten to fifteen pounds of weight on the cover so that the steam will be under pressure. Boil the clothes for one hour; this will kill all the lice and most of the nits." Burnham says he found in clothing not badly infested the nits could be removed by carefully pressing with a very hot iron. This has the ad- vantage of sparing woolen garments from no inconsiderable shrinkage. Of course the garments should be turned inside out and carefully pressed along the seams. Furs and shoes, if dry, may be disinfected by exposure to hot air (60 C.) for 30 minutes. In military service where delousing measures are carried out on a large scale, treatises on military practice should be consulted. Care of the Patient. A cleansing bath of soap and warm water should be given daily. Late in the disease particular care should be given to prevent the formation of bed sores by turning the patient from one side to the other frequently, by rubbing the points of pressure, keeping the parts dry, and, when the parts show signs of pressure by persistent redness or bluish discoloration, using rings or cushions to lift the part off the bed. When bed sores form, if superficial, they are to be treated by scrupulous cleanliness and the utilization of some drying powder such as stearate of zinc, or zinc oxide, talcum and starch mixtures. If the sores 628 TREATMENT OF ACUTE INFECTIOUS DISEASES are more extensive they should be treated on, surgical principles and the utilization of a water bed or air bed may be necessary. The mouth and nose should be treated as in other, infections by keeping them clean with such mild antiseptics as boric acid solution 2 per cent, to 4 per cent, or some mild alkaline solution of which there are many on the market. This care should be exercised after every feeding and particular attention should be given to the removal of food particles from between the teeth and from the dead spaces in the mouth between the gums and teeth. In the severe cases the mouth becomes very dry, the tongue heavily coated and sordes appears upon the teeth and lips. The ease with which otitis and parotitis ensue upon a foul condition of the mouth emphasize the importance of these measures. The treatment will be found detailed in the article on Typhoid Fever (Chap. XIV). Diet. Of prime importance is the administration of an abundance of water; a sufficiency of water diminishes dryness of the mouth, torpidity of the bowel and heightens the efficiency of the emunc- tories. The mental condition of the patient is such that one should offer him water at frequent intervals, at least hourly, and not wait for expres- sion of thirst on his part. All the water should be given that the patient will willingly take, and this may amount to three, four or more quarts a day. The administration of food is determined by the same physio- logical necessity as in any continued infection (see Diet in Acute In- fectious Diseases, Chap. II), and the rules laid down for diet in Typhoid Fever hold for Typhus, except that it is to be remembered that the urgency for a high caloric diet is not so great because the infection runs a shorter course, and further, that the degree of toxemia as a rule makes the feeding more difficult than in Typhoid Fever. One may have to depend almost entirely upon liquids or semi-liquid foods, such as are set forth in the Typhoid dietaries. Fever. The fever is usually high and is sustained often at 104 F. to 105 F. throughout. Except in rare cases of hyperpyrexia the treat- ment directed at the fever is really directed at the toxemia and its effects upon the circulation and respiration ; hence, simple antipyretics, such as the coal tars, are contraindicated; first, because the fever, per se, is not a menace to the patient, but, except in hyperpyrexia, is rather a purposeful reaction of the body harboring toxic material; secondly, because these drugs are direct and potent depressants of the circulation. The antipyretic measures, however, which are legitimate are those TYPHUS FEVER 629 which are at the same time stimulating to the vital functions and are used because of this latter effect. They are, first, the use of cold water, and one may have recourse to the same hydrotherapeutic measures as in Typhoid; the baths, the slushes, the packs, the sponges, with the same indications and contra- indications as in Typhoid (for which see Typhoid Fever, Chap. XIV) ; second, open air. The preparation of the patient and his bed for open air treatment is identical with that of Pneumonia (see Pneumonia, Chap. IX) and, as in Pneumonia, the delirium of the patient necessi- tates the constant presence of nurse or attendant to prevent the patient from leaving his bed and doing himself some injury. Circulation. Except in fulminating cases the circulation does not show the depressing effects of the toxin until the second week; then the rapid heart, the low blood pressure and the change in the quality of the heart sounds bespeak its depressing effects. One may use digitalis and other circulatory stimulants in the same manner as described for failing circulation in pneumonia. (See Pneumonia.) It must be remembered, however, that more potent than these drugs are the effects of fresh air and cold water as described under Pneu- monia. Bowels. Early in the disease the intestine should be thoroughly evacuated by the use of Epsom or Rochelle salt in doses of 1/2 ounce to 1 ounce (15-30 Gm.) or by castor oil in the same dose or by calomel, grains 1 1/2 to 2 grains (0.10-0.12 Gm.) followed in four hours by a salt as above. If there be nausea or vomiting, calomel is especially indicated but in divided doses, 1/4 grain (0.015 Gm.) every quarter hour until six or eight doses are taken. Later the bowel is to be moved by an enema. In this disease constipation and meteorism occur not infrequently and when the circulation is embarrassed or the lung involved the latter constitutes a true danger. It is to be combated in the same manner as in Typhoid. (See Typhoid, Chap. XIV.) Nervous Manifestations. These are particularly shown in the severe headaches, the delirium or the stupor. The headache is often intense and is best met by the use of the ice-cap; in the more violent headache morphine may be necessary. Delirium and Headache. During the first half of the first week the mind is usually clear; then delirium or stupor intervenes; the delirium is violent and hallucinations of a terrifying character occur. The patient is peculiarly alert and requires continual watchfulness. The delirium increases during the development of the eruption. It is to be treated by the application of the ice-bag to the head ; in milder forms by bromides, 630 TREATMENT OF ACUTE INFECTIOUS DISEASES 15 to 30 grains (1-2 Gm.) three or four times a day; but in the severe types necessitates the use of morphine. Lumbar puncture may afford relief. Instead of delirium the patient may go into stupor. and coma; all the nervous symptoms are likely to be less severe or are ameliorated by use of the cold bath or by treatment in the open air, but in the latter case some restraint and constant guarding are necessary. The temperature as a rule subsides by crisis or rapid lysis occupying a couple of days. If the defervescence occupies a much longer period one should think of the possibilities of complications. Convalescence. Convalescence is usually rapid; the diet is in- creased and the patient is allowed to sit up in bed, then in the chair, and then to walk around. These efforts are determined by the patient's returning strength and by evidences that the circulation has regained its strength as shown by no great increase in pulse rate when these efforts are made. Complications. Laryngitis is fairly common and may be treated by inhalations of steam, or steam medicated with compound tincture of benzoin, oil of pine, or the oil of eucalyptus, a teaspoonful on the hot water in the croup kettle or a substitute for it in the shape of a pitcher or pail. Edema of the larynx sometimes occurs and may require intu- bation, tracheotomy or scarification. Bronchitis and Pneumonia as well as Pleurisy and Empyema can take place, and are to be treated as under other circumstances. Frequently turning the patient lessens the congestion that favors the onset of these complications. Diarrhea. While constipation is the rule, diarrhea sometimes is seen. Profoundly toxic patients may suffer from incontinence. Proper care of the bowels from the start renders the onset less probable; it is to be treated by Bismuth subnitrate in 30 grain (2 Gm.) doses every two hours, or by small doses of castor oil, 10 minims (0.60 c.c.) every two hours, to which 1 minim (0.060 Gm.) of the deodorized tinc- ture of opium may be added with benefit. In either case it is well to administer a large dose of castor oil, y% ounce to 1 ounce (15-30 c.c.), every second day. Parotitis. This complication may result from neglect of the mouth. If mild, it requires no treatment or the application of an ice-bag, but if suppuration follows it must be treated on surgical principles. Otitis may result from infection from the mouth. In all stupor- ous patients and children the ears should be daily inspected. The con- dition is to be treated as under other circumstances. In some epidemics or in some individual cases, the disease may be so mild as to require little treatment other than good nursing; again TYPHUS FEVER 631 it may be fulminating in character defying all effort, and resulting in death in three or four days. Relapses are exceedingly rare. Disinfection. This consists in the destruction of the parasite, the louse, either by burning the clothing worn by the patient or by disinfecting it as described above. An assurance must be had that the patient's body is freed from the pediculi and the room must be disinfected by burning sulphur, either the sticks or the flowers, 5 pounds per 1000 cubic feet, leaving the room closed twelve to twenty-four hours. Formaldehyde is of doubtful value in the destruction of the parasite. Prophylaxis is determined by a knowledge of the mode of convey- ance of the disease. The doctor and nurse are both in great danger in handling fresh patients and their louse-burdened clothes. Protection by gloves and gowns and caps are obvious; prompt disinfection of clothes and patients must follow. Delousing plants in infected communities should be of great assistance. Instruction of the public by every possible means should be used. It has been suggested that crude naphthalene finely powdered be dusted on the underclothing, nightdress and sheets in infested areas. SUMMARY Isolation. The disease is conveyed by the body louse. Clothes worn by patient should be burned or Boiled or pressed. (See text.) Hair shaven from head, pubes, axillae. Burn hair. Patient scrubbed with soap and water, sponged with 75 per cent, alcohol. Spray entire body with crude petroleum. Apply mercurial ointment to the axilla, pubes. Put to bed in a vermin-free room and bed. Disinfect former bed, mattress, bedclothes and room. (See text.) Room. Choose with reference to light, air and convenience for nursing. Bed. (See Typhoid Fever, Chap. XIV.) Care of the body. Daily cleansing bath. Try to prevent bed-sores by turning patient. Rubbing the point of pressure. Keeping the parts dry. Using rings or cushions. 632 TREATMENT OF ACUTE INFECTIOUS DISEASES For superficial sores. Keep sores scrupulously clean. Use drying powders such as S tear ate of zinc, Zinc oxide, Talcum and starch mixtures, Aristol. Deep sores. Treat on surgical principles. Use water bed or air bed. Mouth and nose. Use mild antiseptics, such as 2 per cent, to 4 per cent, boric acid solution, especially after feeding. When mouth is in bad condition, treat as in typhoid fever. (See Chap. XIV.) Bowels. As in other infectious diseases. (See Typhoid Fever, Chap. XIV.) Diet. Rules for feeding and details for feeding may be borrowed from Typhoid Fever. (See Chap. XIV.) Water should be given freely, and, if patient is stuporous, offered every hour. Symptomatic treatment. Fever. Hydrotherapy, baths, slushes, packs and sponges as in typhoid fever. (See Chap. XIV.) Open air. Just as in Pneumonia. (Chap. IX.) Circulation. Just as in Pneumonia. (See Chap. IX.) Nervous manifestations. Headache. Ice-cap or coil. Morphine in intense headache. Delirium. Great watchfulness. Ice-bag. Bromides, gr. xv to gr. xxx (1-2 Gm.) in water three or four times a day. Morphine sulphate, gr. 1/12 to gr. 1/4 (0.005-0.015 Gm.), hypodermi- cally. Stupor and coma. Sp'enSreatment. TYPHUS FEVER 633 Convalescence. Usually rapid. Increase diet. (See text.) Complications Laryngitis Medicated steam, using Compound tincture of benzoin, or Oil of pine, or Oil of eucalyptus, 3i (4 c.c.) in a croup kettle, or pitcher or pail with paper cone to conduct it. Edema of the larynx. Intubation. Tracheotomy. Scarification. Bronchitis, Pneumonia, } As under other circumstances. Pleurisy, Empyema. Diarrhea. Prevention proper care of bowel from beginning. Castor oil in small doses or Bismuth subnitrate (See text.) (See summary under Bacillary Dysentery, Chap. XVI.) Parotitis. Precautions, proper care of the mouth. When mild no treatment, or see Parotitis or Mumps (Chap. XXIII). Suppurative treat on surgical principles. Disinfection. Destruction of body louse. See above for treatment of clothes and patient's body. Room. Burn sulphur, 5-8 pounds per 1,000 cubic feet. Prophylaxis. Doctors, nurses and attendants should take precautions to prevent infection. (See text.) Debusing. (See text.) Use of crude naphthalene powder. (See text.) CHAPTER XXIX PLAGUE PLAGUE is a disease due to an infection by the Bacillus pestis bu- bonica isolated by Yersin in 1894 and often accredited to Kitasato. This organism affects peculiarly the lymphatic glands, the swelling of which gives the characteristic appearance to the infected and the designation "bubonic plague." The especial carriers of the organisms are rats and the fleas infest- ing them afford the communication between the rat and man. Rats, however, are not the only carriers; for example, in this country the California ground squirrels have been shown to be infected and conveyance may be made through other insects than fleas, and through the patient by pus, vomitus, sputum, sweat and urine. While the bubonic form of the plague is the common one, the pre- dominance of other clinical symptoms may warrant other designations, as when the lungs or intestine are the organs especially affected ; hence, Pneumonic or Intestinal Plague; or, when the toxemia dominates the picture and is termed Septicemic or Fulminating Plague or the opposite obtains and the toxemia and local manifestations are slight, Pestis minor or Abortive or Ambulatory Plague. So rapid and wide-spread is the plague, so frightful its consequences that the consideration of the community overshadows that of the in- dividual and renders the chapter on prophylaxis by far the most impor- tant in the story of Plague. This will be considered presently. Therapy. An article of this kind can deal only with the gen- eral principles applicable to the individual. A stricken community demands the accumulated fruits of experience in precautions, details and technique that can only be afforded by more exhaustive treatises or infinitely better yet by the presence and control of men of actual experience in plague epidemics. Isolation. The knowledge that each individual is a centre of infec- tion, through his secretions, makes his isolation imperative and that this infection may be conveyed by insects, such as flies and ants con- taminated by these secretions or through the bites of infected insects, as the flea, demands screening against all insects. Room. The room should be well aired and accessible to sunlight, as darkness and dampness favors the persistency of the organism; an PLAGUE 635 ideal is a temporary shack or shelter rather than in an old and rat- infested house. The bed should be of the hospital type; of iron, hence, readily kept clean. The room should be stripped of everything except the absolutely necessary. Physician and nurse should wear gowns, caps and especially rubber gloves and in pneumonic cases protect the face with gauze masks such as are used by surgeons, which may be kept moist with some antiseptic solution, and glasses to protect against infection coughed into their faces. Doctors and nurses should take advantage of such protection as vaccine by Haffkine's or Shiga's method will afford. Sputa should be received on gauze or rags and these should be burned. Vomitus, feces and urine should be disinfected and clothes, bed linen, utensils and instruments sterilized as in Typhoid Fever. (See Typhoid Fever, Chap. XIV.) Cleansing baths, the care of mouth, nose, eyes, skin and genitals all demand the same consideration as in Typhoid Fever. (See Chap. XIV.) Diet. Without forcing the food against the patient's distaste, an effort should be made to approximate food needs, however remotely. Milk and milk preparations, cereals, broths thickened with cereals or farinaceous foods, moistened bread or toast, eggs, may all be used. Water should be given abundantly. Bowels. An initial cathartic with divided doses of calomel, gr. 1/4 (0.015 Gm.) every quarter hour for six or eight doses, followed in two hours by a salt, Rochelle, Epsom, or Glauber's 3ss.-3i (15-30 Gm.) may be given. Later, at two-day intervals milder salines or enemata may be used. Bladder. It must not be forgotten that in the very ill urine may be retained and, if lesser measures of heat or cold over the hypo- gastrium fail, catheterization, with all precautions, must be under- taken. Fever. The temperature is rarely high enough to demand espe- cial consideration. It lasts, as a rule, from a week to ten days and is very irregular. Sometimes, however, the fever lasts for several weeks and then the increased caloric needs and protein destruction, effects of the toxemia, demand particular consideration of the dietary. Rarely excessive fever requires antipyretic treatment which is best afforded by cold water in the shape of sponges and packs or if the buboes are not discharging or too painful as tubs. Antipyretic drugs are de- pressing to the circulation and should not be used. Circulation. Good nursing, fresh air, food and cool or cold spong- ing are the best guarantees of a good circulation. 636 TREATMENT OF ACUTE INFECTIOUS DISEASES If drugs are to be used the indications are, the same as in the other acute infections. (See Pneumonia, Chap. IX.) Nervous Symptoms. Headache is best controlled by the ice-bag applied to the head. Delirium may demand restraint. Sleeplessness is to be met by the milder hypnotics or morphine may be needed to control these symptoms. Buboes. As the swelling increases rapidly the pain may be very great. Perhaps the best means to relieve this is the application of the ice-bag. At times the pain may be so severe as to demand morphine. Hot fomentations are also used to hasten suppuration. When fluctuation occurs incision is indicated and the wound treated on surgical principles. Diarrhea. When this occurs the best drug to use is bismuth sub- nitrate. Some writers consider opium contraindicated, as defeating the effort at elimination of toxins. SPECIFIC TREATMENT Serum. An anti-plague serum comparable to antidiphtheria serum has never been elaborated, but, especially, the Yersin-Roux has been tried with results that have elicited different interpretations. I quote from Wherry's article in Forchheimer's Therapeusis of Internal Disease. "The discussion concerning the value of the Yersin-Roux anti- plague serum has apparently been satisfactorily disposed of by Chosky. His series includes 1,081 cases treated in India during 1905-1907. In this series only every alternate case was treated with the serum, the others acting as controls. Very mild cases and severely septicemic and moribund cases were excluded. "The general mortality was reduced to 49.6 per cent. In cases treated during the first day of the disease the mortality was 30 per cent.; this increased to 52 per cent., among those treated on the second day, and to over 60 per cent., among those treated on the third day." Of course the value of such statistics increases with their number. As the general mortality of the Plague in India at this time was 89.9 per cent., the reduction under the serum treatment was remarkable; but in addition the disease was shortened, and the complications les- sened. Early administration is all important and a sufficiency of serum 100-200-400 c.c. should be given and early repeated, in six and eight PLAGUE 637 hours and again at weekly intervals as the condition of the patient seems to demand. Intravenous administration is always to be preferred, but intra- muscular and subcutaneous are often combined with it. The best serum at present seems to be the so-called Yersin serum, obtained by inoculating horses with dead organisms, and later with increasing quantities of living virulent organisms. Sequelae. Aside from the rarer sequelae prolonged suppuration of buboes and cardiac weakness in convalescence are matters of moment. Convalescence. Fresh food and fresh air and prolonged rest with watchfulness over the state of the circulation are the essential measures. Disinfection. This should be thorough and effective and much the same measures should be pursued as in Scarlet Fever. (See Scarlet Fever, Chap. XVII.) Prophylaxis. Since the Indian Commission has so clearly dem- onstrated the role of the rat and his fleas and with our knowledge of the contagiousness of the secretions of infected men, prophylactic meas- ures can be directed with definite ends in view. It must not be forgotten, however, that while rats are the usual carriers, other animals may harbor and convey the infection and that in our own country the California ground squirrel especially plays this r61e. Jackson, in Hare's Modern Treatment, sums up protective measures for the community in this way: "(1) Active warfare against rats and other plague affected rodents, and their fleas; (2) quarantine applied to persons, goods and animals; (3) disinfection of cargoes shipped from infected ports; (4) isolation of the sick and proper disposal of the dead; (5) international notification between governments of the occurrence of plague within their respective territories; (6) lastly, but perhaps first in importance, the early recognition of the presence of the plague and rapid diagnosis in individual cases, both dependent upon laboratory workers." Warfare against the fat entails the building of rat-proof structures in ports; the prevention of ingress and egress of rats when ships are in port, by protection of hawsers and raising of planks at nightfall; the proper disposal of garbage on which they feed, stopping up of their holes and the use of poisons and traps. In some communities cats have been employed for the purpose, though not entirely a safe procedure as cats have been shown to develop a chronic form. The presence of plague 638 TREATMENT OF ACUTE INFECTIOUS DISEASES in any community is so dire a threat to its welfare, the possibility of spread in the community so great that ifc immediately becomes a public health problem. It is beyond the scope of a handbook of this type to elaborate upon the details that should be carried out by public health officers. Immunization. Prophylactic measures may be applied to the indi- vidual as well. Perhaps the most efficacious of these methods is the use of Haffkine's prophylactic inoculation. It consists of a broth culture of bacillus pestis killed by heating and preserved in 0.5 per cent, carbolic acid and injected subcutaneously in amounts of 0.5 to 4 c.c. repeated in larger amounts after 10 days. The reaction is often quite severe. That it has protective power, that it has modified both the incidence and mortality statistics seem now to have been proved beyond a doubt; but the protection is not absolute even though immunity seems to be marked in the second year and remains in a slight measure in some cases for five years. A modification of this method has been devised by Shiga that has the advantage of quicker preparation. If given within a few hours after first appearance of symptoms it seems to have some curative value. SUMMARY Isolation. Room. Well aired and light and screened from flying insects. Bed. Hospital type preferred. (For technique of bed-making, see Typhoid Fever, Chap. XIV.) Physicians and nurses. Wear gowns and gloves and in pneumonic cases wear gauze masks to protect face against the patient's cough. Prophylactic vaccination is a wise precaution. Care of patient. Care of body and mouth, nose, eyes and genitals as in any acute in- fectious disease. (See Typhoid Fever, Chap. XIV.) Sputa should be received on gauze or rags and burned. Vomitus, feces, urine disinfected and clothes, bed-linen, utensils, and instruments sterilized as in Typhoid Fever. (See Chap. XIV.) PLAGUE 639 Diet. Do not force, but keep in mind food requirements. (See Chap. II.) Milk, milk preparations, cereals, broths thickened with cereals, or farinaceous foods, moistened bread and toast, eggs. Water should be given freely. Bowels. Initial cathartic. Calomel in divided doses, gr. 1/4 (0.015 Gm.) every quarter hour for six or eight doses, followed in two hours by Epsom salt, Rochelle salt or Glauber's salt, gss. to 5i (15-30 Gm.) in three-quarters glass of water. Later. Milder salines, Hunyadi, citrate of magnesia, Milk of magnesia or enemata every day. Retention of urine. Apply heat (hot stupes) or cold to epigastrium. If these fail catheter- ize. Fever. Cold sponges. Cold packs. Cold tubs. Circulation. (See Pneumonia, Chap. IX.) Nervous symptoms. Headache. Ice-bag or coil. Delirium. Restraint. Bromides, gr. xxx (2 Gm.) one to three times a day. Morphine hypodermically, gr. 1/8-1/4 (0.008-0.015 Gm.). Hyoscine hydrobromide, gr. 1/150 (0.0004 Gm.). Sleeplessness. Bromides, gr. xxx (2 Gm.) in water. Trional, gr. xv (1 Gm.) in a little hot water or whiskey or as powder. Chloralamid, gr. xxx (2 Gm.) in cold water or whiskey or powder. Morphine sulphate, gr. 1/8-gr. 1/4 (0.008-0.015 Gm.). Buboes. Ice-bag. Morphine sulphate for pain, gr. 1/8-gr. 1/4 (0.008-0.015 Gm.). Hot fomentations to hasten suppuration. Incise when fluctuation is detected. Treat on surgical principles. 640 TREATMENT OF ACUTE INFECTIOUS DISEASES Diarrhea. **-. <* Bismuth subnitrate, gr. xxx (2 Gm.) every two hours. Specific treatment. (See text.) Convalescence. Fresh food. Fresh air. Prompt rest. Disinfection. (See Scarlet Fever, Chap. XVII.) Prophylaxis. (See text.) CHAPTER XXX DENGUE DANDY FEVER. BREAK BONE FEVER DENGUE, essentially a tropical disease, is confined in the United States to the Southern tier of States. Although epidemics have been reported as far north as Philadelphia. It is characterized by a suddenness of onset, and a rise of temperature with severe headache and a striking soreness of the ocular muscles, giving rise to exquisite pain with each movement of the eyes and pains all over the body that closely simulate Influenza but with especial localization about the joints. These manifestations of intoxication last two to five days and are followed by a drop in temperature often critical and accompanied by nose bleed, diarrhea or a sweat and by a remission or intermission of symptoms of twelve hours to three days, only to be in turn followed by a second febrile period of twenty-four to thirty-six hours. An erythema may accompany the first period, but the characteristic rash, a measles like eruption, occurs with the second access of fever involving hands first, spreading to arms and later in- volving lower extremities and trunk. The blood picture is a leucopenia and relative lymphocytosis. Profound depression of spirits accompanies the attack and the con- valescence is slow. The mortality is, however, very low. This disease, like Malaria and Yellow Fever, is in all probability transmitted by a mosquito (Culex fatigans) as suggested by Graham of Beirut, though as yet not definitely proved. Some workers have suspected the stegomyia to be the host. Ashburn and Craig, by transmitting the disease through the filtered blood of an infected person, have made it more than probable than the infecting agent belongs to the group of ultramicroscopic organisms. Therapy. The room chosen for the patient should be as cool and airy as possible or better yet a shaded portico. This should be screened against mosquitoes, not merely as a protection to the patient, but as a protection to others against the patient. The bed should be selected with a view to comfort as the bodily pains are so great as to make any position one of discomfort. (See Rheumatic Fever, Chap. III.) 642 TREATMENT OF ACUTE INFECTIOUS DISEASES Diet. No effort should be made to forqe food during the period of anorexia, but after this has passed milk and milk preparations, cereals, bread-stuffs and eggs, cereal broths or mutton and chicken broths thickened with rice, sago or barley may be given as freely as the patient will accept them, while during the long and tedious con- valescence a greater variety of foods temptingly prepared and with a consideration of the patient's caloric needs (see Chap. II) should be offered. Water should be given freely throughout the febrile periods or fruit juices such as lemonade or orangeade or juice of grape fruit. Bowels. At the beginning of the disease the bowels should be freely moved by small doses of calomel and salts, e. g., calomel gr. 1/4 (0.015 Gm.) every quarter hour for six to eight doses, followed by 5ss. (15 Gm.) of Epsom or Rochelle salt, and every second day a mild saline such as a Seidlitz powder or liquor magnesii citratis gviii-xii (240-360 c.c.) or Hunyadi water may be administered. There should be no purging as the condition does not demand it and the patient's pains and discomforts are greatly aggravated thereby. Pains. The milder anodynes such as salicylates in gr. x (0.65 Gm.) doses every two hours or phenacetin (acetphenetidin) gr. iii to v (0.20-0.30 Gm.) at like intervals should be tried first, but the pains are commonly too severe to yield to such measures and one should have re- course to codeine sulphate or phosphate gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) every two hours. At times, however, the headache and pain is so acute that one must use morphine. It is always well to administer this drug hypodermically rather than by mouth and hi the smallest doses that will effect the desired results, e. g., a beginning dose of gr. 1/12 (0.005 Gm.). Local Treatment of Pains. An ice-bag to the head may miti- gate the severity of the headache while hot cloths, stupes or poultices may give relief to aching back and joints. Fever. No effort is to be made to combat the fever as such, as hyperpyrexia is very rare, but measures to assuage the discomforts incident upon the temperature are legitimate, such as cool sponges, cool- ing drinks, ice-bag to head. Tub baths add too much to the patient's pains in the handling to warrant the procedure unless hyperpyrexia should obtain. Circulation. The pulse is characteristically slow about the third day, but the circulation is rarely threatened. Should one be dealing with a poor circulation as the result of an antecedent condition, the toxemia, or both, the indications are the same as in a case of Pneumonia. (See Pneumonia, Chap. IX.) DENGUE 643 Nervous Symptoms. To a patient suffering from Dengue nothing is more gratifying than to be let alone. Quiet and good nursing and the exclusion of visitors are of first importance to him. Insomnia may be overcome by excluding causes of nervous irritation, by the artifices of efficient nursing and lastly by drugs, e. g., sulphon- ethylmethane (trional) gr. x (0.65 Gm.) in the early evening and a repetition of the dose two hours later if needed or chloralamid gr. xxx (2 Gm.) at the same intervals. If pain is the cause of the insomnia codeine phosphate gr. 1/4 (0.015 Gm.) to gr. ss. (0.030 Gm.), may be used to assist the operation of the hypnotics, but in cases of severe pain only morphine, as already specified, will be of use. With this the other hypnotics are unnecessary. Complications. Occasionally hemorrhages may occur from nose, stomach, intestine or uterus. Milder hemorrhages need no consideration, but if abundant or in weakly patients, the same measures are to be pursued as in hemorrhages from other causes. (See Typhoid Fever, Chap. XIV.) Convalescence. It is curiously protracted for an infection so little fatal and is to be hastened by a sufficiency of food, fresh air, quiet and milder tonics such as mix vomica and iron. Prophylaxis. Accepting the theory that the mosquito is the transmitting agent of the disease efforts should be made to rid the community of the pests by draining swamps, obliterating or treating with oil all stagnant water, ponds, pools, cisterns, and removal of smaller containers, such as buckets, cans, etc., together with screening of dwellings and protection of the exposed parts of the body at night- fall. Especially, as has been said, the infected patient should be screened. Diagnosis. Features of diagnostic significance are the two febrile periods separated by the remission, the severity of the pains, the slow pulse, the rash of the second period, the low white cell and polymor- phonuclear count (e. g., 3,200 whites and 51 per cent, polymorphonu- clears) and the protracted convalescence. SUMMARY Room. Cool and well ventilated. Shaded and screened porch or veranda desirable. Bed. Preferably of hospital type, with woven wire springs, firm mattress and smoothly laid sheets. 644 TREATMENT OF ACUTE INFECTIOUS DISEASES Diet. Do not force during period of anorexia. Milk, milk preparations, cereal broths, mutton or chicken broth thickened with rice, barley or other cereal or farinaceous flour. Water. Give freely. Lemonade, orangeade and other diluted fruit juices. May add sugar to increase food value. Bowels. Calomel and salts or a salt alone. Calomel, gr. 1/4 (0.015 Gm.) every quarter hour for six to eight doses. Epsom salt 5ss. (15 Gm.). Rochelle salt 5ss.-i (15-30 Gm.). Seidlitz powder. Liquor magnesii citratis 5viii to xii (240-360 Gm.). Hunyadi water. Treatment of symptoms. Pain. Local. Hot fomentations. (See Pneumonia, Chap. IX.) Poultice. (See Pneumonia, Chap. IX.) Sodium salicylate or acetylsalicylic acid (Aspirin), gr. x (0.60 Gm.) every two hours. Phenacetin (acetphenetidin), gr. iii to gr. v (0.20-0.30 Gm.) every two hours. Codeine sulphate or phosphate gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) every two hours. Morphine sulphate hypodermically, gr. 1/12 to gr. 1/8 (0.005- 0.008 Gm.). Fever. Cool sponges. Cool drinks. Ice-bag to head. Circulation. Rarely threatened. (If stimulation is indicated, see Pneumonia, Chap. IX.) Nervous symptoms. Marked irritability allayed by quiet and good nursing. Insomnia. Sulphonethylmethane (Trional), gr. x (0.60 Gm.). (May repeat in two hours.) Chloralamid, gr. xx (1.30 Gm.). (May repeat in two hours.) DENGUE 645 Codeine phosphate, gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.). (If due to pain.) Morphine sulphate, gr. 1/12 to gr. 1/8 (0.005-0.008 Gm.). (If due to pain.) Complications. Hemorrhages. (See text.) (If severe same as Typhoid Fever, Chap. XIV.) Convalescence. Protracted. Increase food intake. Fresh air. Strychnine sulphate, gr. 1/60 to gr. 1/20 (0.001-0.003 Gm.) or Tincture of nux vomica, m. x to m. xv (0.60-1 c.c.) three times a day. Iron as carbonate, gr. v (0.30 Gm.) three times a day, as either B laud's pills, or Vallet's mass. Prophylaxis. War on the mosquito. (See Malaria, Chap. XV.) CHAPTER XXXI ASIATIC CHOLERA ASIATIC CHOLEKA is due to a definite organism, the so-called " comma bacillus" discovered by Koch in 1883 or more technically, the vibrio cholerse asiaticse. It is conveyed by the dejecta of the infected directly or through the medium of water and always gains entrance through the mouth. Its toxin and endotoxin acts specifically on the endothelium of the intestinal canal to induce those alterations in function that constitute the symptoms of the disease, namely, excessive diarrhea with collapse. The mortality is high, approximately 50 per cent, and is especially fatal to the two extremes of life. Isolation. During a cholera epidemic the slightest diarrhea should be looked upon as suspicious and the patient should be put to bed and everything be done to conserve his strength for the coming struggle. The problem of protection against infection is a simple one, for we know the source of the infection through the feces, its mode of convey- ance through hands, articles, insects, food and drink contaminated by the dejecta and the portal of entry through the mouth. Isolation prevents the ignorant and careless who come into contact with the patient from becoming infected and spreading the disease and prevents added infection to the patient. Doctor and nurse by an appreciation of the facts just stated should, by use of gowns and gloves, careful cleansing of hands, sterili- zations of contaminated objects, and destruction by fire and strong antiseptics of excreta, protect themselves and those with whom they may come in contact. Room. During an epidemic, of course, the vast majority of patients must be treated in hospitals, camps, etc., but for the favored few, who may be treated under more fortuitous environments, a room, as cool and as well ventilated as possible should be chosen and this stripped of all furnishings and hangings. In fact the source and mode of conveyance of this disease is so like typhoid fever that the details of room, bed, sterilization of articles used, and care of the body are identical problems. (See Typhoid Fever, Chap. XIV.) Diet. At first it is well to eliminate all food-stuffs, except barley- water, which is best given hot. Later other farinaceous gruels, such ASIATIC CHOLERA 647 as arrowroot water, rice water, whey, and then cautiously animal broths thickened with farinaceous foods, and then milk. These are dietetic measures similar to those we use in the gastro- enteritis of infancy. Water is given abundantly in small quantities freely and not too cold. Early Treatment. The sooner the patient is put to bed after the looseness of the bowels appears the better. He should be covered warmly, given hot drinks, hot weak tea or lemonade and hot stupes or poultices should be applied to the abdomen. At this early stage opium may be given, but later in the disease it is a dangerous drug. Indeed, Stitt advises against its use in any stage. One may give m. xx (1.30 c.c.) of the tincture or 3ss.-3i (15-30 c.c.) of paregoric or in smaller and frequent doses, as m. ii (0.13 c.c.) of the tincture or gr. ii (0.13 Gm.) of Dover's powders or 3i (4 c.c.) of pare- goric every hour. Cathartics. Rogers, whose masterly article in Hare's Modern Treat- ment, should be read with attention by all who deal with this disease, decries the use of cathartics in cholera at any stage. Stage of Collapse. Rogers' treatment while not specific, is deduced so logically from what we know of physiological requirements, that I shall summarize it for the purposes of this article with a frank confes- sion of the shortcomings of such a summary. Rogers recognizing the obvious fact that the loss of fluids from the tissues constitutes the danger of the disease and that its replacement is the procedure that the logic of the situation demands, finds his success in the appieciation of the significance of certain minor details. He recognized that not only is there a loss of fluid by the tissues, but also a marked loss of salts, both of which should be replaced, and argued that if salts were introduced in hypertonic solution osmotic currents could be determined toward the blood from the bowel instead of away from it as induced by the toxic agents. Some of the tropical workers report that equally good results have been obtained from the use of normal saline as from the hypertonic solution. The condition of the blood Rogers estimated by determining its specific gravity. This he does by blowing a drop of blood into mixtures of glycerin and water of known specific gravities from 1040-1076 cor- responding to the normal specific gravity of the blood and noticing whether it sank, rose or remained for a time suspended. A small urin- ometer suffices to determine the specific gravities of the glycerin and water mixture. The state of the circulation is gauged by the sphygmomanometer. If the pressure is 70 mm. or over, saline may be absorbed from the 648 TREATMENT OF ACUTE INFECTIOUS DISEASES bowel and unless indications are urgent treatment may be begun in this manner. He uses a solution of sodium chloride gr. 90 to one pint (6 Gm. to 500 c.c.) at blood heat 1/2 to 1 pint (250-500 c.c.) introduced very slowly two hours or by the Murphy drip method. This is kept up until the kidneys act freely. If, however, the blood pressure is below 70 mm. Hg., or the patient has severe cramps, is restless or cyanotic a saline should be given intravenously as the subcutaneous method is often ineffectual due to failure of absorption. Owing to the collapse of the vein it is usually necessary to cut down upon the vein to insert the needle. The efficacy of this method Rogers attributes largely to the con- centration of the solution. The formula he advises is as follows: Sodium Chloride 120 grains. (8 Gm.) Calcium Chloride 4 grains. (0.250 Gm.) Potassium Chloride 6 grains. (0 . 370 Gm.) To each pint of water (500 c.c.). This is injected at body temperature. Three to four pints are usually injected, aiming to bring the blood pressure up to 110 mm. Hg. The injection is carried on at the rate of about 1 pint in five minutes. A salvarsan apparatus with a large container may be used for this purpose. (See Pneumonia, Chap. IX.) Indications for interruptions of the injection or lessening the rate of inflow are headache, dyspnoea or sense of oppression in chest. Rogers' second point of attack is on the toxins of this disease before absorption. For this purpose he advocates highly the use of calcium or potas- sium permanganate, preferably calcium as an oxidizing agent. He gives it in the drinking water, 4 or more grains to the pint (0.25 Gm. to 100 c.c.) (much more than 4 is not readily swallowed) in such quantities as the patient can be made to drink, or in gr. ii (0.125 Gm.) pills coated with salol (phenyl salicylate) or keratin every quarter hour for four doses, then every half hour until gr. xx are taken, in four hours, then omit four hours (or take gr. v (0.30 Gm.) bismuth salicylate every hour for these four hours), then one pill every half hour for four hours, then stop four hours and so on over again until stools change color and become less (usually in twenty-four hours). At the beginning of the second day 16 grains more are administered. Lately Rogers has been using atropine sulphate gr. 1/100 (0.006 Gm.) morning and night with satisfactory results. Sellards uses 0.5 per cent, saline solution and 0.5 per cent, sodium ASIATIC CHOLERA 649 bicarbonate solution, injecting in the adult as much as two litres of saline at an interval of 15-20 minutes. The improvement is often very great, but purging continues and collapse is almost certain to return. He re- peats the infusion at 6 to 8 hour intervals. He notes that patients who recover begin to show inprovement on the second day. Sellards did not find that the hypertonic solution used by Rogers and others afforded the results that theory seemed to promise. Other substances, such as colloidal solutions, added to the saline failed to convince Sellards of an additional value. Vomiting. As lesser measures one may try cracked ice or a mustard paste to the epigastrium or subcarbonate of bismuth in gr. xv (1 Gm.) doses or if the vomiting is very severe lavage may be tried. In the early stages a hypodermic of morphine sulphate gr. 1/4 (0.015 Gm.)- is warrantable and perhaps more likely to be efficacious than any other measure, but during the stage of collapse Rogers maintains its use constitutes a real danger. During collapse warmth to the surface of the body is indicated by the applications of hot blankets and hot-water bottles. Hot drinks are also given, friction to the skin and extremities and stimulants ad- ministered (see below). Heat, however, should not be applied during intravenous injection as the febrile reaction accompanying it may pass over into hyperpyrexia. Stage of Reaction. With a cessation of vomiting, a diminution in the stools, improvement in their consistency and color (bile re- tained), a slowing of the pulse, and wanning of the body surface, the stage of reaction sets in and brings hope with it and yet this period is fraught with no inconsiderable dangers that has warned the physician to abate no jot or tittle in his vigilance. The possibilities for disaster in this stage rest in hyperpyrexia, sup- pression of urine and ursemia. Hyperpyrexia. Large bodies of statistics attribute 10 per cent, of deaths to hyperpyrexia. Rogers believes it due not so much to pyrexia as the rapid absorption of toxins from the gut as the circulation picks up under the febrile reaction. He believes his permanganate treatment has lessened the mortality from this cause. He also warns against the use of heat applied to surface of the body during saline infusion. Anuria is to be met by the supply of fluid to the tissues by fre- quent administrations by mouth and rectum and if specific gravity of blood is not too low (Rogers) by vein as saline solutions. Sellards recommends intravenous injections of 2 per cent, sodium bicarbonate in place of normal or hypertonic saline as being more effica- 650 TREATMENT OF ACUTE INFECTIOUS DISEASES cious in this Condition, while be believes it is -equally potent in relieving collapse. The kidneys may be cupped, cardiac stimulants such as-strophan- thin gr. 1/120-gr. 1/60 (0.0005-0.001 Gm.) or rapid vaso-motor stimu- lants such as adrenalin m. x-xv (0.60-1 c.c.) into muscle or m. ii-v (0.125-0.30 c.c.) into vein to be used. Uremia is particularly likely to occur even in the milder cases, in the state of reaction, and Sellards' studies show it is connected inti- mately with an acidosis. Because of this tendency toward acidosis Sellards early in the stage of reaction increases the strength of the solu- tion used in collapse to 1.5 per cent, of sodium bicarbonate and omits the sodium chloride. If the urine does not become alkaline to litmus or but little urine is passed he increases the strength to 2 per cent, sodium bicarbonate. Proper precaution in the sterilization of the sodium bicarbonate solu- tion must be taken to prevent its conversion into sodium carbonate. This may be done by passing carbon dioxide gas through the sterilized solution until the carbonate is reconverted into the bicarbonate. The gas is passed through sterile tubes and filtered through sterile cotton before it enters the solution. Even 60 to 90 grams of sodium bicarbonate was given intravenously within 24 to 48 hours with most satisfactory results. The method of intravenous infusion is described in detail under the administration of serum in pneumonia, Chap. IX. The rate is much more rapid than in serum injection. Two litres may be given within 15 to 30 minutes. The intervals are 6 to 8 hours or on the reappearance of collapse. Bicarbonate is discontinued when the urine becomes al- kaline. Specific Treatment. Serum has been used but unfortunately as yet with little result. Prophylactic inoculations of the cholera vibrio by Haffkine have been adopted. Such treatment after evidences of infection occur is of no value and there are theoretical reasons for the belief that it is then distinctly harmful. Stimulants. A sufficiency of water in the circulation is the best stimulant and that the intravenous injection seeks to assure. However, if this fails, we must use whatever other means we have at hand that gives us any promise of assistance and look for such among the drugs. Probably no drug is comparable to digitalis for sustained effect upon the circulation and should be administered in doses of m. xx (1.30 c.c.) of the tincture every six hours. It requires some thirty-six hours or more, however, for it to exert its effect and it seems to me that for more immediate effect strophanthin in doses of mg. 1/2-1 (gr. 1/120-1/60) in- ASIATIC CHOLERA 651 travenously would be indicated here as in other acute infections accom- panied by circulatory failure. For vaso-motor stimulants one may have recourse to camphor gr. v (0.30 Gm.) in oil or caffeine sodio-salicylate or caffeine sodio-benzoate gr. v (0.30 Gm.) in watery solution every four hours or alternate at two- hour intervals or strychnine sulphate gr. 1/40 (0.0015 Gm.) every three to four hours. All should be given deep into a muscle or if collapse is severe into a vein. Sellards would allow coffee in small amounts as being both agreeable and possibly beneficial to both heart and kidneys. Prophylaxis. Wherry has divided this subject into (1) Communal and (2) Individual Prophylaxis. Communal Prophylaxis. This means proper quarantine, sani- tary supervision and control of water and food supply, bacterial ex- amination of the excreta of all suspects, which includes all persons coming from foci of infection, many of whom may be true carriers, themselves free from any symptoms of the disease. Isolation of Suspects. This should entail a detention of at least five days. Individual Prophylaxis. This entails the realization that the in- fection enters by the mouth; that it comes by way of drinking water; hence, all water should be boiled ; that it comes by way of food ; hence, only recently cooked foods, carefully protected from flies, and no raw foods should be eaten; that it comes from fingers or utensils soiled by excreta; hence, careful sterilization of utensils, protection of hands by gloves, when in contact with patients, and by cleansing in sterile water and antiseptic solutions ; that it comes from flies or other insects bearing excreta on their legs to food and drink; hence, screening of patient and of food ; that anything which reduces the resistance of the epithelial lining of the intestine enhances the likelihood of an attack; hence, especial atten- tion should be given to diet during a cholera epidemic. This means eat- ing in moderation, avoidances of all questionable messes and highly sea- soned and garnished dishes; raw fruits and vegetables, large quantities of very cold water and alcoholic excesses. Vaccines have been used as a prophylactic measure with some degree of success. These vaccines have been variously prepared and administered and it seems probable that their use will become more extensive. Complications. These are numerous but pneumonia, prolonged dysentery, profound weakness determining a long convalescence are the most common. 652 TREATMENT OF ACUTE INFECTIOUS DISEASES Convalescence is to be met by a careful -return to a sufficient diet, good air and rest. I cannot do better than quote bodily the summary of treatment from Rogers to whose excellent article I owe so much. Summary of Rogers' Treatment. "In the first place, the blood- pressure and specific gravity of the blood should be estimated and the axillary and rectal temperature taken. If the blood-pressure is 70 millimeters of Hg. or over, the patient quiet, and the general condition good, rectal saline injections may be tried, a careful watch being kept on the pulse, so that any further fall may at once be detected and more active measures adopted. If the specific gravity is very high, such as 1070, transfusion should not be delayed. If the blood-pressure on admission or later falls below 70, and especially if the patient is restless, cyanosed, and suffering from severe cramps, no time should be lost in giving an intravenous injection, the hypertonic Ringer solution being used. Sufficient should be injected to obtain not only a fair, but a strong, full pressure-pulse, so as to at once restore the urinary secretion. Four pints are commonly necessary in a severe case in an adult male, and pro- portionately less in women and children. It should be given at body heat unless the rectal temperature is below 90 F., when the temperature of the solution should be a few degrees higher until the surface temperature is restored. A careful watch should be kept on the temperature reaction which always follows intravenous salines, and the necessary measures taken to prevent an excessive rise occurring. "In the acute stage nothing should be given by the mouth except the permanganate, drinks and pills, and some antiseptic, such as bismuth salicylate. If the acute stage is prolonged, barley-water may also be necessary. If the collapse recurs, the hypertonic injection must be repeated, being given at a slower rate if the specific gravity of the blood is not much raised, and at a subnormal temperature if there is fever present. "If a second hypertonic injection is required, the prognosis be- comes much graver, although a majority of even such cases may be saved. "Once the stage of copious evacuations and collapse is past, the all- important indication is to dilute the blood to at least the normal point, and to raise the blood-pressure high enough to restore the secretory activity of the kidneys, and so insure the excretion of the toxins and the prevention of the uraemic complications. If the specific gravity of the blood remains above normal, and is not rapidly reduced by continuing the salines by the bowel and the water by the mouth, a further smaller subcutaneous or slow intravenous injection of normal saline solution is ASIATIC CHOLERA 653 indicated. In addition, cardiac tonics and vaso-constricting drugs are of great service. "Great caution is necessary in adding to the diet during early con- valescence, animal albumins being especially liable to induce a relapse, while starvation for two or three days is less injurious in otherwise healthy subjects whose age is not at either extreme of the scale." (Hare's Modern Treatment.) For Sellards' treatment, see text. SUMMARY Isolation. Of all real cases and all suspects (those who during an epidemic have diarrhea). Destruction of all dejecta and sterilization of objects coming in con- tact with the patient or his excretions. (For details, see Typhoid Fever, Chap. XIV.) Doctor and nurse. Should use gowns and gloves in performance of duties about patient. Cleanse hands with soap and water, and follow with alcohol or 1 to 1,000 bichloride, even if gloves were worn. Room. Chosen with reference to ventilation. Stripped of all hangings and ornaments. Take especial care to keep flies from the room and dejecta. (For details of care of room, care of the bed, and sterilization of ob- jects, see Typhoid Fever, Chap. XIV.) Diet. At first only barley-water, best given hot. Little later other farinaceous gruels. Arrowroot water. Rice water. Animal broths thickened with farinaceous foods (cautiously). Whey, then Milk. Water freely in small quantities frequently, not too cold. Rest. Put to bed at earliest sign of diarrhea. Give hot drinks, weak tea or lemonade. Cover warmly. Hot stupes or poultices to abdomen. (For technique of stupes, see Chap. XIV.) (For technique of poultices, see Chap. IX.) 654 TREATMENT OF ACUTE INFECTIOUS DISEASES Opium. M May be given early, not late. Tr. opii m. xx (1.30 c.c.). Paregoric gss. to i (15-30 c.c.). May divide above doses and give at short intervals Dover's powder gr. 1/5 (0.010 Gm.) every hour. Cathartics. Should not be used at all. Rogers' treatment of hypertonic salt solutions and potassium per- manganate. (See text.) Vomiting. Cracked ice to suck. Mustard paste to epigastrium. (For technique, see index.) Bismuth subnitrate in doses of gr. xv (1 Gm.). If severe, lavage. Morphine, gr. 1/4 (0.015 Gm.). Collapse. Warmth to body. Blankets. Hot-water bottles. Friction to the extremities. Stimulants, see below. Conditions arising during the Stage of reaction. Hyperpyrexia. Cold sponges. Anuria. Fluid to tissues. (See Rogers' treatment, text.) Cup kidneys. (For technique of cupping see index.) Cardiac and vaso-motor stimulants, see below. Specific treatment. (See text.) Stimulants. Sufficiency of fluids to the tissues. Digitalis, m. xx (1.30 Gm.) every six hours. Strophanthin in urgent cases gr. 1/120 to gr. 1/60 (0.0005-0.001 Gm.) to initiate the digitalis. Camphor gr. v (0.30 Gm.) in oil 5 per cent, or Caffeine sodium benzoate, gr. v (0.30 Gm.) either every four hours or alternate one with the other every two hours, or Strychnine sulphate, gr. 1/40 (0.0015 Gm.) ; all given into muscle or vein. For immediate effect Adrenalin m. xv (1 c.c.) into muscle or m. iii (0.20 c.c.) into vein. ASIATIC CHOLERA 655 Prophylaxis. 1. Communal. Quarantine. Supervision and control of water and food supply. Bacterial examination of excreta of all suspects. Isolation of suspects for five days. 2. Individual. Boil water. Don't drink large amounts of cold water. Avoid alcohol. Eat no raw foods. Eat only recently cooked foods. Protect food from flies. Eat in moderation. Sterilization of utensils. Protection of hands with gloves when in contact with patients. Convalescence. Careful return to sufficient diet. Fresh air. CHAPTER XXXII MALTA FEVER MALTA FEVER in the great ocean of diseases, has like its habitat Malta seemed until recently, an island and a small island at that, of interest only to the physician practicing there or treating the Eng- lish soldier invalided home, but an article by Ferenbaugh in August, 1911, suddenly made us aware that we harbored the disease in this country in the great State of Texas. This disease, which affected so widely the British troops stationed in Malta, Gibraltar and a few other Mediterranean localities was found by Bruce in 1887 to be due to a definite organism, the bacterium meli- tensis. The mode of its distribution was elucidated by the Mediterra- nean Fever Commission in their work of 1905-7. They showed that it came largely through the use of the milk of goats so plentiful in the is- land; that 50 per cent, of the goats were infected, acting as carriers, and that 10 per cent, of them secreted the bacteria in their milk. In Edwards County, Texas, and in adjacent territory an unclassified slow fever had been recognized under various local designations and had even been associated with the goat and by some called "goat fever." The investigators mentioned found all their cases to be in the goat raising country, among those drinking uncooked goats' milk or handling goats (for the Mediterranean Fever Commission found these animals excreted the bacteria in their urine and feces as well as in their milk), and though the organisms were not found in the milk of the Texas goat, 34 per cent, gave a positive reaction to the agglutination test. The complement fixation test has since been used in the investigation with positive results. Gentry and Ferenbaugh give the warning that some of the so-called typhoid fever cases in these sections might prove to be Malta Fever. The incubation period seems to be about two weeks. The disease is characterized by the peculiar course of the fever, the curve of which, rising and falling like the waves of the sea, have given it the name of undulating fever. It is very drawn out, often lasting months (averages give 90-120 days some last a year or more) and is rife with discomforts, such as headache, backache, neuralgic pains, swollen painful joints, perspiration, gastric disturbance, and not uncommonly an orchitis. MALTA FEVER 657 Relapses are the rule and are repeated. Treatment. Here, as in most diseases, our best treatment lies in husbanding the patient's strength for his own battle with the infection. This is achieved by rest, consideration of the diet and good nursing. Bed. Certainly during the febrile exacerbations and during the period of pain the patient should be kept in bed and will undoubtedly be willing, but during the remissions an insistency on the bed may not be feasible, but a maximum amount of quiet should be enjoined. Each febrile period is considerably prolonged and the bed should be chosen with a view to comfort and convenience as in Typhoid Fever. (See Chap. XIV.) In a state of so great discomfort good nursing counts for much; quiet should be secured, every annoyance avoided and the bed-pan be in- sisted upon. The room should be cool and shady and screened against insects. The urine and feces which contain the organisms should be destroyed, and clothes, bedclothes and utensils sterilized as in Typhoid Fever cases. Nurses and physicians appreciating the mode of infection should guard against it by wearing gloves when handling contaminated ob- jects and carefully clean their hands. The rules given under Typhoid Fever serve here. (See Chap. XIV.) Care of the Body. Sponge baths with soap and water, talcum powders, alcohol rubs, frequent changing of position keep the skin in condition and avoid bed-sores. The mouth and nose should be kept free from secretions, the tongue and teeth especially looked after. It has been advised, on account of the neuralgias and joint pains, that just as in rheumatism the clothes next the skin should be of flannel or contain wool, and this the more especially because the perspiration is profuse and, when cotton garments become wet through, chilling of the skin may ensue. Of course frequent change of clothes for the same reason is demanded. For details (see Typhoid Fever, Chap. XIV.) Diet. The general rule for feeding in fever should be followed (Diet in Acute Infectious Diseases, Chap. II) with a view to caloric needs and that, especially, because the fever is long drawn out. As, however, the gastro-intestinal canal is in an irritable condition in the early days, food should not be forced and should at first consist of diluted milk, with soups, cereal waters and jellies, and meat broths (if desired) which may.be thickened with cereals or farinaceous meals to enhance their food values. Goat's milk should not be used, but if deemed imperative it should be boiled or at the least be pasteurized to kill any bacteria melitenses that may be present. 658 TREATMENT OF ACUTE INFECTIOUS DISEASES Drinks. Water, saline waters or drinks, containing fruit juices should be given freely. Bowels. The bowels should be freely opened at the .beginning with calomel and salts or salines alone, Calomel gr. iii to v (0.2-0.35 Gm.) followed by Epsom or Rochelle salt 5ss. to i (15-30 Gm.). The calomel may be given in divided doses of gr. 1/4 (0.015 Gm.) every ten to fifteen minutes for eight or ten doses. Constipation is the rule throughout the disease and the use of enemata or drugs cannot be dispensed with. Calomel has been much used be- cause in addition to its cathartic action it has been assumed to exert a good effect upon the disease itself and jalap for the same reason. Of course this usage rests on individual opinion and not on a rational basis. Better for this purpose it seems to me are the milder salines, citrate of magnesia, Hunyadi water and the like, cascara, compound licorice powder, aloin and occasionally more drastic salines like Epsom, Rochelle or Glauber's salt or castor oil. Retention of urine sometimes occurs and should be looked for. Hot fomentations to the hypogastrium or the sound of running water may relieve this; if not the catheter must be used with all due caution to prevent infection. Specific treatment has as yet been illy developed; vaccines have been used in the more chronic forms of the disease and good results have been reported. It would seem a legitimate field of endeavor, but their use should not be undertaken in the acute manifestations of the disorder except by men well versed in the theory and application of vaccine therapy, as real harm may be done. In the suitable cases the dosage has been 5,000,000 bacteria and the number of doses one to ten (Basset-Smith). Some use as high as 50,000,000. Symptomatic Treatment. The discomforts of the disease are so great that a considerable demand is made on medical procedure. Pain. Neuralgic pains, joint pains, backache and headache are con- stant and characteristic phenomena. When it is possible the measures of physical therapy should be given preference, such as the ice-bag to the head, hot cloths to the back and joints or mustard plasters or poultices or massage or light rubbing with or without liniments and counter-irritants such as chloroform liniment or a 10-15 per cent, methyl-salicylate or menthol or the two combined. The joints should be treated as in rheumatism, swathed in cotton batten or flannel and if it affords more comfort, mobilized. (See Rheu- matic Fever, Chap. III.) MALTA FEVER 659 If drugs are used, one may try acetyl salicylic acid (aspirin) or other form of salicylate in doses of gr. x-gr. xv (0.65-1 Gm.) every two hours or coal tars, acetphenetidin (phenacetin) gr. iv to gr. viii (0.25-0.5 Gm.) at the same intervals or acetanilid gr. ii to gr. iv (0.15-0.25 Gm.) These drugs, however, have been very disappointing and in the severest cases morphine has to be used. Fever. When within proper limits, 104 F. or less, this requires no other treatment than that directed at comfort such as follows a cool sponge bath; but in hyperpyrexia 105 F. or above or even 104 F. or less, when very sustained, measures aimed at it should be pursued and none are comparable to cold water. The procedures and their details when there is sustained fever will be found under Typhoid Fever (see Chap. XIV and may be adapted in regard to temperature, length and frequency of bath and, indeed, in all particulars. In cases of sudden high temperature the rules given under "Rheumatic Fever" (Chap. Ill) should be followed. Hyperpyrexia is one of the real dangers of the disease and should be watched for and provision made for prompt treatment. When cold water cannot be obtained, antipyretics may be used but they are illy efficient and danger- ously depressant. In the lower temperatures they should not be used. Vomiting. During vomiting food should be stopped or if the vomit- ing is persistent give small quantities of egg albumin, beef -juice, or milk peptonized or diluted in water or cereal water. Champagne is sometimes well borne, lessens vomiting and furnishes a little fuel in its alcohol content. Cracked ice may be used, mustard paste 1 part of mustard to 3 or 4 of flour, or mustard leaf may be applied to the pit of the stomach, bismuth subnitrate gr. xv to gr. xxx (1-2 Gm.), bicarbonate of soda gr. x to gr. xv (0.65-1 Gm.), cerium oxalate gr. v to gr. x (0.35-0.65 Gm.) may be given singly or in combination. In very severe cases cocaine hydrochloride gr. 1/5 (0.012 Gm.) may be of value, or calomel in gr. 1/10 (0.006 Gm.) doses, or if exhaustion threatens morphine sulphate gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) hy- podermically. Sleeplessness may require bromides in early evening in gr. xxx (2 Gm.) doses or trional gr. x to gr. xx (0.65-1.35 Gm.) or chloralamid gr. xv to gr. xxx (1-2 Gm.) or in prolonged or persistent sacrifice of sleep chloral gr. x to gr. xv (0.65-1 Gm.) or even morphine gr. 1/8 (0.008 Gm.) hypodermically. Toxemia. If this is marked the hydrotherapeutic measures men- tioned under hyperpyrexia will be found most efficient. If the circulation is threatened digitalis should be given in doses 660 TREATMENT OF ACUTE INFECTIOUS DISEASES of the tincture m. xxx (2 c.c.) three or four times a day for three or four days or the equivalent dose of the infusion 5 ss. (15 c.c.) or powdered leaf gr. iii (0.2 Gm.). For more immediate effect the vaso-motor stimulants caffeine in soluble form, double salt of sodium salicylate or benzoate gr. v (0.35 Gm.) every four or every two hours intramuscularly or camphor gr. v (0.35 Gm.) in oil, 10 per cent, by the same method at the same intervals. Orchitis. Is not an uncommon complication. It is to be treated like orchitis from other causes. The testicle is supported, hot fomen- tations applied or "dry poultices," i. e., a heavy non-absorbent cotton dressing and counter-irritants used, of which light application of the actual cautery is the best. (See Parotitis, Chap. XXIII.) Convalescence. Fresh air and plenty of good food are the best tonics during convalescence, though iron as carbonate gr. ii to gr. v (0.15-0.35 Gm.) arsenic gr. 1/40 to gr. 1/30 (0.0015-0.002 Gm.) and strychnine gr. 1/40 to gr. 1/30 (0.0015-0.002 Gm.) may be used singly or in combination. Prognosis is good, the mortality is only about 2 per cent, to 3 per cent, and immunity against a second attack is probably conferred. Prophylaxis. The etiology makes the problem clear. The infected goat should be eliminated from the herd, and tests made of herds in infected districts from time to time. When this is not possible the goat's milk in infected districts should not be drunk or at least should be boiled or pasteurized before using. Knowledge should be disseminated in infected districts of the possi- bility of infection from handling the goat, whose urine, feces and milk excrete the organism. Care should be taken lest the water supply or food be contaminated by the excreta. Filth harbors the infection while sunlight readily kills the bacterium; hence, the importance of cleanliness and light. The patient's excreta, too, containing the bacteria are sources of infection and should be properly disposed of as mentioned above. It is well to screen the windows and doors against insects that may bear infected excreta on their bodies to food; for by food the disease is nearly always conveyed. As in typhoid fever some of the patients become carriers after con- valescence and have been shown to excrete the bacteria for two years. MALTA FEVER 661 SUMMARY Rest. In bed; certainly, during exacerbations. Bed. (For technique of bed-making, see Typhoid Fever, Chap. XIV, or Dysentery, Chap. XVI.) Room. Cool and shady. Screen against flies. Urine, stools, bedclothes, utensils, etc. (See Typhoid Fever, Chap. XIV.) Physicians and Nurses. Should wear gloves in handling secretions. (See Typhoid Fever, Chap. XIV.) Care of the body. Sponge baths, daily, with soap and water. Talcum powder. Alcohol rubs. Frequent change of position. Mouth, teeth, etc. (See Pneumonia, Chap. IX.) Woolen next to the skin on account of neuralgias, joint pains and abundant perspiration. Diet. Early days. Diluted cow's milk (not goat's), soups, cereals, jellies, broths thickened with cereals or farinaceous flours. Drinks. Water, mineral waters, lemonade, orangeade, grape-juice, Im- perial drinks, freely. Bowels. In the beginning. Calomel gr. iii to gr. v (0.20-0.30 Gm.) or in divided doses, fol- lowed by a salt, Epsom or Rochelle, gss.-gi (15-30 Gm.) or a salt may be given alone. Throughout the disease constipation is the rule. Calomel. Citrate of magnesia. Hunyadi water. Cascara, e. g., fluid extract m. xv to m. xlv (1-3 c.c.) in water. Compound licorice powder, 3ss. to 3ii (2-8 Gm.) given in water. Aloin, gr. ss. to gr. i (0.030-0.060 Gm.). 662 TREATMENT OF ACUTE INFECTIOUS DISEASES Retention of urine. Hot fomentations to epigastrium. (For technique, see Typhoid Fever, Chap. XIV.) Sound of running water. Catheterize. Specific treatment. (See text.) Treatment of symptoms. Pain and neuralgias. Ice-bag to head for headache. Fomentations to back and joints or mustard plasters. Poultices. Chloroform liniment. Methyl salicylate and menthol 15 per cent, in vaseline. Acetylsalicylic acid (Aspirin), gr. x to gr. xv (0.60-1 Gm.) every two hours. Acetphenetidin (Phenacetin), gr. iv to gr. viii (0.25-0.50 Gm.) every two hours. Acetanilid, gr. ii to gr. iv (0.120-0.25 Gm.) every two hours. Very severe. Morphine sulphate, gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.). Fever. Cold water, sponges, packs, baths. (For technique of bath, see Typhoid Fever, Chap. XIV.) Vomiting. Cracked ice to suck. Mustard paste to epigastrium. (For technique, see index.) Bismuth subnitrate, gr. xv to gr. xxx (1-2 Gm.). Sodium bicarbonate gr. x to gr. xv (0.60-1 Gm.). Cerium oxalate gr. v to gr. x (0.30-0.60 Gm.) or combination of above drugs. Very severe. Cocaine hydrochloride gr. 1/5 (0.012 Gm.) . If exhaustion threatens. Morphine sulphate, gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) hypoder- mically. Sleeplessness. Bromides, gr. xxx (2 Gm.) in water in early evening. Trional, gr. x to gr. xx in warm water, in whiskey, in powder. Chloralamid, gr. xv to gr. xxx (1-2 Gm.) in cold water, in whiskey or in powder. If more resistant. Chloral, gr. x to gr. xv (0.65-1 Gm.) in water. Morphine sulphate, gr. 1/8 (0.008 Gm.) hypodermically. Toxemia. Circulation. (See Pneumonia, Chap. IX.) MALTA FEVER 663 Complication. Orchitis. (See Parotitis, Chap. XXIII.) Convalescence. Fresh air. Good food. Iron. Arsenic. Prophylaxis. Elimination of infected goats. Herds tested. Milk should not be drunk. Instruction in regard to the infectivity of milk, urine and feces of infected goats. Care of the water and food supply. Disinfection of patient's excretions. Screen room of patient against insects. CHAPTER XXXIII ROCKY MOUNTAIN SPOTTED FEVER (TICK FEVER OF THE ROCKY MOUNTAINS) THIS disease as the name would indicate pervades the Rocky Mountain Districts, including the States of Washington, Oregon, California, Ne- vada, Idaho, Utah, Montana, Virginia and Colorado. It has been characterized as an " acute, endemic, non-contagious, but probably infectious, febrile disease, characterized clinically by a continuous moderately high fever, severe arthritic and muscular pains and a profuse petechial or purpural eruption in the skin, appearing first on the ankles, wrists and forehead, but rapidly spreading to all parts of the body" (Maxey). It is transmitted by a tick, Dermacentor venustus (Derma- centor andersoni). The virus with which the tick becomes infected is entertained by certain rodents on which they feed, chipmunks, ground squirrels, mountain rats. The virus will not pass through a Berkfeld filter and for a time was believed to be bacterial, but Wolback has isolated a micro-organism which he believes to be a parasite of a different nature. He can identify it neither as a bacterium nor protozoon. He proposes for this causative agent of Rocky Mountain Spotted Fever the term Dermacentroxenus rickettsi in honor of Rickett's pioneer work in this disease. This virus was shown to be transmitted hereditarily in ticks. It occurs almost wholly in the Spring and is at its height in May or June. This corresponds exactly with the period of activity in the life history of the tick. The incubation period is usually 4 to 6 days, the extreme limit being 3 to 12 days. It requires on an average 10 hours of feeding time for the tick to infect. Symptomatology. The onset is abrupt with a chill though the chill may be preceded by a few days of malaise and it has been noted that when such is the case as in most instances in Idaho, the disease is less fatal. The discomfort suggests a grip attack with severe pain in bones, joints and muscles, small of back and head; a little dry cough and photo- phobia are common and epistaxis occasionally. The temperature rises fairly quickly, reaching 102 to 104 F. on the second day and continues ROCKY MOUNTAIN SPOTTED FEVER 665 to 104 to 105 F. and in exceptional instances 106 F. and 107 F. in the second week and it begins to fall by lysis toward the end of the second week and strikes normal at the end of the third. The pulse at first is not very rapid, but later increases out of propor- tion to the temperature, i. e., a pulse of 120 to 102 F. of fever is common. In the more severe cases the pulse increases and signifies a bad outlook. The spleen is enlarged and palpable early in the disease. The rash usu- ally appears on the third day, but varies between the second and seventh. It is noted first on the wrist, ankles, back, forehead, arms, legs, chest and lastly abdomen. It is well out in 24 to 36 hours after appear- ance; but later it may appear on palms and soles and the mucous mem- brane of the propharynx. The rash at first is a rose-colored macule disappearing on pressure, but gradually it darkens to a purple and at the end of a week fails to disappear on pressure. It then tends to become petechial and considerable subcutaneous hemorrhages may be seen. Often the rash is confluent. It begins to disappear as the fever begins to go down, but often remains for some time as pigmented spots. When remaining discrete this pigmentation has been likened to the markings on a turkey egg. In severe cases, owing to occlusion of the vessels of the skin, necrosis of the skin of the fingers, toes, prepuce, scrotum, lobes of ears, or of the soft palate may occur. A general desquamation follows the subsidence of the rash. Restlessness, sleeplessness, stupor are common and, in severe cases, delirium and coma before death. Even convulsions have been reported. Constipation is the rule, vomiting in severe cases and slight jaundice in the second week. The blood shows a slight leucocytosis and a noticeable increase in the large mononuclears. One attack appears to confer permanent immunity. The mortality varies in different localities. In Montana, in the Bitter Root Valley, it has run above 70 per cent., in Idaho about 5 per cent. Outside of the Bitter Root Valley it runs between 7 per cent, and 13 per cent. This disease has many points of resemblance to Typhus Fever. Treatment. These cases occur in localities where all the niceties of nursing are difficult of attainment and in environments where the most must be made of what is at hand. The disease runs a rather long course and is rife with discomforts and in some localities almost uni- versally accompanied by a high and dangerous degree of toxicity. The coolest, best ventilated room should be chosen or the case may be treated in the open air, if shade and protection can be afforded. So far as possible, the choice of the bed, its care, the care of the body, baths, 666 TREATMENT OF ACUTE INFECTIOUS DISEASES care of mouth, nose, eyes, skin and genital^ should be carried out as directed under Typhoid Fever (Chapter XIV); the only danger of infection being through the bite of the tick, the disposition of excretions and the precautions in handling the patient insisted on in Typhoid Fever need not be observed beyond the usual rules of sanitation and clean- liness. Diet. As there is not much gastro-intestinal disturbance after the onset and as the course is prolonged, an abundant dietary would seem indicated and the diet advised for Typhoid Fever would seem logical. Water, alkaline drinks and fruit juices should be liberally administered. The Bowels. An initial cathartic may be given of castor oil 5 ss.-5 i (15 to 30 c.c.) or of a salt, Epsom, Rochelle or Glauber's 5ss. to 5i (15 to 20 grams) which may or may not be preceded by calomel gr. iss. to ii (0.066-0.120 Gm.), better in divided doses, especially if there is nausea and vomiting. One gives gr. 1/4 (0.015 Gm.) every 1/4 of an hour until the above dose is completed. For the discomforts, aches and pain aspirin in 10 grain doses (0.66 Gm.) at 2 or 3 hours intervals may be used or very small doses of acetanilid gr. iss. combined with bicarbonate of soda gr. i (0.06 Gm.) and citrated caffeine gr. ss. (0.03 Gm.) at half hour intervals until 6 doses are taken, then every two hours, but this should be only in the early stages and never when the circulation is impaired. If pains are intense it is better to use codeine phosphate gr. 1/8 to gr. 1/2 (0.008 to 0.03 Gm.) at 2 to 4 hour intervals. The drug is more potent administered hypodennically. In the worst cases, and especially if sleep is lost, morphine sulphate should be used gr. 1/8 to gr. 1/4 (0.008 to 0.015 Gm.) hypodennically. Headache is relieved by the above measures and an ice-bag (see Pneumonia, Chap. IX) may be applied to the head. Fever. Unless very high or long sustained had better be left alone. Cool sponges afford relief and are a tonic to the general nervous system. Antipyretics should not be used, for they are for the most part depres- sants to the circulation. Excessive temperatures may be controlled by cold sponges or cold baths, such as the slush baths and the cold pack. (See Typhoid Fever, Chap. XIV and Scarlet Fever, Chap. XVII.) Insomnia. The exhaustion that ensues upon loss of sleep cannot be overemphasized. If sleeplessness is due to pains and discomforts or exhaustion is threatening there is no use of temporizing with milder hypnotics. Morphine sulphate should be used hypodennically in doses of gr. 1/8 (0.008 Gm.), to be repeated if necessary. If there is delirium begin with morphine sulphate gr. 1/4 (0.015 Gm.). For milder cases one may use bromides in doses of gr. xv-gr. xxx (1-2 Gm.) either potassium bromide or the mixed, sodium, ammonium and potassium salts. Give in a glass of water in the early evening or trional in doses of ROCKY MOUNTAIN SPOTTED FEVER 667 gr. v to xv (0.33-1 Gm.) or chloralamid gr. xx-xxx ((1.33 to 2 Gm.). Delirium indicates the use of morphine as specified above and hyoscine hydrobromide gr. 1/200 to gr. 1/150 (0.0003-0.00045 Gm.) may be used with caution, for it is a depressant. An ice-bag to the head and cool sponges are helpful. The circulation should receive serious attention. It is well to digitalize the heart early to anticipate a depression that may steal on us unawares. For the procedure consult the chapters on pneu- monia or influenza. In urgent cases the digitalization should be as rapid as in those diseases, but in more moderate cases more time may be taken to attain digitalization and then the dose may be dropped to gr. iii to gr. iss. (0.20 to 0.10 Gm.) a day. (See Pneumonia and Epidemic Influenza, Chaps. IX and XII). Emergency cases must be treated with intramuscular or intravenous administration of strophanthin. (See Pneumonia, Chap. IX.) There is no specific treatment Immune serum has been tried without result. A great variety of drugs have been advocated but without any perceptible beneficial effects. Midrie and Parsons as the result of experimental work on guinea pigs have recommended the use of 5 per cent, sodium citrate solu- tion intravenously in doses of 60 c.c. (3ii) twice a day. Complications. Pneumonia is an infrequent complication and is to be treated as under other circumstances. Prophylaxis. The knowledge that the disease is always conveyed by the tick and that it takes the tick an hour or more to become attached to and feed upon the host, makes a systematic search for ticks on the person after exposure a very important prophylactic measure. SUMMARY Treatment Coolest and best ventilated room or Treat in open air. For care of the body, mouth, nose, skin. (See Typhoid Fever, Chap.. Diet. Abundant, if disease is protracted. (See Typhoid Fever, Chap. XIV.J Fluids. To be given in abundance. (See Typhoid Fever, Chap. XIV.) Bowels. Initial cathartic of castor oil, 5ss. to 5i (15-30 c.c.) or A salt, Epsom, Glauber's or Rochelle (15-20 Gm.). 668' TREATMENT OF ACUTE INFECTIOUS DISEASES May or may not be preceded by calomel,^ gr. iss. to ii (0.060-0.120 Gm.). Better given in divided doses especially if there is nausea. Aches and pains. Acetyl salicylic acid, gr. 10 (0.66 Gm.) at 2 to 3 hour intervals or Acetanilid, gr. iss. (0.10 Gm.) combined with sodium bicarbonate gr. i (0.06 Gm.) and citrated caffeine, gr. ss. (0.03 Gm.) at half- hour intervals until 6 doses are taken and then every two hours. Take only in early stages and never if circulation is impaired or Codeine phosphate gr. 1/8 to gr. 1/2 (0.008 to 0.03 Gm.) at two to four hour intervals or Morphine sulphate, gr. 1/4-1/8 (0.008 to 0.015 Gm.). Headache. May be relieved by above measures or ice-bag. (For technique, see Pneumonia, Chap. IX.) Fever. Give no drugs. Let alone unless high or long sustained. Cool sponges for relief. Excessive temperatures use cold sponges, cold baths ^-such as slush baths and cold pack. (For technique, see Typhoid Fever, and Scarlet Fever, Chaps. XIV and XVII.) Insomnia. If due to pain or exhaustion, morphine sulphate hypodermically, gr. 1/8-1/4 (0.008-0.015 Gm.). Repeat if necessary. Insomnia with delirium. Morphine sulphate, gr. 1/4 (0.0015 Gm.) hypodermically. Less urgent insomnia. Bromides, gr. xv-xxx (1-2 Gm.). Trional, gr. v-xv (0.33-1 Gm.). Chloralamid, gr. xx-xxx (1.33-2. Gm.). Delirium. Morphine as above. Hyoscine hydrobromide, gr. 1/200-1/150 (0.0003-0.0045 Gm.). Ice-bag to head. Cool sponges. Circulation. Well to digitalize the heart early. (See Pneumonia, Chap. IX.) In urgent cases rapid digitalization. (See Pneumonia, Chap. IX.) Emergency cases. Strophanthin intramuscularly or intravenously. (See Pneumonia, Chap. IX.) ROCKY MOUNTAIN SPOTTED FEVER 669 Specific Treatment. Immune serum has been tried without results. Complications. Pneumonia infrequent. (See Pneumonia, Chap. IX.) Prophylaxis. Search for the tick after exposure in tick-infected localities. CHAPTER XXXIV LEPROSY To no other unfortunate has the term " unclean " clung through- out the ages so insistently as to the leper. Its importance to us is that Leprosy has invaded North America and while its distribution is not so uniform as is the case with most of the in- fectious diseases, still its distribution is no respecter of climate and in our own country it is found in Minnesota in the North and Louisiana in the South, just as abroad it finds residence in the cold of Norway and the heart of India. Fortunately in this country the numbers are not large nor the spread rapid, still its mutilations carry no less horror to-day than in biblical times, even though more knowledge protects the community from unreasoning fear and the unfortunate from ill-usage. At least we have fixed the cause in a definite organism, the bacillus leprae and learned something of its habits 1 and the present time is witnessing no incon- siderable impulse to investigation in this field among our own workers. Three facts of practical importance about bacillus leprse are, first, that in all possibility its portal of entry into the human organism is the naso-pharynx, second, that it is discharged by way of all the secretions including discharges from sores, and thirdly, that it is peculiarly tena- cious of life even in an adverse environment. The organisms infect all the organs and tissues but have a peculiar predilection for the skin and peripheral nerves and the clinical picture depends on which of these structures is predominatingly affected. Isolation. The isolation of the leper has been throughout the ages the fruit of experience and recent pleas to free the leper in the com- munity meet with prompt rebuttal in facts educed by a study of his dis- tribution of the infecting germs. Colonization is the modern method of isolation; a colonization directed by every humane effort to relieve this life-long divorcement from the world. Precautions of Attendants. It is essential for all who come in contact with the patients to know that the bacilli of leprosy have been found in all the secretions, urine, feces, sweat, milk, sputum, in the secretions from the nose, the vagina, the urethra, as well as in the secre- 1 Strong in Forchheimer's Therapeusis of Internal Diseases would imply that identification of the organism of Leprosy is by no means certain. LEPROSY 671 tions and pus of sores and that all these secretions should be destroyed by burning or, when contaminating useful articles, by boiling or by powerful antiseptics. It should be particularly remembered that the lesions are apt to be early and severe in the upper air passages and that this may be conveyed by the spray of a sneeze or a cough or even in talking. Again it is to be remembered that the bacilli are peculiarly insistent and will remain virulent for months in dried secretions and in soiled linen. It must be borne in mind, too, that insects may be the means of con- veying infection and that non-infected animals may become carriers. That the disease is not highly infectious is shown by the fact that long contact with infected persons seems necessary for its conveyance. Cleanliness of the skin, the mouth and nose, sufficiency of good, well-cooked food and, in short, careful consideration of the rules of health are doubly important to those exposed to the disease. Leprosy is a curable disease and that always means that it is the body's own forces that must be called upon. This knowledge accentuates the importance of diet and hygiene, measures that contribute to the body's efficiency. The fight is a long one and the improvement slow, in this respect like tuberculosis; and so, as in the latter disease, all efforts in the patient's behalf must be persistent. Diet. After all it is from the food that all the energy used by the body must come, for the production of immune bodies as well as for other purposes; consequently, it should be abundant, well selected as to quality and well prepared. Fresh Air. The life of the leper like that of the tubercular should practically be in the open, the same provision being made for sleeping out of doors. Baths. Cleanliness is most important and baths not only keep the pores of the skin open and subserve the functions of that structure, but they have a tonic effect on the nervous system and, when the lesions of the skin are pronounced, serve as a vehicle for suitable medication. Hot baths are found especially grateful. Such supportive treatment is of infinitely greater value than any empirics or specifics that we have at our command. Empirical Treatment. An empiricism means merely a groping; the drugs that find favor are legion and none very satisfactory. Of all the drugs yet employed there is greater agreement on the value of Chaulmoogra oil than on any other. Chaulmoogra Oil (Oleum gynocardiae). This oil is expressed from the seeds of the gynocardia odorata. Mode of Administration. It has been given by the mouth, by 672 TREATMENT OF ACUTE INFECTIOUS DISEASES the rectum, hypodermically and applied to the skin. By far the most common method is by the mouth. Dosage. The amount given must be considerable to be effective; but, as it is illy borne at first by the stomach, the initial dose should be small and gradually increased. It is well to begin with 3 or 4 drops at a dose three times a day and increase a drop or two to the dose every three or four days until the limit of tolerance is reached or the dose totals 100 to 130 drops three times a day. The limit of tolerance is determined by the stomach's irritability. It is perhaps better given before meals, using as vehicles hot coffee, hot milk, cordials or milk of magnesia or it may be given in capsules or in pill-form, although the administration by these last two methods would be feasible only at the beginning. It has always seemed to me undesirable to give a disagreeable or disagreeing medicine in food, lest a distaste for a useful food be acquired by association. By Rectum. It has been so administered in milk as a vehicle, but this would scarcely be the preferred route. Hypodermically. Some irritation may ensue from the oil used in this manner, but when sterilized by heat this is said to be, for the most part or quite, avoided. The oil so treated as to lessen its irritating qualities has been brought forward under the name of "anti-lepral." It is said to be less irritating to the stomach. As much as 5 c.c. a day for months has been tolerated when so given. These are also supplied in ampoules of from 1/2 to 1/5 mg. Externally. Chaulmoogra oil diluted to 5 per cent, to 10 per cent, with some bland oil has been used as an inunction. Two rubbings a day are given. Latham and English's system of treatment gives the following formula for its local use; Chaulmoogra, 4; soft paraffin, 6; hard paraffin, 1. There can be no doubt that the rubbing itself would be beneficial to the infiltrated or anesthetic skin, but as compared with its dose by the mouth this and other methods are of dubious value; little is known of its modus operandi in cases which improve, beyond the fact that as fat it has some food value. Local Treatment. Two and 1/2 per cent, solution of benzoylchloride as a nasal spray and an application to leprous ulcers is said to be followed by improvement in these lesions, but one may have to have recourse to surgical treatment. The disadvantages in its use rest upon its irritating action on the LEPROSY 673 gastrointestinal canal which induce vomiting and diarrhea. This seems not difficult to avoid if care be taken in its administration. Opinions differ about its value. Dyer, whose experience in Louisiana, where it is endemic, gives him authority, speaks highly of it in Osier's Modern Medicine, and reports twelve cures in his own experience since 1894. Wooley on the other hand grants no gain to its use and believes improvement due to a better appetite and better functioning of the skin following its use, such as follow certain systems of baths. It must be said, however, that the results of this treatment have made a considerable impression on most men who have employed it and is perhaps the best weapon at hand at the present moment. Other Drugs. Among other drugs of less repute are Nastin, a bacterial fat which is diluted in benzoylchloride to lessen its irritative effects to the strength of .05 per cent., called Nastin B, and to .2 per cent. Nastin B. 2 Bercovitz reporting from China on the method advocated by Heisser, uses hypodermically a mixture of this formula Camphorated oil 60 c.c. 5 Chaulmoogra oil 60 c.c. 5 " Resorcin 4 grams. gr. Ix This after sterilization is injected under the skin of the arms and legs in doses of 1 c.c. of the mixture, weekly for three doses, then gradually increase to 3 c.c. weekly. There was always a slight reaction after the first dose, causing a mild headache with malaise and nausea. With this treatment he combined a bath of 2 per cent, soda bicarbo- nate taken immediately after the injection three times a week and fol- lowed by complete rest for a half hour and by a saline cathartic the next morning, and a compound of iron and arsenic. Inside of four weeks he found a distinct amelioration in all patients so treated. This was the more noticeable in the tubercular type. One c.c. subcutaneously once a week for five or six weeks is used of the weaker dilution, then is followed by weekly injections of the stronger. This has its advocates but elicits no such commendation as the Chaulmoogra oil. Calmette's Serum. Dyer attracted by the belief among cer- tain West Indians that the bite of certain reptiles cured leprosy, used Calmette's Antivenomous Serum in doses of 5 c.c. to 20 c.c. under the skin, sometimes as often as every day and found excellent results, re- porting three cures. Specific Treatment. Very naturally in this day of serum and vaccine therapy efforts have been made to utilize the products of bac- 674 TREATMENT OF ACUTE INFECTIOUS DISEASES terial action to enhance the production of?immune bodies, and as a matter of course there have been many disappointments. Among the later efforts and one giving some promise is a toxin derived from the bacillus leprse by Rost and called "leprolin." Its use, of course, attempts an active immunization. Its dose is 10 c.c. given intravenously at two to three day intervals and further dosage determined as in the use of tuberculin or vaccines, by the reac- tions induced. It is said to be contraindicated in the presence of pulmonary or kidney complications. It is hardly fair as yet to draw conclusions, but judicial clinicians seem to be optimistically inclined toward it. Tonic Treatment. More or less emphasis is laid on the value of tonics; and strychnine or nux vomica, phosphates and iron are used as in other conditions which are believed to indicate their use. At the moment of the revision of this work an elaborate study of the chemotherapeutics of Chaulmoogra oil by Walter and Sweeney appeared in which they concluded that the therapeutic action of the drug was due to its "direct antiseptic and bactericidal action on B. leprse." They suggest that the oil or its acid esters like other fats, may well be stored in the tissue until the concentration becomes bactericidal. Surgical Treatment. It is important to evacuate any pus. Sores and mutilations demand the removal of diseased tissue of skin or bone. Amputations, excision of nodules, stretching of nerves for pain, etc., may be necessary. X-Ray treatment is said to reduce the size of the tubercles. Prognosis. So evil a reputation has leprosy borne throughout all history that the impression one receives of the prognosis is of the worst; and yet a study of the disease shows that it is self -limited at any stage and that a mode of life aimed at improving the general health quickens the process of cure more than anything else can do. That death or mutilation is the final issue in most of the cases, how- ever, is all too true. Prophylaxis to the community consists in isolation; to the indi- vidual in avoidance of contact with the secretions and discharges. It has long been noted that long contact seems necessary for infection. Extremely interesting results bearing on this fact have followed upon the work of Duval and Gurd on animals. I quote from their article: "Two factors are of great importance in effecting infection. In the first place, a sufficiently large number of organisms must be employed, and, what is still more important, second and subsequent inoculations are more liable to produce leprous lesions than are the primary injections. LEPROSY 675 "Such preliminary doses, whether they consist of living or dead organisms, produce a condition of hypersensitiveness or allergy which renders it possible by a second injection of viable bacilli to induce the development of a reactionary lesion. Lesions arising as the result of a second inoculation develop more rapidly, increase in size more quickly, and persist for a longer period than those taking place as the result of a single inoculation, even though very large doses are used. Moreover, the bacilli in these lesions are more liable to lead to metastasis and to a generalized infection. We regard the results of these experiments as having considerable bearing upon the development of the disease in human cases, since we find that it is chiefly among those living in pro- longed intimate contact with leprous patients that leprosy develops." (Journal of Experimental Medicine, Aug. 1, 1911.) I have already spoken of the danger to those in contact with patients that arise from secretions, discharges and spraying of coughing, sneezing, etc., and how these secretions should be disposed of. That the naso- pharynx is probably the portal of entry accentuates the precautions that should be taken not to carry the infection by the hands to this locality. The possibility of infection by way of the skin by minute traumata or bites of insects must not be forgotten. It would seem almost unnecessary to mention the dangers attendant on marriage, and the precautions that should be taken in the employment of nurses, wet nurses or others coming into close contact with members of a household who live in an area where leprosy is endemic. Another fact of importance is the remarkable viability of the bacilli leprse, which will survive for months or years in a locality once inhabited by a leper. This makes disinfection of houses and articles subjected to contamination doubly imperative and demands thoroughness. It also emphasizes the importance of colonization. The dead should be cremated; for the leper bacillus has been found viable months after burial. SUMMARY Isolation. By colonization the common method. All secretions and excretions, urine, feces, sweat, milk, sputum, those from the nose, vagina, urethra, all contain the bacillus and should be destroyed by fire or antiseptics. (See Typhoid Fever, Chap. Attendants must remember that the spray of sneezing, coughing and talking can convey the organism. Insects can convey infection. Attendants must give especial attention to their personal hygiene 676 TREATMENT OF ACUTE INFECTIOUS DISEASES Diet. Must be sufficient. Fresh air. Life in the open; sleep in open air. Skin. Must be kept clean by daily baths. Empirical treatment Chaulmoogra oil. Dose. Three or four drops three times a day. Increase a drop or two every three to four days until 100 to 130 drops three times a day are given or until irritability of the stomach prevents. May be given in hot coffee, cordials, milk of magnesia, hot milk, capsules; best before meals. Hypodermically. External use. Under sterile precautions give hypodermic injections of: Camphorated oil .......... ......... 60 c.c. Chaulmoogra oil ................... 60 c.c. Resorcin ........................... 4 Gm. (gr. Ix). M. et S. 1 c.c. each week for three doses. Increase gradually to 3 c.c. once a week. Follow each dose immediately by a bath of 2 per cent, sodium bicarbonate. Rest for one-half hour after bath. Follow each dose by a saline cathartic the next morning. Duration of treatment four to six weeks. (Bercovitz.) Other drugs and measures. Nastin. 1 , Q , , >. Calmette's Serum. J (See tert ') Specific treatment. Leprolin, 10 c.c. intravenously every two to three days. Tonic treatment. Strychnine or Nux Vomica. Iron. Arsenic. Phosphates. Local treatment. Two and one-half per cent, solution of benzoylchloride as nasal spray and as application to leprous ulcers. LEPROSY 677 Surgical treatment. } , , . _ \ (See text.) X-Ray treatment. J v Prophylaxis. Isolation, Avoid contact with secretions and discharges. Thorough disinfection of all objects in contact with a case of leprosy. Dead should be cremated. CHAPTER XXXV ANTHRAX ANTHRAX is a disease that affects peculiarly domestic animals, the horse, cattle, sheep and goats. Many infected hides are now coming into the country from epidemic centres in China, India, Africa, South America and more cases of anthrax are seen than before the recent war. An investigation of the shaving brush industry traced the source of infected hair not only to points out- side the country, but to Chicago as well. The causative agent is the bacillus anthracis, a large spore-bearing organism, and the first shown to have causative relationship to an in- fectious disease. The disease is conveyed to man through contact with animals or their secretions. It may enter and infect the skin through minute wounds or abra- sions, so is most likely to occur on exposed surfaces and in individuals handling the sick animals, their carcasses or hides, wool or hair such as drovers, farmers, veterinarians, butchers, porters of hides, wool sorters, tanners, etc. The skin, too, may be inoculated by the bite of the stable-fly, and by the use of the shaving brush. The lesion is called "malignant pustule." At first a papule, then vesicles and pustules, soon with deep and extensive involvement of the subjacent and adjacent tissues, appear. Or it may take a malignant edematous type in which pustules may be absent or an erysipelatous type, difficult to differentiate from ordinary facial erysipelas without bacterial findings. The external form begins with a minute red, hard pimple at the site of inoculation. This papule becomes a vesicle and is soon surrounded by an area of edema; the vesicle becomes a pustule, turns black and in 36 hours forms a black eschar that gave it the French name charbon. The lymphatics become swollen and painful in 3-4 days. Of the cutaneous lesions those occurring in the head and neck region are especially dangerous and are associated with extensive edema. The mortality in these cases is given at 40-45 per cent, against 12.5 per cent, in upper extremities and 1.2 per cent, in trunk and lower extremities. Characteristic is the freedom from pain, in spite of the extensive ANTHRAX 679 infiltration. Sooner or later, depending on the virulency, the symptoms of general infection follow. It may be rapidly fatal; if not it runs a course of 9 or 10 days. Fortunately the tendency of the disease in man is to remain localized. On the other hand it may enter the body through the air passages or by way of the mouth. Infection of the lungs occurs so commonly among one class of workers that their occupation has given a name to the disease, the "wool-sorter's disease," due,- of course, to inhalation of spores borne in the dust raised by their work in the wool. The course is rapid ; two, three or four days. The symptoms point to an involvement of the lungs but neither subjective nor objective signs are characteristic. Rapid asthenia sets in, followed by death. When the infection is by way of the mouth the intestine is affected. There is a selective action on the lymphatics resembling that in ty- phoid fever. The inflammation is intense with edema and hemorrhagic extravasations and there may be perforation of all the coats with sero- purulent peritonitis. This usually occurs through eating of infected and improperly cooked meat or drinking infected milk, or it may come from food contaminated in the handling or from the patient's hands. It may, however, localize in the intestine by the blood route. This form is rare in man. It is manifested by stormy gastro-intestinal symptoms that resemble a poi- soning or may simulate intestinal obstruction. It is rapidly fatal. One speaks of it as "Intestinal Anthrax." Death follows in two to six days. Treatment. The treatment aims at supporting the patient's strength, as in any other infection, the use of specific remedies, the treatment of the local lesion and the relief of symptoms. As it is only the external form of infection that we can hope to attack with success and that only when seen early, we will begin with a consid- eration of the local treatment. Local Treatment. This is distinctly a surgical problem. It would seem to me that a lesion rife with such fatal possibilities as malignant pustule should have the most radical treatment and that complete ex- cision going well wide of the lesion out into the sound tissues should be practiced. 1 It is universally advised that, in addition, the open wound should be thoroughly cauterized with phenol (liquified carbolic acid) or with actual cautery. In addition, some authors advise injections of carbolic acid into the tissues at several points around the area of excision, as the bacilli on their way to the lymphatics may be harbored there. It 1 Carey reports a cure by this method since the above was written. A. J. M. S., May, 1920, Vol. CLIX, No. 5, p. 742. 680 TREATMENT OF ACUTE INFECTIOUS DISEASES may be used in 3 per cent, watery solution. Others prefer liquified carbolic acid as less likely to be absorbed from the site of injection. There seems to be of late a growing preference for an expectant treat- ment over excision, using bichloride of mercury dressings, boric acid dressings, or alcohol compresses (70 per cent.). Gray ointment has found some favor. Rest to the part affected is of cardinal importance. To give specific direction for excision I cannot do better than borrow from Dudley's article in the Journal of the A. M. A., Jan. 5th, '18. He cleanses the lesion thoroughly with soap and sterile water, rinses with sterile water, paints with 8 per cent, (or stronger) phenol " (1 part of ordinary carbolic acid to 12 parts of water) " and rinsed with alcohol. He then paints the lesion with collodion to prevent contamination of the line of incision. Following this preparation of the pustule, 8 per cent, phenol is injected into the tissues all about the lesion to wall off the infection. This re- quires usually some 6 c.c. One-quarter inch outside the phenolized zone he injects 5 to 6 syringefuls of 25 per cent, alcohol (6-10 c.c.) These, he says, are about 11/2 inches outside the centre of the lesion. The line of incision is painted with 8 per cent, phenol solution and an area 2 1/2- 31/2 inches in diameter excised. After the excision the base and edges are painted with pure 95 per cent, phenol and neutralized at once with absolute alcohol. The skin is cleansed with alcohol and a wet dressing then is applied of boric acid solution 2 to 4 per cent., 20 per cent, alcohol or hypertonic salt solution. If in spite of this, slight edema appears at the angle of the wound, further steps are taken. He injects 3 to 4 syringefuls (6-10 c.c.) of 8 per cent, phenol into the edematous tissue and if this fails to cure incises freely into the line of the edema and puts in gauze drains and injects more 8 per cent, phenol. Finally he applies an ice-bag to the area. Dr. D. F. Dudley in a personal communication says: "I have come to believe that excision of pustules near the eye or nose is always a failure as the region cannot be well prepared with the usual strong antiseptics and since a large amount of tissue cannot be excised in these locations. Lesions about the eye and nose should be walled off with the phenol solution and treated by serum; incisions in the edema but not into the pustule may be made later if necessary and phenol solution again in- jected. I am now preparing a paper on 'The Choice of Treatment' this is necessary because of difficulties in certain locations and because I have found that the age, health, presence of some other trouble such as heart, lungs or high blood pressure are factors to be considered before taking a chance either on serum or excision. I can't emphasize too ANTHRAX 681 much the importance of choosing the cases which shall be excised in- stead of using serum and vice versa." At Camp Hancock, Ludy & Rice have dissected out the lesion with a nose cautery after infiltrating the surrounding tissue with 30-50 c.c. of anti-anthrax serum. The line of incision should go at least 1/2 inch from the border. They dress the wound over in 24 hours with a solution of phenol 3 parts; camphor 7 parts; glycerin 40 parts; and alcohol 180 parts. At Guy's Hospital, following excision, ipecac has been sprinkled on the wound and has been administered at the same time internally. Carbolic Acid. Carbolic acid has been used, too, around the site of the infection and as originally recommended, as often as every hour or even more frequently, 10 to 15 minims of the 3 per cent, watery solution or even the liquified phenol. Hot poultices are applied to the infected area. Bloodgood and McGlannan favor this treatment when excision will result in much mutilation. In one case successfully treated with antitoxin, the local treatment consisted only of soaking in hot bichloride solution and the application of a Bier bandage. As another caustic, caustic potash has been recommended. The wound is dressed with a wet dressing. Specific Treatment. Serum from immunized sheep or asses has been used in the treatment of animals and more lately of man. In the cases reported 30 to 80 c.c. of the serum was used daily both intra- venously and subcutaneously. One should favor liberal doses. Ludy and Rice give 75 c.c. of anti-anthrax serum with 50 c.c. of physiological sodium chloride solution intravenously and 75 c.c. of the serum intramuscularly. The serum is repeated every 8 hours, if needed. Dudley, using the serum furnished by the U. S. Bureau of Animal Industry gives 35 c.c. intravenously for the first dose, followed in 8 to 16 hours by a second intramuscularly or intravenously; this is repeated if necessary. Raj an continued local treatment with intramuscular some 50 c.c. at first, somewhat smaller doses on such succeeding days as serum is in- dicated. At Bellevue in some of the cases 40 c.c. of serum was given into the vein every four hours and into the tissues about the pustule about 10 c.c. in multiple punctures of 1/2 to 1 c.c. each, thus thoroughly infil- trating them, at 4-hour intervals. This seemed fairly effectual. The serum may be obtained from the Department of Agriculture. 682 TREATMENT OF ACUTE INFECTIOUS DISEASES The specific serum should be injected about the pustule or if excised in the adjacent area. One uses an antitoxin needle and syringe. The needle is inserted just outside the margin of the lesion and directed toward the subcutaneous tissue at the base of the eschar, using 10 to 15 c.c. of the serum. This is done, of course, with intravenous and intramuscular administration of the serum. The general mortality in a considerable series not receiving serum was given as 27 per cent., but may be very much higher in individual series. The results reported certainly make the use of the serum impera- tive. The mortality has been lowered to 6 per cent, or less by the use of serum. There has been much controversy as to what constitutes the specific- ity of the serum. By some it is maintained that the results are due merely to the reaction provoked by any foreign protein, provocation of leucocytosis, possibly a mobilization of ferments, the phenomena of the so-called shock therapy; for this reason, other non-specific sera have been advocated, especially normal beef serum, which seems to be less likely to provoke disagreeable reactions than horse serum. The methods have been by hypodermic injection or in severe cases or septi- cemic cases intravenously. The dose is 10-30 c.c. or more. I should incline to more liberal dosage, as the amount administered does not determine toxicity, and to frequent administrations, daily or oftener in severe cases. The reaction will be a sharp rise in temperature, leucocytosis, then a fairly prompt fall of temperature below the level determined before the injection, with an improvement in symptoms general and local. (Hyman & Levy.) Graham and Detweiler in one successful case of septicemia, with recovery of the organism from the blood, made use of chloramin-T (Dakin) intravenously with the serum. They used 100 c.c. of the chloramin-T and 80 c.c. of the serum. They attributed much of the good results to the use of the chloramin-T. I have had no personal experience with this method. See Jour. Am. Med. Asso., Mar. 9, 1918, p. 671, Vol. 70, No. 10. When constitutional symptoms are manifest, as they are from the beginning in internal anthrax and as they are after a greater or less period in malignant pustule, supportive treatment should be vigor- ously begun. This, of course, means rest in bed in a room chosen with a view to convenience and ventilation and one where isolation may be main- tained. ANTHRAX 683 If this room is accessible to porch, verandah, or lawn, where open-air treatment may be maintained, it is a distinct advantage. The body should have proper attention, such as baths for cleanli- ness, care of mouth, nose, genitals, attention to pressure points, in other words all that pertains to good nursing. (See Typhoid Fever or Pneumonia.) Especial attention should be given to the destruction of discharges from the pustules and the secretions and the excretions of the body, which contain the anthrax bacilli. The diet should be sufficient and based on the same considerations as determine the dietary in other acute infections. (See Diet in Acute Febrile Conditions, Chap. II.) The severity and stormy course of the infection in internal anthrax and the violence of gastro-intestinal symptoms in the intestinal form of anthrax, will, of course, modify these rules considerably. Symptomatic Treatment. The temperature is rarely high and requires no consideration, per se. Sooner or later the circulation begins to wane and stimulation be- comes necessary. To the failure of vaso-motor centers such drugs as caffeine or camphor are directed, in doses of gr. v (0.33 Gm.) at two to four hour intervals, the former as a soluble salt of sodium sali- cylate or benzoate and the latter in oil, 10 per cent. Both are used under the skin or better still into the muscle. Strychnine may also be used in doses of gr. 1/40 to gr. 1/30 of the sulphate (0.0015-0.002 Gm.) at three to four hour intervals. To support the heart, digitalis in sufficient doses, gr. ix to gr. xii (0.6-0.8 Gm.) a day of the leaf or its equivalent of the tincture 3iss. to ii (6-8 c.c.) or of the infusion fresh 5iss.-ii (45-60 c.c.) until results are obtained or 30 or 40 grains have been given. From this point pro- ceed cautiously with 3 to 6 grains a day. If the need is urgent strophanthin into muscle or vein gr. 1/120-gr. 1/60 (mg. 1/2 to 1), followed by digitalis. It is my belief that in the circulatory failure of any acute infectious disease digitalis or strophanthin is far more valuable than any of the stimulants named. Headache may be relieved by the ice-bag; restlessness and sleep- lessness by codeine phosphate gr. 1/4 to gr. ss. (0.015-0.030 Gm.) or if severe, by morphine sulphate gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.). In- somnia may be relieved by chloral gr. x to gr. xv (0.66-1 Gm.), if the circulation is not impaired. Vomiting will require cessation of food or small quantities of liquid food, cracked ice, sodium bicarbonate or bismuth subnitrate in gr. x to 684 TREATMENT OF ACUTE INFECTIOUS DISEASES gr. xv (0.66V1 Gm.) doses or oxalate of cerium gr. v to gr. x (0.33-0.66 Gm.) or a combination. Diarrhea will need the administration of large doses of bismuth gr. xxx to gr. Ix (2-4 Gm.) every two hours, or opium gr. 1/4 to gr. ss. (0.015-0.03 Gm.) at the same interval or starch enema with opium as tincture m. x to m. xv (0.66-1 c.c.). Delirium will demand restraint, the use of morphine or chloral in doses given or hyoscine hydrobromide gr. 1/200 to gr. 1/150 (0.00030- 0.00045 Gm.). Convulsions demand the use of inhalations of chloroform during the attack and morphine and chloral between. Prophylaxis. Successful stamping out of the disease in man can only be accomplished by stamping it out in animals. Up to 1917 the U. S. Department of Agriculture had not succeeded in finding an efficient and practical disinfectant for hides. (Brown & Simpson.) Certainly more care should be given to disinfection of tools, utensils and vats in tanneries. Instructions should be given to the handlers of hides. Infected animals should be killed and remembering that the spores are peculiarly resistant and that they are aerobic it is important to disturb the carcasses as little as possible and to bury them deep. This same resistance of the spores and the fact that they are ex- creted in urine and feces make it difficult to stamp the disease out of the fields in which the infected animals have been pastured. It must be remembered, too, that these fields are a menace to healthy animals. SUMMARY Treatment of malignant pustule. Complete excision, well out into sound tissue. Cauterize this open wound with liquified phenol (liquified carbolic acid) or with Actual cautery. Carbolic acid either liquified or m. x to m. xv (0.60-1 c.c.) of 3 per cent, watery solution has been injected all about the excised area. Another method Injections of phenol as above about site of infec- tion. Poultice to the infected area (Bloodgood and McGlannan). Wound is dressed with wet dressing. Dudley's method. (See text.) - Specific treatment. Serum 30 to 80 c.c. daily under the skin or into vein. ANTHRAX 685 Bellevue Method: 40 c.c. intravenously every 4 hours 10 c.c. every 4 hours into tissue about pustules given in multiple punctures of one to one-half c.c. Serum from Department of Agriculture. When constitutional symptoms are manifest. Rest in bed. Room. Cool, light, well ventilated. Bed. Hospital type. (See Typhoid Fever, Chap. XIV or Pneumonia, Chap. IX.) rom pustules, secretions and excretions must be de- Care of body. Daily bath. Mouth. Nose. Genitals. Bed-sores. Discharges stroyed by fire or disinfected. (See Typhoid Fever, Chap. XIV.) Diet. (See Chap. II.) Circulation. Digitalis. Strophanthin. Caffeine. Camphor. Strychnine. (See text, or Pneumonia, Chap. IX.) Headache. Ice-bag. Restlessness and sleeplessness. Codeine phosphate, gr. 1/8-gr. 1/4 (0.008-0.015 Gm.). Morphine sulphate, gr. 1/8-gr. 1/4 (0.008-0.015 Gm.). Chloral, gr. x-gr. xv (0.60-1 Gm.). Vomiting. Stop food. Cracked ice. Mustard paste to epigastrium. Bismuth subnitrate, gr. xv (1 Gm.). Sodii bicarbonate, gr. x (0.60 Gm.). Cerium oxalate, gr. v (0.30 Gm.). 686 TREATMENT OF ACUTE INFECTIOUS DISEASES Diarrhea. r Bismuth subnitrate, gr. xxx-5i (2-4 Gin.) every two hours. Opium, gr. 1/4 (0.015 Gm.) every two hours. Starch enema with tincture of opium m. x-m. xv (0.60-1 c.c.). Delirium. Restraint. Morphine sulphate, gr. 1/8-gr. 1/4 (0.008-0.015 Gm.). Chloral, gr. xv (1 Gm.). Hyoscine hydrobromide, gr. 1/200-1/150 (0.0003-0.00045 Gm.), Prophylaxis. Kill infected animals and bury their bodies deep. Avoid use of infected fields. CHAPTER XXXVI GLANDERS OR FARCY THIS disease is peculiarly common among horses and the horse kind, and is communicated by them to man; so that it is in hostlers, drivers, farmers and others in intimate contact with the horse, the mule or the ass that the disease is found. The causative agent is the bacillus mallei, which is found in the purulent discharges and in the secretions from the infected mucous membranes and is inoculated into the air-passages or skin abrasions in man. There is a difference of opinion as to whether it may enter through the unbroken skin. When the infection is received through the air-passages and the lesion is internal it is called Glanders; when through the skin and the lesion is external it is called Farcy. The local effect of the bacillus is the formation of nodules of an inflammatory character, which break down and form pustules and ulcers, whose discharges carry the infection. The disease may run either an acute or chronic course; so that we have Acute or Chronic Glanders and Acute or Chronic Farcy. Treatment. The disease is a toxemia with local manifestations and the treatment that which is applicable to all infections, i. e., meas- ures aiming at the support of the body in its contention with the dis- ease, specific treatment, if there be any, attention to the local lesion and relief of distressing or dangerous symptoms. For the first, rest in bed, with consideration for all that constitutes rest, good nursing, good room, quiet and mental rest, a sufficiency of diet and fresh air, preferably in the open, meet the demands. (See Treatment of Acute Febrile Conditions and Diet in Fever, Chaps. I and II.) The mortality of the disease is high, but, as would be expected, least in the chronic form and when confined to the surface of the body, chronic farcy. Chronic Farcy. The picture is that of a pyemia, in which the local lesion may precede or follow the toxemia, with, sooner or later, multiple abscesses, ulcers and fistulae slow in progress and perhaps with improvement followed by relapse, and death from emaciation, 688 TREATMENT OF ACUTE INFECTIOUS DISEASES asthenia and- overwhelming by poisons; or at any time acute glanders intervenes and hastens the fatal issue. Besides the supportive treatment specified, above one turns to the use of those substances that in a sense may be termed specific, as con- tributing to Nature's own efforts and in the same terms. Unfortunately, the results are but little encouraging, and yet any assistance in so dread an infection is welcome. Of such agents one may mention mallein. Mallein is a toxin obtained from the bacillus mallei much as tu- berculin from the tubercle bacillus and has many parallelisms with the latter. Its particular usage is as a test for the presence of the infection, used like tuberculin for a kindred purpose and provoking like the latter in a true case a febrile response and a local reaction. Like tuberculin, too, it has been suggested as a curative agent, pro- voking in graduated doses increasing response in the tissues in terms of immune bodies. Definite rules of dosage cannot be laid down, but advice should be sought from State or Municipal Laboratories preparing the same and acquainted with the reaction obtained in animals. Few have used it, and their praise is qualified. Vaccines. More hopefully one turns to the use of vaccines and though the reports of successful cases are scanty, nevertheless some have been noted by competent observers. Park (Forchheimer's Therapeutics of Internal Diseases) advises 20,000,000 as a beginning dose and gradual increase up to 200,000,000 or more at four or five day intervals. Dosage is governed by reaction as in use of other vaccines; i. e., by fever, local redness about site of injection or lighting up of local lesions. A moral obligation to familiarize himself with the theory and prac- tice of vaccine therapy rests on the man who uses an agent, which used carelessly is potent to convert a local process into a hopeless general one. (For words of warning, see Theobald Smith, Jour. Am. Med. Association, May 24, 1913.) Serum reactions, used as diagnostic tests, such as the agglutina- tion test and the complement fixation test, bespeak the presence of immune bodies, which together with the results in establishing immu- nity in animals by vaccines encourage the use of serum of immunized animals as a curative agent but unhappily the hope elicited has not been sustained. Treatment of the Local Lesions. The word of warning not to convert a local lesion into a generalized infection has been well given, for too vigorous curettage or rough handling may break down or thin GLANDERS OR FARCY 689 the walls of abscess or ulcer, nature's barriers, to the defeat of her in- tent to localize the infection by these means. Abscesses as in other conditions should be incised and evacuated, thoroughly irrigated and a strong antiseptic applied, but not roughly rubbed about. Liquified phenol (carbolic) is a suitable substance and this may be followed by alcohol to remove the excess. Wet dressings of bi- chloride may be used or iodoform gauze or tincture of iodine and a light packing of gauze to keep the wound open. Ravenel in Osier's Modern Medicine advises as a caustic a 1 to 10 solution of chloride of lime. If the lesion is small and well localized excision is advisable. Chronic Glanders. Less hopeful than chronic farcy, indeed, al- most hopeless is this condition in which the upper air-passages and the lungs are involved, coming on in the majority of cases as a result of the chronic farcy. The treatment is, of course, the same, except that not as much can be expected from the vaccines and still less from the use of mailein. The nose with its ulcerations, necrosis of bones and sinus involve- ment calls for local treatment, irrigations of saline solutions, boric acid or in the case of much necrotic tissue irrigations with permanga- nate of potash solution, of a deep claret color or applications of per- oxide of hydrogen. Insufflations of iodoform have been suggested. The annoying cough may be alleviated by inhalations of steam or medicated with compound tincture of benzoin, oil of pine, creosote, or eucalyptus. A teaspoonful or two may be added to the inhaler or a perforated zinc inhaler (Robinson's) may be worn over nose and mouth with some mixture as creosote, chloroform and alcohol equal parts, 10 to 15 drops on the sponge of the inhaler. Later codeine sul- phate or phosphate in doses of gr. 1/8 to gr. 1/2 (0.008-0.030 Gm.) at two or three hour intervals may be demanded and still later and especially with the distressing dyspnoea morphine sulphate gr. 1/12 to gr. 1/8 (0.005-0.008 Gm.) at four-hour intervals. Acute Farcy. Here both local and general symptoms are so severe that life is despaired of. The picture is one of acute septic poisoning, and intense local infection, erysipelatous or forming ulcers, like gan- grene and widespread pustular eruption. Acute glanders presents the same picture as acute farcy with the additional distress attendant upon involvement of the air-passages. Beside the supportive treatment and relief of symptoms, nothing can be added; for vaccines here can do no good. Circulatory and respiratory needs are met by the use of caffeine, 690 TREATMENT OF ACUTE INFECTIOUS DISEASES camphor, atropine, digitalis or strophanthm as in other infections, but are used rather with a feeling that an effort to do something is better than laissez aller; though from the patient's standpoint that is doubtful. Doctor and nurse should remember that the discharges of the patient are infectious and take precautions accordingly, by burning all discharges and thoroughly sterilizing by heat or strong solutions of carbolic acid clothes and linen contaminated with them; by steril- izing the dishes and implements used by the patient. (See Typhoid Fever, Chap. XIV.) Gloves should be used in doing dressings and handling discharges. Isolation. Acute cases should be carefully isolated and every warning given of the danger of too close contact even in the chronic cases. Prophylaxis. As the disease is always conveyed by the horse, the appreciation of the disease in this animal is of first importance and a skillful veterinarian is often necessary to detect the latent cases. Barnett Cohen 1 advises as an efficient disinfectant of horse troughs the use of hypochlorite of Calcium (i. e., Chloride of Lime). He maintains that two parts of available chlorine in a million in the trough over night will disinfect even in the presence of much organic matter. Infected animals should be killed and the stables carefully disin- fected and the other horses tested from time to time to detect further infection. Individuals handling horses known to be infected should use gloves and if inoculation is known to have occurred excision of the site is advised. SUMMARY Isolation. Must be carefully observed. Doctors and nurses. Should wear gloves. Avoid spray of cough. Destroy all secretions by burning or disinfecting. Disinfect all articles used about the patient. (See Typhoid Fever, Chap. XIV.) 1 Dissolve 0.3 Gm. of Chloride of Lime in some distilled water. Then filter and titrate this stock solution before using each time with standard sodium thiosul- phate N/10 to determine the available chlorine. GLANDERS OR FARCY 691 Chronic farcy. Specific treatment. Mallein. (See text.) Vaccines. Begin with 20,000,000 and increase up to 150,000,000 or 200,000,000. Give every four or five days. Dosage and frequency governed by reaction. Treatment of local lesions. (Read text.) Incise and evacuate. Abscess. Irrigate. Apply liquified phenol (carbolic acid). Apply alcohol to remove excess of phenol. Pack wound with wet dressing of bichloride, or iodoform gauze. Excise, small, well localized lesions. Chronic glanders. Specific treatment, as above. Care of nose. Irrigation with saline, 0.6 per cent. (3i to Oi, 4 Gm. to 500 c.c.) or 2 per cent, or 4 per cent, boric acid solution. If much necrosis Irrigate with permanganate of potash; make solution of rich claret color (1:5,000). Apply peroxide of hydrogen. Iodoform, insufflated has been recommended. Cough. Inhalations of steam, medicated with one of the following Compound tincture of benzoin. Oil of pine. Creosote. Oil of Eucalyptus. A good formula is 3i or ii (4-8 c.c.) on the water of an inhaler. Alcohol, Chloroform, I equal parts. Creosote, S. gtt. v-x on sponge of a Robinson's inhaler (perforated zinc inhaler for nose and mouth) . Codeine sulphate or phosphate, gr. 1/8 to gr. 1/2 (0.008-0.030 Gm.) every two or three hours. Morphine sulphate, gr. 1/12 to gr. 1/8 (0.005-0.008 Gm.) every four hours. 692 TREATMENT OF ACUTE INFECTIOUS DISEASES Acute glanders and Acute farcy Relief of symptoms, as above. Circulatory stimulants. Digitalis. Strophanthin. Caffeine. Camphor. (See Pneumonia, Chap. IX.) Respiratory stimulants. Caffeine. Atropine. Strychnine. Prophylaxis. Killing of infected horses. Disinfecting stables. Testing all animals in contact with sick horses. Wearing gloves in handling sick horses. Excise site of any inoculation. Disinfection of horse troughs. (See text.) CHAPTER XXXVII FOOT AND MOUTH DISEASE (APHTHAE EPIZOOTICAE) ' THIS is essentially a disease of animals, but may include man among its victims. It is extremely infectious. Among animals cattle are the most susceptible; hogs, sheep and goats next; horses, cats and dogs occasionally; certain fowl rarely. Commonly severe among animals, it is relatively mild in man, though there are unfortunately exceptions to this rule. The cause is as yet unknown, no organism proven definitely re- sponsible for the disease having been isolated. The virus has been shown to pass through a Berkfeld filter; hence, is to be classed as ultramicroscopic. It occurs more frequently in Summer than in Winter. The incubation period is put in Osier's Modern Medicine from two to ten days. It begins in man with a fever and other signs of toxemia. There may also be a gastro-intestinal catarrh, especially in children. The mucous membrane of the mouth is swollen, reddened and glazed. The palpebral conjunctive and mucous membrane of the genitals are also involved and in two or three days there appears the characteristic vesiculation in the mouth and between the fingers and toes and fre- quently on the dorsal surface of the hands and feet that gives the name to the disease. These vesicles contain clear serum, which later becomes cloudy and is extremely infectious. They heal without a scar. Saliva- tion accompanies the vesiculation in the mouth. Immunity is said to be very short lived. Recurrences have been noted in 10 to 12 days. Clough, whose article on this condition in the Johns Hopkins Bulle- tin of October, 1915, I especially recommend, epitomizes the disease as follows: "A mild febrile infectious disease, characterized by the appearance of an erythema and a superficial vesicular eruption over the mucous membrane of the mouth and on the skin of the hands and feet; by salivation, by swelling, burning and paraesthesias of the affected parts, with subsequent desquamation; and by healing of the ulcers without scar formation." With the appearance of the eruption the temperature declines. Treatment. There is no specific remedy; so the treatment re- 694 TREATMENT OF ACUTE INFECTIOUS DISEASES solves itself into efforts at relieving the effects of the toxemia and the ulcerations in the mouth and on the skin. The same principles are applicable in this as in other* infectious Rest in bed with the choice of a comfortable narrow bed and firm mattress and a room capable of thorough ventilation and accessible to the sun. Isolation. The disease is contagious, so only those who minister to the needs of the patient should be admitted. Physicians and nurses should use gloves in handling the patient, treating the ulcers and handling the secretions. These latter should be burned. Articles coming in contact with the patient such as thermometers, dishes, bed-pans, urinals, bed clothing, should be handled as in other infectious diseases. (See Typhoid Fever, Chap. XIV.) Diet. Feeding is difficult on account of the condition of the mouth; the ulcerations affecting it in particular and extending into the pharynx, oesophagus, the larynx and trachea. This, of course, makes chewing and swallowing very difficult. The food should be liquid or of nearly fluid consistency and con- centrated; milk, and milk fortified with milk sugar and cream, say an ounce of each to each glass of milk and soups made of milk and farinaceous flours or cereals, cereal jellies and eggs, may be taken as the basis of such a dietary. It may be necessary to use the stomach tube or nasal tube or have recourse to rectal feeding, especially in children or illy nourished in- dividuals. Water should be given freely. It must be determined that the milk does not come from infected sources and if there is an element of doubt it should be boiled. Fever is rarely high or long continued. If any antipyretic measure is used at all, hydrotherapy in the shape of cold sponges offers the only legitimate one. Daily sponge baths for cleanliness should always be given. Circulation. Evidences of faltering circulation should be met by the same measures used in other infections. (See Pneumonia, Chap. IX.) Care of Mouth. This is of the most vital importance for here a fatal sepsis may begin or pain and discomfort sacrifice nutrition to the danger point. The best means of keeping the mouth in condition is by abundant irrigations of warm saline solution (see Scarlet Fever, Chap. XVII), or one may use boric acid 2 per cent, or quarter strength DobelTs FOOT AND MOUTH DISEASE 695 solution. This should be done after each feeding and it were well to give a small irrigation before a feeding on account of the abundant secretions from the salivary glands gathering in the mouth and on account of the detritus from the ulcers. This is especially important in the morning. Food must be removed from the dead spaces between the gums and teeth by swabs on wooden toothpicks or other applicators; one of the above solutions is used to moisten the sponges. The best treatment for the ulcers is to touch each with silver nitrate stick or with small swabs wetted with 25 per cent, to 50 per cent, silver nitrate. If the mouth is very foul one may irrigate with permanganate of potash solution made to a deep claret color (1: 5000). Chlorate of potash solutions may be used as mouth wash or gargle, 1 per cent, to 2 per cent., or if painful, of lesser strength. The nose, too, must receive similar attention. In severe cases the palpebral conjunctiva may be involved. Eye washes of boric acid solutions 2 per cent, to 4 per cent, should be used and if there is much swelling and pain, cold compresses, using the same solutions, may be applied. Vesicles and Ulcers of Skin. These are usually confined to fingers and toes and region of mouth and nose, but in some cases may be more generally distributed. The ulcers are usually shallow. Drying powders, like sterile tal- cum powder, is best used on vesicles and ulcers or such a powder as aristol on the latter. If there is annoying itching those measures recommended for the same condition in Varicella, Measles and Small Pox may be applied. (See Chaps. XXI, XIX, XXVII.) It must be remembered that the contents of these blebs are con- tagious. Gastro-enteric Symptoms. These at times may be severe with much colicky pain and diarrhea. A thorough cleaning out with castor oil followed by small doses of the oil m. x (0.65 c.c.) every two hours or by bismuth subnitrate 3ss. (2 Gm.) every two hours with local applications of heat to the abdomen may relieve the distress, or small doses of opium may be necessary, m. i (0.06 c.c.) of deodorized tincture, every two hours. The duration is about two weeks, though it may last somewhat longer. Death is not a common issue except among sickly children. Prophylaxis. The disease is transmissible through the contents 696 TREATMENT OF ACUTE INFECTIOUS DISEASES of the vesicles of diseased animals and through the saliva, also through the milk or the products of milk, e. g., butter, cheese and cream of diseased animals; hence, workers about animals and children drinking the milk are peculiarly prone to contract the disease, and, as might be expected, the mouth is first affected in those drinking the milk. Cattle affected should be killed and a thorough disinfection of the stable, etc., follow. Suspected milk should not be drunk or should be sterilized and all suspected meat destroyed. SUMMARY Treatment. Local, of ulcerations in mouth and skin. General, to relieve effects of toxemia. Rest. Bed, hospital type preferred. Room, well ventilated and lighted. Quiet. Isolation. Physicians and nurses wear gloves in handling patient and secre- tions. Treatment of objects in contact with patient and of secretions. (See Typhoid Fever, Chap. XIV.) Diet. Liquid or of fluid consistency. Milk, whixjh may be fortified with sugar or cream. Soups of milk, cereals, farinaceous flours. Cereal jellies. Eggs. Avoid milk from infected sources, or if in doubt boil it. May have to use stomach or nasal tube or have recourse to rectal feeding. Water, give freely. Bowels. Initial dose of castor oil 5ss. to i (15-30 c.c.) preferred if there is diarrhea, or a salt gss.-i (15-30 Gm.). Fever. Rarely requires interference, or at the most cool sponges. Circulation. (See measures used in Pneumonia, Chap. XIV.) FOOT AND MOUTH DISEASE 697 Care of mouth. Abundant irrigations of warm saline (see Scarlet Fever, Chap. XVII) or of 2 per cent, boric acid or quarter strength Dobell's solution. Well to precede feeding by a lesser irrigation; especially in the morn- ing. Swabs or toothpicks wetted with solutions mentioned to free dead spaces between cheeks and teeth and interstices of teeth from food. Ulcers of mouth. Touch with silver nitrate stick or 25 per cent, to 50 per cent, silver nitrate solution. Chlorate of potash solution, 1 per cent, to 2 per cent., as a mouth wash. If mouth is foul, Permanganate solution of a rich claret color 1 :5000. Nose. Cleansed with saline, boric acid or Dobell's solution. Eyes. Boric acid solutions 2 per cent, to 4 per cent, as eye-washes. Cold compresses of boric acid solutions, 2 per cent, to 4 per cent. Vesicles and ulcers of the skin. Drying powders or aristol. (For itching see Small Pox and Varicella, Measles. Chaps. XXVII, XXI, XIX.) Gastro-intestinal symptoms. Colicky pains. Hot fomentations. Diarrhea. Preliminary dose of Castor oil 5ss.-i (15-30 c.c.). Follow by castor oil in small doses, m. x (0.65 c.c.), every two hours. Bismuth subnitrate, gr. xxx (2 Gm.), every two hours. If much pain. Opium, deodorized tincture, m. i (0.06 c.c.) every two hours. Prophylaxis. (See text.) CHAPTER XXXVIII PSITTACOSIS THIS is a disease incurred from parrots, resembling an atypical, pneumonia; atypical in its physical signs and in its course, and Osier says characterized by an onset like typhoid fever. An organism belonging to the hog-cholera group was isolated by Nocard and shown by him to precede the disease in other parrots and other animals. The incubation has been set as short as a week and as long as three weeks or more. The diagnosis is made when a case and especially several cases occur in a family where there are sick parrots. It is to be treated like any pneumonia, especially bronchopneu- monia, and the same considerations of choice of room, bed, diet, air and attention to the circulation with relief of annoying symptoms obtain in the one as in the other. (See Pneumonia, Chap. IX.) The disease in cases that get well runs from two to three weeks. The disease is a severe one as the mortality of 35 per cent, to 40 per cent, indicates. Prophylaxis. Caution in handling sick parrots and disinfection of cages and utensils in contact with the bird. Isolation of patient, destruction of secretions, especially bronchial secretions. SUMMARY Treat like a Pneumonia. (See Chap. IX.) CHAPTER XXXIX RABIES (HYDROPHOBIA) THIS disease, relatively rare in the experience of the individual practitioner, when once encountered, leaves on his mind a more indeli- ble stamp of horror than any other he will meet. It is conveyed to man in the vast majority of instances through the bite of the dog. It is true that all mammals are susceptible to it and that here and there on the earth's surface other animals than the dog may play a leading rdle in its transmission, as the wolf in Russia. In this country as high as 4 per cent, has been attributed to the cat, while skunks and horses are to be remembered as sources of rabies. The virus is transmitted by the saliva of the rabid animal and, like tetanus toxin, has an especial affinity for the nervous system, entering the nerve endings at the site of the wound, travelling by the nerve trunks to the spinal cord and by the cord to the medulla and brain, unless the wound be on the face, whence the route to the brain struc- tures is more direct. In respect to its route and in respect to the vari- ability of its incubation period which depends on the length of the route travelled to the central nervous system, it finds in tetanus toxin a close analogue. The source of the virus is probably but not certainly known. Its incubation period and its multiplication in the animal body demands a living organism as its origin. The so-called Negri bodies, charac- teristically present in the nerve centres, and now recognized as the pathological criterion of the disease, are probably the infecting or- ganisms. Competent authorities are inclined to place these bodies among the protozoa and, indeed, to fix them more definitely in sub- orders and families of this kingdom. In the nervous system they are especially readily found in the cere- bral and cerebellar cortex, in the hippocampus major (in the horn of Ammon) and in the corpus striatum (in 98 per cent, or more). Less than 10 per cent, of men bitten by rabid dogs develop hydro- phobia and yet every man developing the disease is doomed to die. What determines on the one hand this relative immunity and on the other the fatal virulency is one of several puzzling problems this disease 700 TREATMENT OF ACUTE INFECTIOUS DISEASES has offered to the student of infections. ..The pathological studies of Paltauf have given reason to believe that the immunity of the 90 per cent, is not due to failure of infection, but to the operation of an unknown mechanism of defense in the central nervous system which is efficient before symptoms arise or fails utterly. (For resume of these studies, see Editorial on Pathology of Rabies in the Journal of the American Medical Association, May 14, 1910.) Incubation. As in tetanus the length of this period depends on the time taken to pass by the nerve from periphery to centre; hence, the length of the nerve trunk, or in other words, the site of the wound. For this reason the incubation period after bites on the face or head is much shorter than bites on the extremities. Moreover some other factor operates to delay the incubation in some cases, lengthening out to months and even a year or more. It may be as short as fourteen days. The average is set by some authors as forty days, but eight to twelve weeks is common enough. When a man is bitten by a dog suspected of rabies our procedures are: 1. Immediate treatment of the wound. 2. Confirmation of the suspicion. 3. Preventive, antirabic or Pasteur treatment. Treatment of the Wound. When there is the least suspicion of the dog the wound should be treated drastically by cauterization. Lacerated bites are worse than others; bites on exposed surfaces more dangerous than those through clothes; for in these much saliva may be rubbed off the teeth; bites on the face or head are more to be feared than those on the extremity, especially, because of the short- ness of the incubation period, and the virulency varies in different animals; wolves are the worst (infection as high as 60 per cent.), and cat's bites are said to be more virulent than those of dogs. No con- siderations, however, of "more" or "less" dangerous should modify the thoroughness of the local treatment. The wound should be thoroughly laid open, especially punctured wounds, bleeding encouraged, or when seen immediately after the bite, may be sucked (a procedure not absolutely free from danger, but still a very slight risk) . The wound should be thoroughly washed and liberally bathed with an antiseptic like bichloride 1 to 1,000, then wiped dry and cauterized. There is a consensus of opinion that fuming nitric acid is the best caustic for this purpose. It may be applied on a glass rod or other suitable applicator and should search all parts of the wound thor- RABIES 701 oughly. When the pain of the procedure, as in children, might lead one to sacrifice thoroughness, it is well to use a general anaesthetic or a local, as cocaine. After the application of the acid the wound may be washed with a physiological salt solution or a saturated solution of bicarbonate of soda and with alcohol. Park says that wounds so treated by the acid, contrary to general opinion, heal well and with little scarring. There is experimental evidence to show that this caustic lessens the incidence of rabies after infection. Other caustics, inferior, but still of value, when nitric acid cannot be had are phenol (carbolic acid), and tincture of iodine. Phenol should be used full strength (95 per cent.) and as thoroughly as the nitric acid. After the cauterization, the excess should be removed by swabbing with absolute alcohol. Bloodgood and McGlannan (Musser and Kelly, Practical Treatment) use first the carbolic, follow it by the fuming nitric acid and then wash the wound with a saturated solution of bi- carbonate of soda. Of the two other caustics mentioned my preference would be for the tincture of iodine. Gumming (Journal American Medical Association, May 18, 1912) prefers 5 per cent, formaldehyde applied to the wound twelve hours to either phenol or nitric acid. The actual cautery has also been used. Nitrate of silver is useless. After the cauterization a dry dressing is applied. If the wound suppurates it is to be treated as from any other cause, kept open and dressed. The sooner the wound is treated the more efficient will be the pro- cedure; this does not mean, however, that the wound should not be so treated, if seen later. In fact, it should be the routine, scabs on older bites should be removed, the wound cleansed and cauterized as above. Rosenau, calling attention to the length of time the virus may remain latent in the wound, suggests, with reason, the excision of the scab and treatment of the wound as an open one. In fresh/ wounds on the extremity a tourniquet may be advisable until the wound can be cauterized. If the wound is sucked, the mouth should be carefully and thor- oughly rinsed with antiseptic solutions. Confirmation of the Diagnosis. If the animal manifest the symp- toms of rabies, the head should be sent to the laboratory for pathological examination and the preventive treatment be begun at once, because a failure of pathological diagnosis should not controvert a clinical diagnosis where the price of an error would be so terrible. 702 TREATMENT OF ACUTE INFECTIOUS DISEASES When the,animal has disappeared and cannot be found, an unwar- ranted attack by the beast should indicate the treatment, while, of course, a provocation of an animal apparently of a normal behavior weighs against the advisability of the measure. Where any doubt exists, however, the patient should receive treat- ment. When the animal is secured and shows no evidences of rabies he should be confined for at least three weeks. But if rabies has occurred recently in the locality, the treatment should be given in the mean- time. If no symptoms develop in this time the danger may be considered past and the Pasteur Treatment unnecessary (Rosenau, Preventive Medicine and Hygiene). Of course, if symptoms of rabies develop at any time during this period of observation treatment should be begun at once. When the wound is on the extremity in an adult the prolonged period of incubation furnishes enough time to establish immunity by the treatment, but when the wound is in a child and more especially on the face or upper extremity the shortened period of incubation makes every day's loss during this term of observation a source of increasing anxiety, but if symptoms in the dog do appear, it will be too late to establish immunity. Animals in the early stages of rabies are prone to lick their mas- ter's hand or face and while the probability of infection by these means are not comparable to that following a bite, the mere fact that Park (Forchheimer, Therapeusis of Internal Diseases) can cite at least eight fatal cases to his knowledge following this mode of infection makes his advice to take the treatment almost an imperative command. Shooting of a dog before symptoms are obvious defeats the diag- nosis, pathological as well as clinical. Symptoms of Rabies in the Dog. The earliest evidences of the disease are perhaps manifested in a change of disposition of the dog; he is unlike himself, secretive, hiding himself, irritable, uneasy and rest- less, abstracted, destructive of objects, apt to run away from home and later bites without provocation, a striking symptom in a gentle dog. A change in the timbre of the voice is very significant. In two to four days the furious delirium hi which the dog attacks man and animals and objects, followed by paralysis, occurs, or the paralytic stage ensues without that of furious delirium (dumb rabies). Unlike the human being the rabid dog has no fear of water. The dog dies in a week or less from the first appearance of symptoms. Two popular beliefs are to be combated; first, that a rabid animal RABIES 703 always froths at the mouth, and second, that rabies is confined to the hot "dog days" of summer. Preventive Treatment. Had Pasteur contributed nothing more to human welfare, his work on rabies alone would have raised for him a sign to all time ten-thousand fold better than a "monumentum acre perennius." The essence of his discovery was that the virus of rabies, localizing in the nervous system could, under certain conditions and environ- ments, be so modified in its virulency as to be used in other animals to provoke the mechanism of defense to the active production of im- mune bodies; in other words, to establish immunity; and that, too, with an expedition that forestalled the multiplication of the virus already introduced to a degree dangerous to the patient. Improvements in technique have been engrafted on his treatment, but it fundamentally remains the same to-day as when he de- vised it. Pasteur first used the virus attached to the nerve tissue of rabid dogs brought in from the street and to this kind of virus has been given the designation of "street" virus. He soon found that the virulency of this "street" virus was variable and that rabbits injected with it showed an incubation period of fourteen to twenty-one days. In his effort to overcome this variability he found that running it through rabbits, that is, dog to rabbit and then rabbit to rabbit, it became progressively more virulent as measured by the shortening incubation period up to a fixed period beyond which he could not go, of six days. This virus he called "fixed" virus and found constant in its potency and in its effects for his purpose. One other mysterious change was wrought in this virus in the process of fixing. It was found to lose virulency in the dog becoming even avirulent in man while it was increasing in virulency in the rabbit. Adequate explanations for these facts are not yet forthcoming and, yet, on it depends its efficacy in treatment. His next step was to obtain this virus in varying but definite de- grees of virulency. This was accomplished by taking the spinal cord (as more easily manipulated than the brain) of a rabbit dead of the effects of the "fixed" virus and drying it over potassium hydroxide in a bottle at 70 F. kept in the dark. Day by day as the cord desiccates it loses its virulency until the fourteenth day when it is no longer capable of inducing infection. For a brief resume of the technique of preparation of the virus used by the New York Board of Health, see Park in Forch- heimer's Therapeusis of Internal Diseases. Portions of the cords dried longest are ground into an emulsion 704 TREATMENT OF ACUTE INFECTIOUS DISEASES in physiological salt solution and injected .under the skin of the ab- dominal wall. Each day this injection is repeated, using portions of cords dried a lesser period, i. e., of increasing virulency (for. the rabbit) until the stronger cords are used. Slight modifications of the original Pasteur scheme of inoculations are adopted by different institutes and laboratories. The suitable scheme for the virus used is furnished the practitioner by the institution supplying the virus, when it is necessary for him to administer treatment. The duration of the treatment is from fifteen to twenty-six days, which fortunately is short of the usual incubation period, in most cases, although full immunity does not obtain until four or five weeks are past. Bites about the head and especially in children may, however, be followed by so short an incubation period or the patient's treatment may be begun so late after the bite that immunization cannot be achieved by the original Pasteur scheme. Shorter incubation periods, too, follow the bites of wolves and cats. It becomes a great desideratum, then, to hasten the process of immunization. It is the custom, therefore, in case of bites about the head to treat the patient morning and evening for the first two days, or to make the treatment more intensive by using the stronger cords earlier. More recent work, however, has given promise of a quicker method of immunization by the use, from the first of unchanged, fresh virus. Proescher of Pittsburg has been a pioneer in this work in this country. (For details, see Archives of Internal Medicine, September 15, 1911.) He uses the "fixed" virus in the brains of rabbits. Three c.c. of an emulsion in physiological salt solution containing 0.01 gram of " virus fixe " is injected subcutaneously in the abdominal wall and 0.05 grams used in the course of the whole treatment of one injection each day for five days. If immunity is really established in this time as from his results Proescher believes it to be, certainly a great stride has been made towards the perfection of the procedure of immunization. When a State or Municipal Laboratory or Institute is at hand, patients should be treated there preferably; but as these are accessible to the relatively few the Treatment at a distance from the laboratory becomes of great importance. This is effected by sending pieces of desiccated cord with instruc- tions for the emulsification or the emulsion is sent in a preservative of carbolic or glycerin or is supplied by manufacturers in syringes ready for use, as diphtheria antitoxin has long been put up. RABIES 705 The U. S. Public Health and Marine Hospital Service have been accustomed to furnish virus to State Boards of Health to be used under their direction and have found the -results perfectly satisfactory. More recently commercial houses have facilitated the use of rabies vaccine by despatching appropriate doses with specific directions to the family physician. The treatment requires no special confinement, but the patient should avoid fatigue or excesses of any kind. Very little or any dis- turbance occurs as a result of the treatment in the vast majority other than those that may naturally be attributed to the concern of the patient as to the outcome of his infection, mild rashes or slight anaphylactic manifestations. In rare instances more serious results ensue in an affection of the nervous system, causing neuralgia, paVaesthesia and even paralysis, paraplegias, ascending paralysis and death. The fatal issue is extremely rare. Whether this is due to the virus itself or is an anaphylactic phenomenon is not settled. They occur late in or following upon the treatment. They last a few days to several weeks. Treatment is symptomatic. There are no contraindications to the treatment. It is remarkable, as has been commented, that in the 100,000 cases in which this living virus from the rabbit has been used, it has induced rabies in no instance. Just how long the immunity so established lasts is not determined but probably for some years; however, a patient bitten again by a mad dog should certainly repeat the process of immunization unless the second bite follows close upon the first. Results of Preventive Treatment. It is hard to confine one- self to the bare statement of facts, when so much that is dramatic invites to an ebulition of enthusiasm. Granted that 10 per cent, of the bites from rabid dogs resulted in rabies. All these cases meant death, without exception. What the preventive treatment has done is best shown by statis- tics; 30,000 cases treated by the Pasteur Institute in Paris gave a mor- tality of 0.5 per cent, to 1 per cent. Park's statistics of 2405 cases treated by the New York Board of Health virus showed a mortality of 4 per cent, among those bitten on the head and 3 per cent, among those bitten elsewhere: but his statistics further show that if time for the full development of im- munity passes, that is two weeks beyond the full course of treatment, the mortality sinks to 0.3 per cent, in the first and 0.2 per cent, in the latter class of cases. 706 TREATMENT OF ACUTE INFECTIOUS DISEASES Symptoms of Hydrophobia. They have been divided into three stages: 1. Premonitory stage, characterized by malaise, irritability, de- pression, anxiety, change in disposition, difficulty in taking water, hoarseness, some nervous twitchings or rigors, lasts a day or two, at times longer. 2. Stage of excitement. Great thirst and spasms of muscles of deglutition, the real hydrophobia, intense hypersesthesia that dreads even the breath of bystanders on the skin, convulsions and delusions. 3. Paralytic stage. Paralysis, coma and death. The paralytic stage may come early and dominate the picture. Treatment of the Developed Disease. I know of no more dis- tressing duty that falls to the lot of a practitioner of medicine than this nor any that has left the indelible impression on my own mind that this sad experience has impressed. To my mind it has only one object, to lessen the patient's sufferings and smooth the way to the end. Another peculiarity that marks the disease as different from others is that there is no partial immunity established; it is all or none. Its onset spells death and the dubious rare report of a recovery (undoubt- edly most often a lyssophobia or nervous symptom complex precipitated by fear) gives no warrant to exhaust those measures designed to pro- long life to the provocation of renewed agonies and to add hours of suffering without result. The room should be darkened and quiet, and all noise, talking, un- necessary handling rigorously excluded. I have heard the patient plead to avoid the draught from an open door, stuff the chinks about the window, stand further away and turn the head while speaking to avoid the air. Only those who can be of help should be present. What little food can be taken should be concentrated and suggest fluid as little as possi- ble, such as ice cream, custard, or junket. The bed should be of the hospital type to facilitate handling. Enemtaa seem to be the only humane way to relieve the intense thirst. In the early stages of nervous irritability and hyperaesthesia large doses of chloral and bromides by the rectum may cause some sedative effect. The doses should be liberal gr. xxx (2 Gin.) of chloral and 3i (4 Gm.) of bromide or even larger doses of both in the adult. When the convulsive paroxysms come on, only chloroform by in- halation is of use, while morphine hypodermatically may lessen their frequency and the patient's suffering and horror in some measure. RABIES 707 The amounts of these drugs that shall be given cannot be accurately stated; they must be given in large doses, large enough to accomplish the end desired. Without these two agents to apply, the sufferings of those who are there to minister would be second only to those of the patient. Other drugs that have been recommended are hyoscine hydrobromide gr. 1/100 and cocaine applied to the larynx. Attendants, while in no great danger, still should remember that the patient may be a source of infection through his saliva and should take precaution to protect themselves by the wearing of gloves, cauter- ization of superficial wounds contaminated and restraint of patient during his maniacal periods. One can conceive the necessity of im- munization of an attendant accidentally wounded by a patient in delirium. It would seen logical to use the serum of an immunized animal during the attack, but its use has proven in every instance useless. Prophylaxis. That such a disease, when preventable, should exist at all within the borders of a State would seem to be a distinct crime against its members. That it does exist in civilized communities is largely due to the difficulty of grasping the just relationship between communal and individual rights. As the disease is nearly always conveyed to man by the dog, stamp- ing the disease out among dogs practically excludes it in a community. The means to accomplish it are so simple, the inconvenience so slight compared with the results, that it seems amazing that enough opposition should be found to defeat legislative efforts to that end, and yet such is the fact. Among the measures advised to accomplish this end are Quarantine. In Australia, where rabies is unknown, the fact is attributed to a law making a quarantine for six months for all dogs brought into the country imperative. Muzzling. Great Britain has succeeded in eliminating rabies from its confines by an efficient muzzling law. This can be effected by muzzling all dogs at large for at least six months after the last case of rabies in the community or its immediate environments. Less drastic and less useful is the use of the leash. Detention. Valuable but less thorough, is the detention, under observation for three or six months of dogs thought to have been in contact with rabid dogs. Licensing. A law to license all dogs with destruction of the un- licensed, lessening the number of dogs by high tax and primitive meas- 708 TREATMENT OF ACUTE INFECTIOUS DISEASES ures, such as holding the owner responsibly for damages done by the rabid animal. These latter measures but provoke resentment. What is needed is a campaign of education in the problem to lay the path to legislation for quarantine or muzzling with compulsory reporting of cases and killing of all animals bitten by rabid dogs. Rabies in This Country. That the laws against rabies is in- efficient is shown by the increase in numbers and distribution of cases. Of course, the States as independent legislative units, have met the problem differently and more or less satisfactorily. In 1908 Kerr and Stimson, under the U. S. Public Health and Marine Hospital Service, collected 1500 cases who applied for Pasteur treat- ment that year from thirty States, and 534 infected localities. There were 111 deaths. All were from the Eastern three-fourths of the country, none in the Rocky Mountains and Pacific Slope. Three years later, 1911, Albert reported 4625 persons receiving treatment from 1381 infected localities. Moreover his report showed the invasion of the Western quarter of the country, where in some localities it was believed the spread was due to skunks. Finally the incidence of cases by States was determined by the more or less efficient measures adopted for the regulation or stamping out of the disease. SUMMARY When a man is bitten by an animal suspected of rabies. 1. Treat the wound. 2. Confirm the suspicion. 3. Institute antirabic or Pasteur treatment. Treatment of the wound. Lay wound open thoroughly. Encourage bleeding. Wash thoroughly. Bathe in antiseptic, e. g., 1-1000 bichloride. Wipe dry. Cauterize. Best caustic is fuming nitric acid; apply on a glass rod or other suitable applicator, searching every part of the wound. If pain prevents thoroughness, give an anesthetic, general or local. Then wash the wound with physiological salt solution, 3i~0i (4 Gm.- 500 c.c.), or with a saturated solution of bicarbonate of soda and with alcohol. Phenol, 95 per cent., or tincture of iodine may be used as caustic in same manner as nitric acid, but is not so good. RABIES 709 When phenol is used remove the excess of carbolic acid by swabbing with absolute alcohol. Method of Bloodgood and McGlannan. Use first phenol, 95 per cent., then fuming nitric acid, then wash wound with saturated solution of bicarbonate of soda. Five per cent, formaldehyde applied twelve hours (Gumming). Actual cautery. Apply dry dressing. Do not use silver nitrate for cauterizing. Suppurating wounds dressed like those from other causes. Keep open and drain. Old bites. Remove scabs. Clean wound. Cauterize as above. Excise area of scab. Treat as open wound. In wound of extremity, if fresh, a tourniquet may be applied until the wound can be cauterized. Confirm suspicion. (See text.) Prevention. Antirabic or Pasteur Treatment (See text.) Treatment of developed case. Fatal issue is certain; hence, treatment is palliative to lessen suffer- ing and smooth the way to the end. Room. Must be quiet, avoiding even talking and all unnecessary handling. Avoid all draughts of air; may be necessary to stuff chinks in win- dows. Diet. Concentrated and suggest fluid as little as possible, e. g., ice-cream, custard, junket. Thirst is intense. Can only be relieved by enemata or Murphy drip method. To lessen nerve irritability. Early stages. Chloral and bromides, large doses. Chloral, gr. xxx to gr. Ix (2-4 Gm.) by rectum (adult). Bromides. Combine with chloral in double the dose of the chloral. Give by rectum in warm milk gii-iii (60-90 c.c.). Convulsions. Chloroform inhalations. Morphine hypodermically. 710 TREATMENT OF ACUTE INFECTIOUS DISEASES Amounts must be sufficient to accomplish desired results. Cocaine to larynx. Hyoscine hydrobromide, gr. 1/100. 4- Maniacal periods. Restraint. Attendants must remember that patient's saliva is infectious. Should wear glasses. Should cauterize superficial wounds contaminated. Should undergo preventive treatment if wounded by patient. Prophylaxis. Enlightened laws and Health Board regulations. Quarantine. Six months for all dogs brought into country (Australia) . Muzzling. All dogs muzzled for six months after a case of rabies (Great Britain) . Less drastic and less effectual. Use of leash. Detention for three to six months of dogs in contact with rabid dogs. Destruction of unlicensed dogs. Public education. CHAPTER XL TETANUS TETANUS is a disease due to the action of an organism first described by Nicolaier in 1884 and named Bacillus tetani. The symptoms of the disease are effected by the operation of a toxin elaborated by the organ- ism, carried to a distance from the site of infection, entering into and acting upon nerve tissue for which it has a striking affinity. In this the Bacillus tetani is like the Bacillus diphtheriae. The toxin affects the motor end plates of the nerves, travels by way of the axis cylinders to the spinal cord and motor nuclei at the base of the brain and arriving here, and only when arriving here, induces by its irritating effects on these centres the characteristic symptoms of the disease. If the infecting wound brings the toxin at once into intimate contact with motor end plates as a wound of a muscle of the leg, the absorption of the nerve supplying that muscle will be facilitated and evidences of the disease will be manifested in this extremity first; hence, is called " local tetanus" and as the other nerves more remote from the site of the wound are affected the symptoms seem to advance up the body; hence, it is called tetanus ascendens, but if the wound is in the sub- cutaneous tissue, as it usually is in man, as Ashurst and John explain, the toxins, diffused by way of the lymph channels, act on all motor end plates practically simultaneously and those centres sending out the shorter nerves would actually be reached earliest; hence symptoms would appear in the territory of the short facial nerves with early trismus and in the longer nerves later, hence, Tetanus descendens. The toxin in all probability also spreads along the cord when carried there by way of the nerve trunks or by way of the general circulation. The sensory as well as the motor side of the cord is affected and the irritability of the reflexes heightened. Incubation. After the infection some little time must elapse between the invasion of the tissue by the bacillus and the arrival of the toxins at the centres. This will depend on the activity of the germ in the wound and the facility of transportation for the toxins; for example, the length of the nerve trunk travelled. The average time is seven to nine days. Under nine days cases are called acute, over nine days chronic. Spores may lie for some time in 712 TREATMENT OF ACUTE INFECTIOUS DISEASES the tissues before they mature and thus the incubation period be length- ened to weeks or even months. It is believed that the invasion by pyogenic organisms of .the tissues in which the spores lie hastens the maturation of the spores. Prophylactic injections of antitoxin, if it does not entirely prevent the development of the disease, materially lengthens the incubation period. The symptoms of this disease, then, are attributable to the heightened and uncontrolled operation of the motor centres under the whip of the toxins, and show first and most marked in the territory of those nerve centres first and most affected. The prodomata occur a day or two after infection and are character- ized by restlessness, sleeplessness, sometimes headache, giddiness and excessive yawning and there may be difficulty in urination due to spasm of the sphincter muscle of the bladder. Then follows trismus (lockjaw) and spasms of the facial muscles giving rise to the so-called risus sardonicus. Stiffness of muscles of neck with retraction; of the muscles of the back with opisthotonus; of the abdomen; curiously enough the muscles of the arms often escape. There may be dyspnoea and cyanosis due to the spasm of the diaphragm and respiratory muscles. These contractions are tonic and continuous, interrupted by clonic convulsions, often severe and painful, which are induced by slight irritations. Moderate fever obtains, sometimes becoming hyperpyrexia, espe- cially, near the end. Sometimes the disease is restricted to that part of the cord supplying the part wounded. It may show itself as trismus, rigidity or spasm of a limb and not infrequently pain about the wound or there may be spasm of the throat muscle. Such localized tetanus may be seen in those partially protected by prophylactic injections. Treatment of the Developed Disease. It is to be regretted that the use of " specifics" has too often invited the thoughtless to an undue reliance on them and to a failure of consideration for equally important measures. Certain measures aiming at the conservation of the patient's energies in his struggle to subdue the infection such as bodily and mental rest, the meeting of energy demands through food intake, and careful nursing are such important measures. Room. A well ventilated room as remote as possible from the noises of the street or the rest of the household should be chosen; this Should be somewhat darkened. The exquisite sensitiveness of the TETANUS 713 sensory-motor apparatus has to be kept in mind and the ease with which slight stimulation of the same precipitates the distressing clonic spasms; so, sudden noises, such as loud talking or exclamations, jarring of doors, windows, or heavy tread, moving of furniture, are to be care- fully avoided. Cotton may be put in the ears. The bed is best of the hospital type, that is one about which the nurse can perform her duties to the patient with the least disturbance to him. A water bed may prove a source of comfort. Skilful nursing is re- quired to subserve the needs of the body without exciting spasms. Baths should be given by sponges and the water be lukewarm as least likely to provoke a shock and a resultant convulsion. Diet. Feeding is a difficult task on account of the locking of the jaws and the spasms of muscles the effort excites. It is obvious that all food must be liquid and as concentrated as possible, as the repetition of the act of feeding is distressing and the danger of aspiration and ensuing pneumonia is always present. Milk, cereal-waters, eggs raw, all fortified with sugar to increase the caloric value are suitable. So difficult is oral feeding, that rectal feeding and nasal feeding are sooner or later necessary as adjuvants to or substitutes for oral feeding, and even efforts at subcutaneous feeding have been made. As a nutrient enema Bloodgood advises 200 c.c. of peptonized milk, two eggs and enough salt solution, physiological (roughly, 3i to Oi) to make up to 500 c.c. and administer by the drop method of Murphy. (See Pneu- monia, Chap. IX.) One may give the milk without peptonization and fortify with sugar, adding salt 5i to the pint (4 Gm. to 500 c.c.) and brandy or whiskey. For example 500 c.c. milk, sugar 45 grams and whiskey or brandy 30 c.c. would furnish 600-650 calories. If slowly introduced the bowel may be made to retain this amount and in this the spasm of the sphincter may assist. Nasal feeding is done by passing a small flexible rubber tube through the nostrils into the stomach. To lessen or overcome the spasm that blocks the passage of the tube morphine in doses of the sulphate gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) hypodermically may be given beforehand or chloroform may be used during the procedure. While little reliance can be put on subcutaneous feeding, olive oil has been used and solutions of glucose, 5 per cent, to 10 per cent. Park mentions the use of normal horse serum, saying that 500-1,000 c.c. can be given. The tissues are in much need of water, which can be supplied best perhaps as a saline solution by the drop method. A pint 714 TREATMENT OF ACUTE INFECTIOUS DISEASES (500 c.c.) may be given four times a day.? Fluid can also be given subcutaneously, but with the extreme irritability of the nerve structures it is not a good method in this disease. Bowels. When seen early a saline can and should be given; later one has recourse to enemata. Obstinate constipation usually obtains after the disease has once begun. Urine. Watchfulness to detect the retention of urine that may occur is necessary and its retention entails the Use of the catheter. The second consideration is the elimination of the focus of infection so far as possible. This is accomplished by rigorous local treatment. The wound should be treated on surgical principles, laid wide open, sloughing material removed, packed and allowed to heal by granulation. Ashurst and John advise swabbing the wound with 3 per cent, alcoholic solution of iodine, followed by hydrogen peroxide and packing with gauze saturated with the iodine solution. They say that if amputation becomes necessary the wound of the stump should be left open and treated in the same way. It has been advised to excise the glands related to the lymphatic system draining the affected area if they seem in any way involved. Cauterization is decried as favoring the growth of the anaerobic tetanus bacilli. Some observers advocate the local administration of dry tetanus antitoxin to the wound after it has been surgically treated and this has been especially advocated in tetanus neonatorum in which the infection comes through the umbilicus. The antitoxin which will be given at once as a prophylactic measure should be introduced into the tissues around the wound so as to saturate these parts with the antitoxin. Specific Treatment. The third measure relates to a neutralization of the toxins of the disease by antitoxin. Unfortunately the combina- tion of toxin with tissue has been so completely effected before treat- ment is begun for the symptoms of the disease do not appear until this combination takes place and furthermore the combination is so stable that results comparable to the use of the analogous antitoxin in diphtheria are not obtained. It is the fact, however, that some toxin is still circulating free in the tissues to add its further poisonous action to the cells that makes the use of the antitoxin imperative, for there is evidence that time is required after the toxin has reached the nerve tissue for the union to become stable, and during this period antitoxin if given in sufficient quantity may attract the toxin out of the nerve substance into a union with itself. TETANUS 715 The Antitoxin. The antitoxin is elaborated in exactly the same way as diphtheria antitoxin in the horse, whose serum becomes the vehicle of its administration. The unit adopted in this country is about ten times the size of the diphtheria antitoxin unit. (See Diphtheria, Chap. XVIII.) Use of Antitoxin. Our efforts are aimed at getting the antitoxin in contact with the toxins both while circulating free and when in loose combination with nerve tissue. These efforts are effected by giving the antitoxin into the subcutaneous tissue and into the vein to secure the first result and into the cord, into the nerve trunk, into the brain and into the muscle about the end plates to secure the second result. Of these routes the intravenous, the intra-spinal and intra-neural are the important. It cannot be too emphatically insisted that if results are to be ob- tained from the use of antitoxin it should be administered as soon as possible after symptoms are evident. Subcutaneously. So readily is this procedure carried out in compari- son with the others that I feel it incumbent on me to emphasize the teaching of the able workers in this field relative to the efficiency of the specific when so administered. Park hi his article in Forchheimer's Therapeusis in Internal Diseases says: "A subcutaneous injection is not wholly absorbed for three days. The water holding the antitoxin in solution is quickly absorbed, but the antitoxin is held back. At the end of six hours only 10 per cent., twenty-four hours 35 per cent., forty-eight hours 65 per cent., and at seventy-two hours and ninety-six hours 100 per cent." In a study on man injected subcutaneously as when given under the skin with 10,000 units Park found the highest antitoxin content of the blood at the end of forty-eight and seventy-two hours amounting to 1 unit per c.c. He goes on to say that when given into a muscle the absorption is three times as fast, being accomplished in twenty-four hours but even here the absorption is uncertain and not comparable with the intravenous method. Dosage. It can readily be seen that because of the slowness of absorption and its great dilution in the blood, lymph and tissue juices, little can be expected of it unless administered in massive doses. These doses are limited only by the expense entailed in their purchase. Over 100,000 units in six hours have been advised, 15,000 and more every three hours and in one case actually 224,000 units were given in three days, happily with recovery. It can only be said that this route should never be preferred to the 716 TREATMENT OF ACUTE INFECTIOUS DISEASES vein if it is possible to get into the latter; if not, the muscle should be preferred to the subcutaneous tissue. Intra-muscular. As has been said, this route is better than the subcutaneous, but, never should be chosen over the vein. Its use in the muscle about the site of the wound to attack the toxin at the end plates has another purpose. Intravenous Injections. This method assures rapid contact of antitoxin with such toxins as are still circulating free in the fluids of the body, while the antitoxin content of the blood is more than twice that obtainable by subcutaneous injection. Dosage. Even by this method the dose should be large and it must be remembered that the efficacy of a given dose is multiplied many fold by being administered early. At the first suspicion of the condition the serum should be administered. The dose recommended is 10,000 to 15,000 units once or twice in twenty-four hours, and this large dose because, as Park says, though it is many times more than enough to neutralize the toxins present in the blood, the antitoxin experiences difficulties in passing from the blood to the cellular fluids, "the tissue fluids only contain about 3 per cent, of the antitoxic content of the blood." (Park.) It has been advised to give one large intravenous dose to start with and smaller subcutaneous doses every day or two until symptoms cease or to give lesser doses by the vein every day. I should feel that in so dire a condition it were wise to lean towards the larger doses and shorter intervals, when the expense does not forbid, always preferring the venous route. Small children may be given one-half the dose and infants one-quarter. Park recommends as "a good working rule," 2,000 units for every ten pounds of patient. In very young children and infants where the intravenous route is impossible, the intramuscular route is the necessary method. Perhaps if only one method of administration could be used the intravenous would prove the best, and in practice it should be given preference as a means of getting antitoxin into the body fluids, while as important adjuvants to its operation methods of bringing the antitoxin into direct contact with nerve tissue should be sought. These methods are the intra-spinal, the intra-neural, the intra- cerebral and the intra-muscular at the seat of the wound. Intra-spinal. This is called the best method by Park and with this I heartily concur. It is conceived that the serum so given will come into more immediate contact with spinal centres and that the more likely if the cord or cauda is wounded by the needle. It TETANUS 717 has been thought, too, to diffuse readily into the blood stream from the cerebro-spinal fluids. The dose should be 3,000 to 5,000 to 10,000 units (6 to 20 c.c.) each day until improvement sets in. For table of amounts to be injected, consult table of Sophian. (See Cerebro-spinal Meningitis, Chap. XXV.) The technique is that of the administration of cerebro-spinal menin- gitis serum. (See Cerebro-spinal Meningitis, Chap. XXV.) One should combine the intravenous and intra-muscular method with it. Intra-neural. Of late an especial plea has been made for intra- neural injections. It is claimed on the basis of experimentation that antitoxin injected into the nerve travels like toxin by way of the nerve to its centres to operate on the toxins there. The large trunks leading from the wounded area are selected and injected at a site as near the cord as is feasible to expose them. The sciatic, the anterior crural, the obturator and cauda equina have been injected in the lower half of the body, while the strands of the cervical plexus, the hypoglossal and spinal accessory are legitimate points of attack in the upper half. Ashurst and Jones have put as much as 1,500 units into the sciatic nerve and 750 into the anterior crural. If injected slowly much is absorbed into the nerve trunk. The disadvantage is the nicety of surgical procedure demanded. It must be remembered that this is only an adjuvant method and that the other nerves have to be reached by other methods. This method was not adopted in the work in the late war. Intra-cerebral. This method was early tried, but the results seem to be so little encouraging and the dangers and sequelae of the pro- cedure so considerable that I am inclined to advise against it. Intra-muscular. Injections of antitoxin may be made about the wound, into the muscles to bring the serum in contact with the motor end plates to be first affected. The instructions of the Board of Health of New York City are to give 3,000 to 5,000 units of the antitoxin intraspinally by the gravity method. This may be diluted with sterile saline making the total volume to at least 5 c.c. An intravenous injection of 10,000 units should be given at the same time to render the blood antitoxic for four or five days. At the end of 24 and 48 hours, repeat the intraspinal injection. At the end of 72 hours (4th day) give a subcutaneous dose of 5000 units. They furthermore advise that if the intraspinal dose cannot for any reason be given increase the dose to 15,000 to 20,000 intravenously. If neither of these methods is possible give at once an intramuscular dose of 20,000 units or more. The experience in the late war has afforded an unparalleled opportu- 718 TREATMENT OF ACUTE INFECTIOUS DISEASES nity for the. study of this disease and of the, efficacy of antitoxin in its treatment. The following table, taken "from Fitzgerald's article in Nelson's Loose Leaf Living Medicine, is an outline of the treatment suggested by the Tetanus Committee of the War Office: Day Subcutaneous Intramus- cular Intraspinal (intraihecal) 1st day 8000 16000 2dday 8000 16000 3d day 4000 4th day 4,000 5th day 2,000-4,000 7th day 2,000-4,000 9th day 2.000-4.000 To get the best results this should be supplemented by intravenous injections in large doses and the rule proposed by Park is an excellent one to follow; i. e., 2,000 units per ten pounds of patient. This will guarantee a high antitoxic content in the blood for four or five days. Local Tetanus. In local tetanus, antitoxin is used by the intramus- cular and subcutaneous methods and need not be given intraspinally. Drug Treatment of the Disease. All such treatment is empirical, having the weakest kind of basis. Such, for example, is the use of Phenol (Carbolic Acid). This method was introduced by the Italian, Bacelli, and its usage has followed his recommendations with slight modifications as to dosage and concentration. He gave 0.30-0.50 grams (gr. v-viiss.) a day. It may be given in 1/2, 1, 2 or 3 per cent, watery solution and has been used in oil 5 per cent. It is given hypodermically and at frequent intervals hourly or every two hours. An injection of m. xx of a 2 per cent, solution at two-hour intervals would give about 5 grains a day; to increase the dose one may make the intervals shorter or the solution stronger, as 3 per cent., which in same amounts and intervals gives about 7 grains. One should remember that if antitoxin is given at the same time it contains as a preservative 5 per cent, trikresol probably operative in the same direction. Evidences of poisoning by inspection of the urine (smoky urine) should be sought for, but the body seems to be peculiarly tolerant in tetanus. The statistics seem too good to be true and especially in the ab- sence of experimental corroboration. When, however, antitoxin is not at hand or in insufficient quantity, phenol should be used. TETANUS 719 DRUGS IN THE TREATMENT OF THE SYMPTOMS The most urgent symptom is the convulsion, because of the great exhaustion it entails and because of the fatal spasms that may occur. There are two classes of drugs used for this purpose, one to lessen the irritability of the centres, lessen the severity of the tonic contractions and frequency of the clonic, a milder group; and the other more im- perative, quelling the convulsion. Among the first belong bromides and chloral, the most important and mentioned together because they should be used together to get the best effects. Large doses should be used; for the pharmacological depressing ef- fect on the spinal centres is sought and the condition for which they are used a thousand times more menacing than their toxic effects on circulation or respiration. Chloral should be given in doses of gr. xv (1 Gm.) every three hours or gr. xxx (2 Gm.) every six hours increased to gr. xlv (3 Gm.) and gr. Ix (4 Gm.) every six hours, if the spasm is severe, and heart and respira- tion are watched. Bromides may be given at double the chloral dose, as potassium bromide or mixed potassium, sodium and ammonium bromide, at the same time or in the intervals. These are adult doses and should be correspondingly decreased for children. They may be given by mouth through nasal or stomach tube if necessary or by rectum, milk furnishing in the latter method a good menstruum. Among other drugs belonging to this group but less reliable are atropine, hyoscine, physostigma and chloretone. Standing between groups one and two is a very valuable drug. Morphine. This drug not only lessens the spasm, but it relieves pain, induces sleep, and given before any disturbing procedure such as dressing the wound, giving enemas or rectal feeding, passing nasal tube or catheter makes the procedure less trying and less provocative of spasm. The doses should be large, gr. 1/4 to gr. 1/3 (0.015-0.02 Gm.), up to gr. iss. or gr. ii (0.1 or 0.125 Gm.) of the sulphate a day. Atropine sulphate is well combined with it. The severity of the clonic spasms and the suffering they sometimes entail demand more dominant measures such as are furnished by the second group of drugs; namely Chloroform. This is given by inhalation during the exacerba- tions of the spasms. It has been used continuously over .periods of hours and days, but it is the conviction of some observers that such usage constitutes a danger in itself. Magnesium Sulphate. Intra-spinal. A method suggested by 720 TREATMENT OF ACUTE INFECTIOUS DISEASES Meltzer of .utilizing the depressant effect^ of magnesium sulphate when brought into direct contact with the cord was eagerly seized upon, but was found to possess dangers of its own; however, the severity of the spasms, pain and exhaustion may be such as to make the measure in spite of its attendant dangers advisable, but it certainly is not to be undertaken lightly. A 25 per cent, watery solution of magnesium sulphate is used. The dose 1 c.c. to every 25 pounds of the patient's weight, discounting somewhat for the very obese and large of frame. The spinal puncture is made as for an exploration (see Cerebro- spinal Meningitis, Chap. XXV), except that the shoulders should be somewhat raised to prevent rapid diffusion of the solution upwards towards vital centres. The needle should withdraw an amount of cerebro-spinal fluid equal to that amount of solution to be used, the syringe then attached to the needle and the salt introduced slowly. The spasms disappear and do not recur for hours or sometimes days. A recurrence of severe type would indicate a repetition of the procedure. The danger lies in respiratory collapse. The patient should be under competent observation during the few hours after the injection and artificial respiration and stimulation undertaken if necessary, and it would seem advisable to withdraw what magnesium sulphate may be left in the canal. DRUGS OF MORE DOUBTFUL VALUE Chloretone. This drug in whiskey by mouth or olive oil by rectum has been used in doses of gr. xxx (2 Gm.) every two hours until the patient sleeps. Even doses as high as 66 and 75 grains (5 Gm.) have been advised. Atr opine. This drug is used in combination with morphine or alone to lessen the spasm and as Bloodgood says finds its principal value in the prevention and relief of the distress due to an oversecre- tion of mucus in the air passages. The dose of the sulphate should be gr. 1/100 to gr. 1/25 (0.0006-0.0025 Gm.) into the contracted muscles. It can be repeated at four-hour intervals up to the well-known physi- ological limit. dilated pupils excessive dryness of mucous membranes or rash. Hyoscine. This drug, like atropine derived from the solanacese acts like atropine to lessen spasm but is more depressing to the cbrti- cal centres and in so far is a desideratum, but it is also depressing to the respiratory and cardiac centres and so has to be watched with care. TETANUS 721 It may be given as the hydrobromide in doses of gr. 1/100 (0.0006 Gm.) twice a day. Phy so stigma or calabar bean, best in the shape of its active prin- ciple, physostigmine sulphate, has also been administered hypoder- mically in doses of gr. 1/6 (0.01 Gm.) every three or four hours. Diarrhea or muscular twitching, if it can be made out during the tonic contrac- tions, indicates the physiological limit and interruption of its adminis- tration. Circulatory stimulants may be indicated in the exhaustion follow- ing clonic spasms. Causes of Death. 1. Spasm of the larynx with ensuing asphyxia. 2. Spasm of the respiratory muscles, intercostals and diaphragm with asphyxia. 3. Cardiac failure. 4. Starvation. 5. Hyperpyrexia. If the patient survives there may be some muscular stiffness for a long time after the subsidence of the attack. Prognosis. The longer the incubation period the better is the prognosis and the longer the symptoms have continued the better is the eventual outlook; that is, fatal cases are likely to be shortly fatal, or in other words the prognosis depends on the severity of the infec- tion and the resistance of the patient. Extensively distributed spasm is of bad omen and hyperpyrexia very fatal. Prognosis depends largely on the promptness and efficiency of the treatment and especially the use of antitoxin. While here and there a man of experience expresses himself in this way: "The mortality has not been reduced by treatment save as to prevention" (Hill in Archives of Internal Medicine, December 15, 1911), others, and the majority, take a more cheerful view of the value of therapeusis. Park says, "If every case were given an intravenous injection of antitoxin at the time of diagnosis, and treated well in other respects, probably 50 per cent, would recover" (Forchheimer's Therapeusis of Internal Diseases, Vol. 2), while lists of statistics may be found attributing a fall in mortality from 80 per cent, to 90 per cent, down to 45 to 30 and less per cent, under antitoxin. A series of over 200 treated cases studied by Irons shows a mortality of about 61 per cent., a drop of 20 per cent, from the average mortality. Far better results are following the intra-spinal method. Prophylaxis. Whatever disagreement there may be about the effi- cacy of treatment by antitoxin there is no dispute about its value as a prevention, though some surgeons believe that tetanus is a rare complication in a wound promptly and properly treated. 722 TREATMENT OF ACUTE INFECTIOUS DISEASES Prophylactic treatment, then, resolves itself into two lines of en- deavor. 1. Treatment of the wound. 2. Antitoxin administration. Treatment of the Wound. The first essential is a knowledge of what kind of wounds under what kind of environment are likely to result in tetanus. While it is possible that an infection under certain conditions may originate in the intestinal canal, for their presence in the intestine is not a rare finding and in hostlers a common one, or that the bacilli may be resident in the catgut used in surgical procedures, still the vast majority come from punctured and lacerated wounds contaminated by dirt from barns, stables, bites or other wounds from horses, punctured wounds from nails, fish bones in garden soil or barnyard refuse; lacerations, by farm-yard implements, machinery, gun-shot wounds, toy-pistols and giant crackers. The Fourth of July harvest has each year taken the heaviest toll of any cause. After cleansing the surrounding parts and the wound with green soap, alcohol and ether or painting with tr. of iodine, every suspected wound then should be laid wide open to the very bottom by a free in- cision, bits of dirt, cloth, wood or powder removed, lacerated shreds separated with scissors or the wound area excised and the wound treated with Antiseptics. For this purpose a 3 per cent, alcoholic solution of iodine may be used or liquified phenol, followed by alcohol. The wound is then loosely packed with the iodine solution and dressed daily after irrigation with peroxide of hydrogen with the gauze soaked in iodine solution or with iodoform gauze. No caustic should be used as the germs are anaerobic and will thrive best under the eschar produced by such agents. The wounds should be kept open and allowed to granulate from the bottom. It has been advised to use powdered dry antitoxin in the wound or the liquid antitoxin itself, applying a loose dressing over it. In other words, the wound is to be treated by sound surgical methods. Use of Antitoxin. This should be given at once. Its efficacy is best demonstrated by the fact that the high death rate from tetanus after Fourth of July wounds has been almost if not quite wiped out in those hospitals where it has been used at the time the wound was dressed. Its use during the late war has placed its value beyond dispute. Dose. The usual dose is 1,500 units given subcutaneously, or better, into the tissues and muscles about the site of the wound, to protect the TETANUS 723 motor end plates at the site of toxin formation first and the remoter nerves next. Repetition of the Dose. It has been shown that in eight or ten days all the antitoxin has been eliminated and for this reason a second dose of the same amount should be given. This second dose will almost surely protect. Some cautious men, however, give a third dose and some continued doses at these intervals until the wound is healing in a healthy manner by granulation. If for any reason a wound has to be opened up a second time a prophy- lactic dose of 1 ,500 units should be given again as the tetanus bacilli locked up in the healed wound may become active as a result of the procedure. Some men have relied on the local use of antitoxin in the wound as described; but, if antitoxin seems indicated at all it should be given as above described except in cases of local tetanus, whether it be used locally or not. The dosage in a child may be a little less, 1,000 units, but there is no objection and some value in the larger dose. Serum Disease. Rashes and joint pains as after diphtheria anti- toxin may appear, but are of little importance. SUMMARY Incubation time. Average seven to nine days. May be weeks or months. (See text.) Symptoms. Due to irritation of motor nerves inducing tonic contraction of muscles interrupted by clonic contractions, which are easily ex- cited by slight stimuli. Treatment Rest. Elimination of every stimulus to the highly irritable motor centres. Room. As far away from the noise of the street and the rest of the house- hold as possible. Avoid sudden noises, such as jarring of doors and windows, heavy tread of feet, moving furniture, loud talking. Cotton may be put in the ears. Room should be a little darkened. Should be well ventilated. 724 TREATMENT OF ACUTE INFECTIOUS DISEASES Bed. Half-bed of the hospital type, with woven wire springs, firm mat- tress, smooth sheets. Water bed may be more comfortable. Care of the body. Baths should be given of sponges of warm water in a warm room, as least likely to provoke a convulsion. Mouth best rinsed with clear warm water or saline solution, or 2 per cent, boric acid from time to time unless it incites the clonic contractions. Diet. Feeding very difficult. Liquid foods; concentrated, administered as infrequently as com- patible with body needs. Milk, cereal waters, eggs; all fortified with sugar. Sooner or later rectal or nasal feeding must be used in part or wholly. Rectal feeding. Two hundred c.c. peptonized milk. Two eggs. Salt solution (3i to Oi) (4 Gm.-500 c.c.) up to 500 c.c. or 1 pint and administer by the drop method of Murphy (Bloodgood) . Or 500 c.c. raw milk. 1 Forty-five grams milk sugar. 1 600-650 cals. Thirty c.c. whiskey or brandy, j Introduce slowly into bowel. Two or three rectal feedings a day is about all the bowel will take for any length of time. Nasal feeding. Use small flexible tube. If spasm blocks the tube give Morphine sulphate, gr. 1/8-gr. 1/4 (0.008-0.015 Gm.) . (Adult dose.) Subcutaneous feeding. Doubtful value. Olive oil. Glucose, 5 per cent, to 10 per cent, (real value). Normal horse serum, 500-1,000 c.c. (Park). Fluids. On account of the difficulty of getting enough water by the mouth. Give physiological salt solution (3i to Oi or 4 Gm. to 500 c.c.) by Murphy drip method by bowel. Give 5 per cent, glucose solution in same quantities by drop method. Bowels. When seen early. Saline. Epsom, Rochelle or Glauber's salt, 5ss.-53/4 (15-20 Gm.), in half to three-quarter glass of water. TETANUS 725 Later. Enemata carefully given to avoid exciting spasm. Bladder. Watch for retention; if it occurs use catheter. Precede by morphine. Eliminate the focus of infection. Wound laid wide open. Remove sloughs. Pack with gauze, let heal by granulations. Swab wound with 3 per cent, of alcoholic solution of iodine, follow with peroxide of hydrogen and pack with gauze saturated with the iodine solution. (Ashurst and John.) Cauterization should not be done. Specific treatment Use of antitoxin. (For discussion of its limitations and the mode of administration, see text.) Subcutaneous. Absorption slow, hence, greatly diluted in blood; requires large doses, limited only by expense, e. g., 100,000 units in twenty- four hours, or Fifteen thousand every three hours. Intramuscular. Better than subcutaneous, but not as good as intravenous. Dose, 10,000 to 15,000 units once or twice in twenty-four hours. Intravenous. Better than above but not comparable to infra-spinal.. Can give one large intravenous dose to begin with and subcutaneous or intramuscular doses every day or two following or daily intravenous doses of smaller amounts. Park's rule. Use 2,000 units for each ten pounds body weight. In addition antitoxin should be brought into more direct contact with the nerve tissue. Intraspinal always to be used if possible. Dose, 3,000 to 5,000 to 10,000 units (6 to 20 c.c.) daily. (For technique, see serum administration in Cerebro-spinal Men- ingitis, Chap. XXV.) For amounts consult Sophian's tables. (See Cerebro-spinal Men- ingitis.) Intraneural. Into large nerve trunks leading from wounded area, as near the cord as feasible to expose them. (As much as 1,500 units have been put into the sciatic nerve.) Not advised. Intracerebral. An early method. The results have not been encouraging. Intramuscular (at site of wound). To bring serum into contact with motor end plates of wounded area. 726 TREATMENT OF ACUTE INFECTIOUS DISEASES For New York Board of Health method .pf combined intra-spinal, intravenous and intramuscular dosage, see text. For the method of the Tetanus Committee of the United States War Department, see text. These are the best methods. Drugs. Purely empirical usage. Phenol (carbolic acid). Dose, gr. v to gr. viiss. (0.30-^0.50 Gm.) daily. Given in 2 per cent, solution in oil. M. xx (1.30 c.c.) every two hours would amount to gr. v (0.30 Gm.) a day. Same dose of 3 per cent, would equal gr. viiss. (0.50 Gm.). Watch urine for smoky urine as evidence of phenol poisoning. Treatment of symptoms. Convulsions. To lessen irritability of centres, and diminish frequency and vio- lence of clonic convulsions. Chloral. Dose, gr. xv (1 Gm.) every three hours, or gr. xxx (2 Gm.) every 6 hours, increasing to gr. xlv (3 Gm.) or gr. Ix (4 Gm.) every six hours if necessary. (Adult dose.) Bromides. In double dose of chloral; either potassium bromide alone or the triple bromides of sodium, potassium and ammonium. Not likely to be effectual alone, but well to combine with chloral. Give in solution in water through stomach or nasal tube, or by rectum in a couple of ounces (60 Gm.) warm milk. Morphine. Lessens spasms, relieves pain, induces sleep. Indicated before any procedure likely to induce convulsions, such as enemas, rectal or nasal feeding, catheterizing. Indicated during a convulsion. Doses, sulphate, gr. 1/4 to gr. 1/3 (0.015-0.020 Gm.) up to gr. i or gr. iss. to gr. ii (0.060-0.10-0.120 Gm.) a day. Atropine. May be combined with morphine. Chloroform. Indicated in severe and painful convulsions. Inhalation. Intermittently at periods of clonic convulsion. Continuous for hours (not free from danger) . Magnesium sulphate. (For intradural use, see text.) Other drugs that have been recommended. Chloretone, gr. xxx (2 Gm.), every two hours until sleep occurs. Give in whiskey by mouth or olive oil by rectum. TETANUS 727 Atropine. Indicated as above with morphine or alone to lessen spasms, also to diminish over-secretion of mucus in air passages. Dose, of the sulphate, gr. 1/100 to gr. 1/25 (0.0006-0.0025 Gm.) into contracted muscles. Repeat at four-hour intervals. Watch for toxic symptoms, widely dilated pupils, great dryness of mucous membranes, rash, delirium. Hyoscine hydrobromide. Has same effect as atropine, but more depressant to cardiac and respiratory centres. Dose, gr. 1/100 (0.0006 Gm.) twice a day. Physostigma. Use physostigmine sulphate, gr. 1/6 (0.010 Gm.), hypodermically every three to four hours. Circulation. Exhaustion from convulsions may indicate use of circulatory stim- ulants. Use digitalis series for sustained effect and caffeine or camphor for immediate effect. (See Chap. IX.) Prophylaxis. Treatment of the wound. Cleanse wound with soap, water, and alcohol, or paint with tinc- ture of iodine. Lay wound open to bottom. Remove foreign particles. Cut away lacerated flesh or Excise wound area; then use Antiseptics. Three per cent, alcoholic solution of iodine or phenol liquified, followed by alcohol. Pack loosely with gauze saturated with the iodine solution. Dress daily, irrigating with peroxide of hydrogen. Let wound granulate from the bottom. Powdered or liquid antitoxin has been used in the wound. Antitoxin administration. Should be 'given at once. Dose, 1,500 units. Best into muscles about the site of the wound. Second dose of same amount should be given in eight or ten days. Third dose or repeated doses at these intervals until wound is healed are given by most cautious. In a child 1,000 units may answer, but 1,500 are better. Serum disease, as after diphtheria antitoxin, may follow. It is of small consequence. CHAPTER XLI INFECTIOUS JAUNDICE (WEIL'S DISEASE) THERE is some question as to the propriety of using the terms Infectious Jaundice and WeiPs Disease as synonymous. Of late Infectious Jaun- dice has been taken to mean a definite infection attributable to a spiro- chete, the spirocheta ictero-hemorrhagiae, the clinical picture of which is fairly clear cut. This same term had been applied long ago to a group of cases later described by Weil and to which his name is generally attached in the literature. Weil's disease and Infectious Jaundice as now understood have in common the distinguishing features of jaundice and hemorrhages, accompanying a toxemia, but in some minor details vary. It means probably that Weil's Disease covers a heterogeneous group of conditions with which the major manifestations mentioned are associated. We shall discuss here the spirochetal infection; but the measures mentioned, with the exception of specific therapy, are applica- ble to one and the other. According to the Japanese workers, to whom we owe so much in the investigation of this disease, the portal of entry is by the skin, broken or intact, or by the gastro-intestinal tract. Excretion occurs in the feces and urine and the organism is readily recovered from the latter, from early in the disease up to 5 to 6 weeks, but usually by the end of the second week. In the body the spirochetes are distributed especially to the kidneys, the liver, the lymph nodes and spleen. They are found in the heart muscle, too. The most obvious lesion is curiously confined to the duodenum, the pyloric end of the stomach and the upper portion of the jejunum. Here the congestion is intense and the papilla of Vater involved. The ob- struction seems to be at the papilla, for the gall-ducts, gall-bladder and liver are but little affected, considering the intensity of the jaundice. It is to be noted that the toxemia seems to be due to the sptrochetosis rather than the jaundice and indeed, jaundice may be absent. The incubation period when infection occurs by the skin is 5 to 7 days. It is seldom later than two weeks. Symptoms. The onset may be sudden or gradual with the usual symptoms of acute infection, malaise, fever, headaches, generalized pains, cramps in muscles, prostration, anorexia, often vomiting and pain in the upper abdomen, striking constipation and marked congestion INFECTIOUS JAUNDICE (WEIL'S DISEASE) 729 of the conjunctiva. Herpes is common. The blood count shows a moderate leucocytosis and polynucleosis, exceptionally both are quite high. The pulse is relatively slow, the blood pressure is normal. In the early days spirochetes may be recovered from the blood and the blood shown to be infective to inoculated animals, but by the fifth day this infectivity is markedly diminished, due probably to the formation of antibodies. By the fifth day spirochetes are usually excreted by the urine. This initial or febrile period lasts six to seven days. The tempera- ture in the beginning may be 102 F. to 103 F. and comes down by lysis nearly to normal. During this period hemorrhages are common, occurring from the lungs, nose, stomach, intestine and kidneys, together with, in some cases, purpura, and Dawson and Hume note a "curious purplish discoloration in the abdomen, loins and lower part of the chest in those cases which were most deeply jaundiced." The second or icteric stage begins at about the end of the first week. Most commonly the jaundice appears on the fifth day, though it may appear as early as the second day or be delayed until near the end of the second week. The degree of jaundice varies. Bile appears in the urine and the stools are clay colored. During this period, too, occur hemor- rhages and marked general weakness. Convulsions have occurred in some fatal cases and the heart may show some inefficiency, though this is not characteristic. It is in this second period that fatal issues com- monly occur. A secondary rise of temperature, after an afebrile period of two to ten days takes place at the end of the second week in a certain number of the cases, 30 per cent, to 40 per cent. This rise varies in its duration, but may last several days, be quite irregular, be trivial or be quite as marked as the original fever or even higher. The third and last period is that of convalescence. It begins with the third week unless delayed by the relapse or after fever, the secondary rise. The icterus gradually fades and the anaemia and emaciation become more pronounced. Spirochetes are no longer found in the blood, but may still be recovered from the urine, especially in the relapsing cases. Indeed, though diminishing after the twenty-fifth day, they may be found in the urine as late as the 40th day in the average case and even later in the exceptional. Treatment. That of all acute infections. (See Chap. I.) The patient is put to bed in a well ventilated room, to which the sun has access, in a comfortable bed. Daily sponge baths are given, the mouth properly attended to and quiet and good nursing afforded. Diet. Gastro-intestinal symptoms are fairly constant and some- 730 TREATMENT OF ACUTE INFECTIOUS DISEASES times severe. It is useless to force the diet while these disturbances obtain. It is better to respect the meaning of the anorexia and refrain from giving food until nausea and vomiting cease and then begin tentatively with milk (better skimmed) or broths, such as mutton and chicken (freed from fat), white of egg, thoroughly cooked cereals, toast; enlarging on the diet as the patient demonstrates his ability to handle larger quantities. Water should be given frequently in small quantities if there is nausea, in larger amounts if the stomach retains it. Specific Treatment. The Japanese workers Inada, Ido, Hoki, Ito and Wani recommend the use of a specific serum. As in the use of all specific sera, early administration constitutes a most important factor in success. Dose. Sixty c.c. should be given in 24 hours, in divided doses at 5 to 6 hours' intervals. The intravenous route is the best; next, the intramuscular. It was the experience of the investigators quoted that the serum rarely failed to cause a complete disappearance of spirochetse from the cir- culating blood. The mortality was reduced from 30.6 per cent, to 17.3 per cent in their series. Bowels. When first seen a saline may be given of Epsom salt or Rochelle salt or if there is nausea and vomiting, divided doses of calomel, gr. 1/4 (0.015 Gm.) every half-hour for five or six doses, followed by the salt; or a salt in divided doses of 3i (4 Gm.) every quarter hour for five or six doses. Neither the calomel nor the salt should be used in drastic doses. Later enemata or mild salines every day or every second day may be used. Nausea and vomiting may be alleviated by cracked ice, the appli- cation of mustard paste to the epigastrium, stomach washing or the use of such drugs as bismuth subnitrate gr. xv to gr. xxx (1-2 Gm.), bicarbonate of soda gr. x to gr. xx (0.6-1.3 Gm.) or oxalate of cerium gr. ii to gr. v (0.15-0.30 Gm.) or a combination; codeine sulphate gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) or cocaine hydrochloride gr. 1/5 (0.01 Gm.) are indicated in more severe cases and even morphine in the worst. Diarrhea. Attention to the bowels as set forth above, restriction of fat in food and sufficiency of water to lessen the incidence and severity of the diarrhea. Bismuth subnitrate in doses of gr. xxx (2 Gm.) every two hours is the best drug to use; opium being reserved for the most severe forms. Colicky pains are relieved by hot fomentations. INFECTIOUS JAUNDICE (WEIL'S DISEASE) 731 Fever. Temperature of 102 F. to 103 F. are reached by the second or third day and gradually decreases throughout the first week. It but rarely requires treatment other than that which contributes to the patient's comfort, afforded by sponge baths. Nervous Symptoms. Headache, delirium or coma may occur. For the headache the ice-coil is to be recommended, delirium may re- quire small doses of morphine. Pains in the legs are at times very hardly borne and the applications of hot stupes and mild analgesics, such as the salicylates are required. Jaundice appears on about the fifth day. This jaundice lasts about two weeks. There is no treatment that probably affects the degree or intensity of the jaundice, but the salicylates as being thought to stimu- late biliary output have been much used, either as salol, sodium sali- cylate or aspirin in doses of gr. v to gr. x (0.3-0.60 Gm.) every three or four hours. They have the advantage, too, of acting as antipyretics and analgesics. Nephritis is a complication that is not uncommon and demands daily examination of the urine. It is to be treated like acute nephritis under other circumstances. (See Scarlet Fever, Chap. XVII.) Rarer Complications. Hemorrhages from nose, lungs, stomach, bowel into skin or serous sacks. Hemorrhages should be treated as under other conditions. (See Typhoid Fever, Chap. XIV.) The intoxication in infectious jaundice is severe; often the patient sustains much loss of flesh, and strength is but slowly regained. Fresh air out of doors, a sufficiency of good food and, when feasible, a change of climate does more to shorten the period of convalescence than drugs. If these are used, such simple tonics as strychnine sulphate gr. 1/30 (0.002 Gm.) three times a day or tincture of mix vomica m. x to xx (0.60-1.30 Gm.) three times a day are given. Iron may be used. Prophylaxis. Active Immunization. Ido, Hoki, Ito and Wani brought this about by three subcutaneous injections of vaccine at five days' intervals. They used such a suspension as contained 60 to 150 spirochetes in a field,. 1/12 oil, immersion, ocular 3 (Leitz) under dark illumination, in 0.5 per cent, carbolic acid. The first injection consisted of 0.5 c.c. of this sus- pension, the second 1 c.c., the third, 2 c.c. Active immunization should prove a potent prophylactic measure. In Japan this infection seems to be common among miners; hence, draining of the mines and disinfection of the ground with lime is advised. The infection through the gastro-intestinal canal can only be avoided 732 TREATMENT OF ACUTE INFECTIOUS DISEASES by such precautions of cleanliness in handling food and boiling water and disposing of infected secretions as are detailed, for example, under Typhoid Fever. (See Chap. XIV.) The urine and stools should be disinfected for at least 40 days and as much longer as the presence of spirochetes in these excretions indicate. Bloody sputum during the attack is a source of infection and must be destroyed. In that group of cases that cannot be attributed to spirochetal in- fection and may still be classed under Weil's Disease, the conclusions of Barker and Sladen, resulting from a series of cases may be quoted. "The sequence of events in our cases, it seems to us probable, was as follows : "1. Ingestion of tainted meat, containing living paratyphoid ba- cilli; (2) development of gastro-enteritis due to this microorganism, and (3) the appearance of a catarrhal jaundice due to extension of the gastro-enteritis to the 'biliary passages/" SUMMARY (For general principles, see Chap. I.) Diet. Refrain from urging food until gastro-intestinal symptoms subside or ameliorate; then Milk, broths, cereals, white of egg, toast, all tentatively. Enlarge on diet gradually. Water. Give freely when well borne. Specific treatment (See text.) Precautions. Destroy all secretions. (See Typhoid Fever, Chap. XIV.) Bowels. Salts, Epsom or Rochelle 5ss. to 5i (15-30 Gm.) in three-quarters glass of water. If there is nausea or vomiting precede the salt with calomel in divided doses, gr. 1/4 (0.015 Gm.), every hour for four to five doses. Later. Mild salines, milk of magnesia, citrate of magnesia or Hunyadi water or enemata. INFECTIOUS JAUNDICE (WEIL'S DISEASE) 733 Nausea and vomiting. Cracked ice. Mustard paste (1 to 4 or 5 of flour) to epigastrium. Lavage. Bismuth subnitrate, gr. xv to gr. xxx (1-2 Gm.). Sodium bicarbonate, gr. x to gr. xx (0.60-1.30 Gm.). Cerium oxalate, gr. ii to gr. v (0.15-0.30 Gm.). Combine the above. Give every two or three hours in water or in the milk. Codeine sulphate, gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.). Cocaine hydrochloride, gr. 1/5 (0.01 Gm.). Severe cases. Morphine sulphate, gr. 1/16 to gr. 1/8 (0.004-0.008 Gm.). Diarrhea. Give water freely. Restrict fat in food (skim the milk) . Boil milk. Bismuth subnitrate, gr. xxx (2 Gm. every two hours). Most severe cases. Powdered opium, gr. ss. to gr. i (0.03-0.06 Gm.) every four hours. Colic. Hot fomentations to abdomen. Headache. Delirium, coma. Ice-coil or ice-bag to head. Severe cases. Morphine sulphate (hypodermically), gr. 1/12 to gr. 1/4 (0.005- 0.015 Gm.). Pains in legs. Hot stupes. Salicylate of soda, gr. v to gr. x (0.30-0.60 Gm.), every two hours or Aspirin same dose and interval. Complications. Nephritis. (See Scarlet Fever, Chap. XVII.) Hemorrhages. (See Typhoid Fever, Chap. XIV.) Convalescence. Often slow. Open air. More food. Change of climate, when feasible. 734 TREATMENT OF ACUTE INFECTIOUS DISEASES Tonics. Strychnine sulphate, gr. 1/30 (0.002 Gm.), three times a day or Tr. nucis vomicae, m. x-xx (0.60-1.30 c.c.), three times a day. Iron. three times a day. Prophylaxis. Active Immunization. Avoid possibility of ingesting tainted meat and polluted water. (See text.) In infected districts boil water. Precautions in handling food. Disinfect urine and stools for 40 days or as long as spirochetes are present. Destroy bloody sputum. CHAPTER XLII YELLOW FEVER THIS disease, in the elucidation of whose mysteries American physi- cians have played the leading role, like Malaria, is transmitted by the mosquito; more definitely by the female of Stegomyia calopus (Sedes calopus). She becomes infected during and only during the first three days of man's illness with yellow fever and herself passes through an incubation period of from ten to twelve days before she can convey the disease to another man. After this she may remain infective for a considerable time; for fifty-seven days in one instance. Although the details of the mode of infection had been marked out elaborately the organisms concerned had defied detection until the careful investiga- tions of Noguchi seemed to be rewarded in 1919. He found in the blood of persons sick with yellow fever an organism that morphologically closely resembles the leptospira ictero-homorrhagise of infectious jaun- dice, but showing different immunological characteristics. This organism he was able to detect in fresh blood by the dark field illumination; he obtained it in pure culture; by the injection of blood and tissue of yellow fever patients, he produced in animals a disease characteristic of yellow fever; he recovered it again from the blood and organs of these animals; and it gave a Pfeiffer phenomenon. Furthermore he was able to trans- mit the disease from animal to animal. Symptoms. The onset is sudden with chilly sensations, rise of temperature, headache and backache. After some irregularities the temperature abates about the third or fourth day at which time con- junctival icterus may be seen. After a brief intermission or remission of the temperature and diminution of evidences of intoxication, a re- newed fever and toxemia with deepening jaundice, gastric distress, vomiting, even a bloody black vomit, delirium and coma ensues. Hemorrhages and kidney incompetency are often accompaniments. The pulse is characteristically slow (Faget's sign). Stitt states that the blood pressure during the sthenic period is very high, sometimes 200, but begins to fall on second day progressively until in the asthenic period it is very low, sometimes down to 70. Isolation. We now know definitely that there are three links in the chain of transmission, any one of which, abolished, will prevent in- 736 TREATMENT OF ACUTE INFECTIOUS DISEASES fection: (1) Sjegomyia calopus; (2) its access, to a yellow fever patient; (3) its access later to a well person. The prevention of (2), then, by isolation becomes imperative; more- over, during an epidemic all suspects, suffering from what may be deemed early symptoms of the disease, should be isolated until the diagnosis can be determined. White's instructions as given in his article in the American Journal of Medical Sciences, March, 1913, are so succinct that I will quote them here. "In dealing with the houses in which known or suspected cases of yellow fever have been discovered, it was my custom first to see whether the house had been properly screened with eighteen-mesh to the inch wire cloth, and to have screening done promptly, using mosquito netting as a substitute for wire cloth, and having the sick-room itself, as a double precaution, screened from the remainder of the house. The sick-room can be easily screened by tacking two ample widths of the netting to the top and sides of the door, arid attaching a wooden rod to the bottom of each width, so that the ends projecting in to the door are higher than those at the side resulting in the rod dropping into place and pulling the folds together immediately behind any one passing through. "With Guiteras I believe in careful screening and in covering all cracks around the sick-rooms; also in the quietness with which the work is done, to prevent disturbing either patient or mosquito. The sick- room window should be screened from a ladder on the outside of the window. In order to prevent escape or entrance through the chimney a cap should be placed on the top, or failing in this, some loose paper should be burned in the fireplace, with a little petroleum to make a rapid flame, and the front of the fireplace covered with a screen of wire netting. "After the patient is in condition to be removed to another room or house, three days having elapsed since he became ill, he is removed and every crack pasted over into which an insect may hide, and all drawers opened, so that the fumigant used may reach all places in the room, care being taken that no mosquitoes are shut between the outside screen and the window in closing it. The room and its contents are subjected to either sulphur dioxide or cyanide, burning pyrethrum powder or any other fumigant. The whole house is simultaneously treated in the same fashion if the patient can be removed to another house; otherwise we must treat part at a time with more than usual care." It is seen, then, that after three or four days the patient is no longer a source of infection, but that he is still to be protected against further infection by infected mosquitoes. His room should be one to which air has the freest access and these YELLOW FEVER 737 patients do very well under a tent in the open air. The room should be darkened. The room, of course, is to be screened until such time as the patient may be removed from the room in which he was taken ill; that is, at the end of the first three days of his illness, during which his blood contains the virus. If his condition warrants, he is then removed, and the room is fumi- gated to destroy the mosquitoes. Doctor and nurses should protect parts of the body liable to be bitten and more especially toward nightfall. The choice of the bed and the care of the bed observe the same rules as in other acute infectious fevers. (See Typhoid Fever, Chap. XIV.) The certain knowledge of the only mode of conveyance of the dis- ease, i. e., by the mosquito, makes the elaborate use of antiseptics, as, for instance, in typhoid unnecessary. Rest. There are abundant theoretical reasons and such as appeal to common sense, as set forth in the chapter on Treatment of Acute Infectious Diseases (see Chap. I), that should urge getting a patient to bed on the first suspicion of infection, beside the conviction of those experienced in the treatment of this disease that cases put to bed early are less severe and less likely to be fatal. Isolation makes rest more easily attained than when friends and visitors have free access to the patients. Bed pans are to be used and in feeding, the glass tube or feeding cup. Diet. Gastric irritation is a characteristic of the disease and makes the matter of feeding a difficult one. All writers advise against adminis- tering food during the first period of three or four days, while the gastric disturbance continues or the fever remains up; even in the second period if above 102 F. After four or five days' abstention from food the weakness of the patient may urge upon us the necessity of affording nourishment in some form and recourse may be had to rectal feeding. In severe cases this is almost impossible and in any case great care must be taken not to aggravate the irritability of the colon and rectum. Agramonte advises feeding in this manner on alternate days, and suggests as a food formula: Milk 3 ounces (better peptonized) Whiskey ^ ounce Normal salt solution 3 ounces When conditions as above enumerated would seem to permit of it food may be begun with caution by the mouth, commencing with much diluted milk, with barley water, ice-cream or gelatine jellies. 738 TREATMENT OF ACUTE INFECTIOUS DISEASES Drinks. It is very desirable to administer fluids, if the stomach will entertain them. Alkaline waters seem the best borne. Carroll advises Vichy or other mineral water, to which is added sodium bicarbonate grains xxx (2 Gm.) to the pint (500 c.c.), while Anderson is enthusiastic over his effervescent mixture of potassium bicarbonate grains xxx (2 Gm.) to a dessert-spoonful of freshly expressed and strained lime juice given effervescing in Vichy every two hours. Mild lemonade may also be administered. All food and drinks should be ice-cold. Bowels. A saline 3iv-vi (15-24 Gm.) of Epsom or Glauber's salt, best in 5i (4 Gm.) doses at frequent intervals, should be given. This may be preceded by calomel grams iii to gr. v (0.20-0.35 Gm.) or this may be divided. If not effectual a plain enema should follow. Cathar- tics are only indicated at the beginning of the disease. Care of the Body and Mouth. The same rules are to be followed as after any severe acute infection. (See Typhoid Fever, Chap. XIV.) Specific Treatment. At the time of writing, the experimental work of Noguchi holds out some promise of our ultimately acquiring an im- mune serum of value. Treatment of Symptoms. The onset, as has been stated, is sudden and severe and accompanied by headache and backache, often intense. Headache. It is altogether better to avoid drugs, since the depressant effects of the coal tars and the other pharmacological actions of the morphine series are undesirable, and to rely upon cold applied to the head in the shape of cold compresses or the ice-bag or the cold coil. Experienced clinicians advocate the application of heat to the trunk and extremities at the same time, as a hot pack, a hot mustard foot- bath or heat otherwise applied to the feet (see Pneumonia, Chap. IV), and hot drinks such as lemonade if the stomach will stand it. They believe that not only is the headache bettered, but the nausea relieved and the congestion of the kidneys lessened. Backache. The hot pack, hot stupes, mustard pastes or plasters and rubbing afford relief. Gastric Distress. Pain, nausea and vomiting are early manifesta- tions often persistent and later in many instances giving rise to the characteristic and ominous black vomit. No food should be given while the stomach is so irritable; a counter- irritant, mustard paste or mustard leaf, may be applied to the epigas- trium or the application of the ice-bag to the same site may be tried. Cracked ice is sometimes efficacious or ice-cold drinks in small quan- tities frequently, such as the alkalinized Vichy water described above YELLOW FEVER 739 and effervescing drinks, as champagne or ginger ale in tea-and table- spoonful doses. If the violent vomiting still persists one must have recourse to mor- phine in doses of grains 1/4 (0.015 Gm.) hypodermically. If tenderness is severe or hiccoughing occurs, Carter highly recom- mends cocaine hydrochloride, which he gives in doses of one-half a grain to a grain in a capsule to be taken with a minimum amount of water as a preventative of the black vomit. He finds morphine sulphate gr. 1/16-1/12 (0.004-0.005 Gm.) an useful adjuvant if the kidneys do not contraindicate the use of it. Black Vomit. Among the measures recommended to relieve the serious condition are the hemostatics, such as adrenalin by mouth for its constricting effect on the small arteries. Tincture of ferric chloride in doses of minims 5 (0.35 c.c.) every two hours for the styptic effect on the bleeding orifices may be given in limejuice and glycerin; calcium chloride (Guiteras) for its effect on the coagulation of the blood and oil of turpentine in doses of minims x (0.65 c.c.) for the same pur- pose. If there is much pain in the stomach, Carter recommends cocaine as given above with or without morphine. Fever. The period of fever is short-lived and rarely excessive and demands no measures except those designed for the comfort of the patient, as sponging with hike-warm or cool water. If the pyrexia, however, attains high figures or for any time persists above 103 F., the sponges should be given with colder water from 70 F., down to 60 F., or 50 F., depending on the reaction, at four-hour intervals. Such cold sponging should have a favorable effect on the circulation and on other structures burdened by the toxins. Urine. Great danger attends the not uncommon involvement of the kidneys and the suppression resulting. Examinations of the urine should be made daily and estimates of intake and output of water noted. The capacity of the kidney for secretion of water is more im- portant than the amount of albumin in the urine. Administration of a sufficiency of water is important, but on account of the gastric irritability difficult of accomplishment. For this reason saline rectal injections are of value given in amounts of 10 to 16 ounces at four-hour intervals, or the Murphy drip may be tried, but care must be exercised not to aggravate the irritability of the intestine from which hemorrhages are so likely to occur. At the same time hot fomentations should be applied to the lumbar region or the area cupped in an effort to relieve the congestion. Circulation. The condition of the heart and of the principal vessels 740 TREATMENT OF ACUTE INFECTIOUS DISEASES should be determined by frequent examinations and blood-pressure readings. Depression of the circulation should be met in the same way as in other acute infections. (See Treatment of Acute Infectious Diseases, Chap. I, and Pneumonia, Chap. IX.) Convalescence. The period depends on the degree of intoxication throughout the illness. In the usual case it is relatively short, so that after the fever has subsided for several days the patient may be allowed to sit up. The patient gets back onto solid food gradually, the condition of the stomach and kidneys affording the criteria for enlarging the diet. The kidneys are rapidly restored to normal condition. Prophylaxis. Three lines of endeavor to prevent infection are to be pursued. (1) Destruction of mosquitoes and elimination of their breeding places. (2) Isolation of the infected individual. (3) Precautions against bite of stegomyia by non-immunes. To effect (1), the destruction of the mosquitoes and the elimina- tion of their breeding place^, the following measures are undertaken: First, as described under the section on isolation, by carefully screen- ing the room from the first and by removal of the patient after three days of illness with care not to disturb the mosquitoes, followed by fumigation of the tightly sealed room. White calls the stegomyia calopus a domestic mosquito; that is, that it clings closely to the habitat of man and breeds in water collected in artificial receptacles, cisterns, barrels, tubs, cans, broken crockery, pools, vases, fountains, drains, roof gutters, in fact in any stagnant water commonly to be found about a dwelling. Of course, all useless litter should be destroyed or disposed of; cisterns, drains, etc., properly screened with wire netting or constantly covered with a film of petroleum, while small fish devour the breeding mosquitoes in fish ponds and fountains. Swamps, ponds or stagnant waters about the locality infected must be drained, filled in or treated with petroleum. (2) The isolation of the infected individual to prevent his being a source of infection to others through mosquitoes first biting him has been dealt with. (3) Precautions against bites of stegomyia by non-immunes are first a knowledge of the habits of stegomyia calopus and second, personal protection. Carroll says the stegomyia is a twilight mosquito, feeding in early morning and from mid-afternoon until late evening (3 P. M.-10 P. M.), and that in well-lighted places between 9 A. M. and 3 P. M. there is little danger to non-immunes even in infected localities. YELLOW FEVER 741 When in an infected locality non-immunes should take care to pro- tect themselves against the bite of stegomyia and that especially at dusk and after dark by wearing mosquito head-nets, heavy gloves and leggings, choosing for a sleeping room as high a room in the house as possible, being assured on retiring that the room is free from mosquitoes, best by fumigating it, sleeping in a screened room and in a screened bed. They should not expose themselves to the environment of an infected individual unless duty calls and then should take such precautions as are observed by doctors or nurses in attendance. SUMMARY Isolation. Of both patients and suspects. (For the technique of isolation, see text.) Doctor and nurse. Must protect themselves against the bite of mosquitoes and more especially toward nightfall. Bed. (See Typhoid Fever, Chap. XIV.) Diet. Gastric irritation makes the problem a special one. (See text.) Drinks. Alkaline waters. Vichy or other mineral water with sodium bicarbonate gr. xxx (2 Gm.) to the pint (500 c.c.) (Carroll). Potassium bicarbonate gr. xxx (2 Gm.) in a dessert spoonful (3ii or 8 c.c.) freshly expressed and strained limejuice given effervescing in Vichy, every two hours (Anderson). Mild lemonade. All drinks ice-cold. Bowels. Epsom, Rochelle or Glauber's salt, 3iv-vi (15-25 Gm.), best in doses of 3i (4 Gm.) at frequent intervals. May precede by calomel gr. iii to gr. v (0.20-0.35 Gm.) in one or divided doses. Care of body and mouth. (See Typhoid Fever, Chap. XIV.) Treatment of symptoms. Headache. Cold to head. Ice-bag. 742 TREATMENT OF ACUTE INFECTIOUS DISEASES Heat to extremities. Hot pact. Hot mustard foot-bath. (For technique, see Pneumonia. Chap. IX.) Hot drinks; e. g., lemonade. Backache. Hot pack. Hot stupes. Mustard paste or plasters. Gastric distress. No food by stomach. Mustard paste or plaster to epigastrium. Ice-bag to epigastrium. Cracked ice to suck. Ice-cold drinks in small quantities. Alkaline Vichy. (See above.) Effervescing drinks. Champagne, 1 Jn teaspoonful or tablespoonful doses. Lunger aie, j If pain in stomach severe and black vomit threatens give cocaine hydrochloride, gr. ss-1 (0.03-0.06 Gm.) in capsule. Morphine sulphate, gr. 1/16-1/12 (0.004-0.005 Gm.) may be used as an adjuvant to cocaine. If vomiting is severe morphine sulphate hypodermically, gr. 1/4 (0.015 Gm.). Black vomit. Adrenalin (epinephrin), 1 :1,000 in doses of m. i to m. xv (0.060^1 c.c.). Tincture of the chloride of iron m. v (0.30 c.c.) in limejuice and glycerin. Calcium chloride (Guiteras) gr. x to gr. xv (0.60-1 Gm.). Oil of turpentine m. x (0.60 c.c.). If black vomit threatens give cocaine hydrochloride, gr. is-1 (0.03- 0.06 Gm.) in capsule. Morphine sulphate, gr. 1/16-1/12 (0.004-0.005 Gm.) may be used as an adjuvant to cocaine. Fever. Needs consideration only when high or very sustained. Cold sponges. Kidneys. Congestion. Hot fomentations over lumbar region. Circulation. As in other acute infectious diseases. (See summary under Pneumonia, Chap. IX.) YELLOW FEVER 743 Convalescence. Usually short. Up after temperature is normal a few days. Increase diet as condition of stomach and kidneys warrant. Prophylaxis. 1. Destruction of mosquitoes. (See Malaria, Chap. XV.) 2. Isolation of the infected individual. (See text under isolation.) 3. Protection of non-immunes against bite of stegomyia. Noting the feeding time, in morning until about 9 o'clock, and evening after 3 o'clock. Wear mosquito head nets, heavy gloves and leggings. Choose as sleeping room one high up. Sleep in screened room and screened bed. It is well to fumigate the room before retiring. Avoid exposure to environment of infected individuals. CHAPTER XLIII RAT-BITE FEVER THIS disease, so recently called to our attention in this country, I am convinced from my own experience with it, is not so rare that any practitioner can afford to disregard it. It is caused as the name denotes, by the bite of a rat (or rarely of a cat, weasel or other animal) , by which the sufferer is inoculated with a spirochete, spirocheta morsus muris. In due time a symptom complex appears, offering two characteristic features, a relapsing type of fever and an eruption. Repeated febrile attacks of 4 to 5 days, separated by afebrile intervals of a few days, more especially when these attacks are accompanied by an eruption should always lead us to enquire for a rat-bite or seek local evidences of it. This disease has long been appreciated in Japan, but has only recently elicited our attention in this country. Not all rats are infected nor are all bites of infected animals necessarily the source of infection, for bites through clothing may be robbed of their virus or abundant bleeding free the wound; bites on exposed parts then are more likely to be infected. There is a curious similarity to rabies in these particulars. There has been no unanimity among investigators as to the causative agent; it having been ascribed to diplococci, spirilla, spirochetae and streptothrix. Many competent men name the organism a streptothrix muris ratti, but perhaps the strongest argument is put up for the spirocheta morsus muris. The spirochete is to be found in the blood, in the exanthem and the lymph glands, especially at the height of the fever during the first few recurrences. Incubation. Arkin gives the average as 12 days and in some in- stances as short as five days. Other writers fix it at a much longer period, 6 to 8 weeks or even months; thus affording much the same discrepancies as is the case in rabies. Symptomatology. The rat-bite may or may not have healed during the incubation period, but with the onset of active manifestations the patient experiences a burning and pain at the site of the lesion and a redness with a bluish tint and some induration develops here, surrounded by some edema. Arkin likens its appearance to extra-genital primary RAT-BITE FEVER 745 lesion in syphilis, sometimes the lesion vesiculates. From this inflamed lesion the lymphatics become involved and show streaks of red; this spreads to the regional glands, which become large and tender. Some malaise is experienced, then the patient suffers a chill, followed by an abrupt rise of temperature to 102 F. to 105 F., accompanied by head- ache and pains and aches, nausea and vomiting and in severe cases with mental disturbances, delirium and coma. The febrile period lasts three to six days and then falls by crisis with profuse sweating. During the attack the eruption appears, though in some instances it is delayed to the second or third or later relapses. It is a reddish-blue macular eruption, later becoming a little elevated, varying greatly in size from 1/3 inch to huge blotches and paler in the centre than at the periphery. I mistook this eruption in one case for an erythema multiforme. It may be confined to the area about the bite or to a limited area, but as a rule is more widely distributed, appearing on face, limbs and extremities, even on the palms and soles and in rare instances in the mouth. The nervous system is often much disturbed. After the febrile attack comes an afebrile period of 2 to 6 days when the fever recurs with a fresh out- burst of the exanthem, and so these febrile and afebrije periods continue, the chart taking on a characteristic appearance that should suggest the infection at once. These grow less in severity and usuafly last about two months but have been known to continue for years with long afebrile periods even for months intervening. In severe cases each attack is worse until a fatal issue may occur. The blood picture is not constant. Usually there is a moderate leucocytosis from 13,000 to 20,000, dropping during the afebrile period. Sometimes there is a marked increase in mononuclears, sometimes in polymorphonuclears and in some cases a moderate increase in eosino- philes. The diagnosis is clinched by finding the organism in the blood, at the site of the rat-bite, in the exanthem and in the lymphatic glands. The organism stains readily with Giemsa's stain, LoefHer's methylene blue and gentian violet and by other methods such as the India ink and Levaditi's. It shows the spirochetal curves of varying numbers, is short and thick in the blood and longer in the tissue and is flagellated, having a rapid movement in the blood. By inoculation of mouse or guinea-pig they may be demonstrated in five to fourteen days. Treatment. The course of the disease is long continued, the fever often deviates from the type as given above, in some cases being con- tinuous. The nervous symptoms may be the essential feature in the disease and the exhaustion be absent. These cases may be very acute with continued or remittent fever or the fever may be absent. In mild cases during the afebrile periods the patients are relatively comfortable 746 TREATMENT OF ACUTE INFECTIOUS DISEASES and out of bed. In the more severe forasmuch careful nursing and medical consideration is needed. The selection of the room, its ventilation, the choice and preparation of the bed, the care of the body, the mouth and the nose are such as should be exercised in any acute infection and are to be found under Typhoid Fever, Chap. XIV. Diet. On account of the long infection the diet should be abundant, affording 3,000 calories, or more if the patient desires it; the choice of the food depending on the presence or absence of fever or its degree. One will find suggestions in the dietary given under typhoid fever. Except at the onset of the paroxysms there is but little gastro-intestinal dis- turbance. Water should be administered freely. Often there is con- siderable thirst during the febrile periods. Fruit-juices, lemonade, orangeade and alkaline waters may be and should be offered freely. Bowels. At the beginning of the attack a cathartic may be given of castor oil 5ss.-i (15-30 c.c.) or salts; Epsom, Rochelle or Glauber's salt, 3ss.-i (15-30 Gm.) which may or may not be preceded by calomel gr. i ss.-ii (0.10-0.120 Gm.) which is often better borne and even more effectual when given in divided doses of gr. 1/4 (0.015 Gm.) at quarter- hour intervals. Such divided doses are better borne in nausea, and indeed, are credited with antiemetic properties. Enemata or mild cathartics may be relied on during the later stages. Pains and Aches which are quite striking in the febrile periods and particularly in the lower extremities as well as headache, hemicrania, neuralgic pains and pain in the bitten part may be relieved by acetyl- salicylic acid (aspirin) in doses of gr. x (0.66 Gm.) at 2 or 3 hour inter- vals or by the use of the coal tars. Of these latter acetphenetidin (phenacetin) and acetanilid are in most common use. The dose of phenacetin for these purposes is gr. iii to gr. v (0.20 to 0.30 Gm.) at 2 or 3 hour intervals; acetanilid gr. ii to gr. iii (0.012 to 0.20 Gm.) at the same intervals. I think excellent results are to be obtained by small doses, for example, gr. iss. of acetanilid at intervals of 1/2 to 1 hour for six doses, then at 2 hour intervals. No coal tar should be used over a considerable period of time and only in sthenic cases, never when the circulation is imperilled. It is well to combine them with equal or double the amount of bicarbonate of soda which lessens the irritating and toxic effects and with caffeine, citrated, in small doses to increase the anodyne effect. This should be omitted if there is insomnia. If results are not obtained in a half a dozen doses of the above, one should have recourse to more potent drugs, such as codeine phosphate in doses of gr. 1/8 to gr. 1/2 (0.008 to 0.030 Gm.) by mouth or with more certain effect by the subcutaneous route. In very severe cases morphine may RAT-BITE FEVER 747 be used hypodermatically, but sparingly and in the least doses that are effectual, beginning with gr. 1/12 (0.005 Gm.) of the sulphate. Sleeplessness. As the disease is long continued and the demand for hypnotics may be considerable it is well to begin with the milder bromides gr. xv-gr. xxx (1 to 2 Gm.), trional gr. v to xv (0.33 to 1 Gm.), chloralamid gr. xx-xxx (1.33 to 2 Gm.), adalin gr. v (0.33 Gm.), barbital (veronal) or sodium barbital (medinal) gr. v-viiss. (0.33-0.50 Gm.). changing from time to time, remembering that often the effects carry- over to the second night. Give early in the morning. If insomnia is due to pain, codeine and morphine may by used in doses given above. For Delirium. Use morphine gr. 1/4 (0.015 Gm.) or hyoscine hydrobromide gr. 1/200 (0.0003 Gm.). Extreme nervousness, paraesthesia and hyperesthesia call for small doses of bromides gr. x to gr. xv (0.66-1 Gm.) or trional in gr. ii (0.120 Gm.) doses every two hours during the day or luminal in 1/2 grain doses (0.030 Gm.), three times a day. Dizziness ringing in the ears, blurring of vision are occasionally symptoms for which, if the source of anxiety and restlessness, bromides may be administered. Fever. Antipyretics should not be used, but cool sponging afford comfort and in the higher degrees of fever slush baths (see Typhoid Fever) or cold packs (see Chap. XVII) may be tried. Skin. This requires only cleanliness and the application of drying powders. Circulation. Failure of the circulation is to be met by vigorous digitalis medication. (For details and the treatment of collapse, see Pneumonia, Chap. IX.) The inflamed and swollen glands may be painful. Local applications of heat, as fomentations, or cold as an ice-bag or 25 per cent, ointment of icthyol may be utilized. The glands do not suppurate. Specific Treatment. There is none that is worthy of the name, but as the causative agent is a spirochete, arsenic combinations are indicated. Arsphenamine (salvarsan) or the neo-arsphenamine has been used with very excellent results in many cases. I think it should be used in every case. The mode of administration is as in syphilis, intravenously, and in the same dosage, 0.40 Gm. in females and 0.60 Gm. in males, of the arsphenamine; 0.10 Gm. to each thirty pound body weight and 0.75 Gm. in females and 1 Gm. to males. The effects seem to be the same whether given at the height of the fever or during the periods of apyrexia. Some cases are cured after a 748 TREATMENT OF ACUTE INFECTIOUS DISEASES single dose; others require more. When the drug is effectual the relief of symptoms is immediate. While the reported results are very gratifying, I have seen a'fatal issue after repeated salvarsan injection in adequate dosage. Mercury has also been recommended. If used one should follow the usual routine in syphilis, especially the hypodermic route. Complications. Nephritis occasionally occurs and then is to be treated as under other circumstances. (See Scarlet Fever.) Ulcerative myocarditis has been reported and attributed to complicating strep- tothrix infection. The disease is often long and exhausting. Throughout a long course the condition of the blood should be studied and iron given for anaemia. My preference is Vallet's mass (Massa ferri carbonatis) in gr. x (0.66 Gm.) doses, three times a day or arsenic may be added, as arsenious acid gr. 1/40-gr. 1/20 (0.0015 to 0.003 Gm.) or one may use sodium cacodylate hypodermically in gr. ss. to gr. i (0.030 to 0.060 Gm.) doses. Green citrate of iron hypodermically may also be tried in doses of gr. 3/4 (0.05 Gm.). Convalescence. Fresh air, sunlight, an abundance of food, change of climate, if it can be brought about, and treatment of the anaemia are the indications. Prophylaxis. Cauterization with fuming nitric acid, thoroughly, even if incision has to be made for it, is advisable. SUMMARY Treatment. Room, bed, care of the body, mouth and nose. (See Typhoid Fever, Chap. XIV.) Diet. 3,000 calories or more if desired by patient. (For details, see Typhoid Fever, Chap. XIV.) Fluids. Offer freely fruit juices and alkaline waters. Bowels. Initial cathartic of castor oil, 5ss.-i (15-30 c.c.) or Salts; Epsom, Rochelle or Glauber's, gss.-i (15-30 Gm.). Calomel gr. iss.-ii (0.10-0.120 Gm.). May be given in divided doses of gr. 1/4 (0.015 Gm.) at quarter-hour intervals. Enemata or mild cathartics in later stages. RAT-BITE FEVER 749 Pains and aches. Acetyl salicylic acid (aspirin) gr. x (0.66 Gm.). Acetanilid, gr. ii to iii (0.120-0.20 Gm.). Any one of these is given at two to three hour intervals. Excellent results are obtained by using small doses at frequent inter- vals; e. g., acetanilid gr. iss. at 1/2 hour intervals for six doses, then every two hours for six doses. Use no coal tars except in the sthenic period and when the circulation is good. May be combined with sodium bicarbonate and citrated caffeine in small doses. If results are not obtained, use codeine phosphate, gr. 1/8 to gr. 1/2 (0.008 to 0.030 Gm.); or if necessary use morphine sulphate, gr. 1/12 (0.005 Gm.) hypoder- mically. Increase the dose sparingly. Sleeplessness. Begin with milder hypnotics. Bromides, gr. xv-gr. xxx. Acetphenetidin (phenacetin) gr. iii to v (0.20-0.30 Gm.). Delirium. Morphine sulphate gr. 1/4 (0.015 Gm.). Hyoscine hydrobromide gr. 1/200 (0.0003 Gm.). Nervousness. Bromides small doses gr. x to xv (0.66-1 Gm.). Trional gr. ii (0.120 Gm.) every two hours during the day. Luminal gr. 1/2 (0.030 Gm.) three times a day. Dizziness. Bromides as above. Fever. Cold sponges or packs. (See Scarlet Fever, Chap. XVII.) Skin. Cleanliness. Drying powders. Circulation. Digitalis. (See Pneumonia, Chap. IX.) Specific Treatment. Salvarsan administered as in syphilis, intravenously, 0.40 Gm. to females and 0.60 Gm. to males. Mercury. 750 TREATMENT OF ACUTE INFECTIOUS DISEASES Anemia. Iron as Vallet's mass gr. x three times a day. May add arsenious acid, gr. 1/40-1/20 (0.0015-0.003 Gm.). Sodium cacodylate, gr. ss.-i (0.0020-0.060 Gm.), Green citrate of iron gr. 3/4 (0.05 Gm.) three times a day. Convalescence. Fresh air sunlight, good food. Treatment of anemia. Prophylaxis. Cauterization with fuming nitric acid thoroughly. CHAPTER XLIV TRENCH FEVER A DISEASE which, contracted in the trenches of the great war, gets its name from the fact. It is essentially a military problem. It will be appre- ciated from the brief description that follows that its mode of conveyance and spread demand certain conditions peculiarly favored by the exigencies of a military campaign; but, no doubt, now that the war has stamped its picture on our minds it may be appreciated as the cause of certain obscure fevers of civil life. The disease is conveyed by the body louse. The virus is present in the feces of this parasite and is very resistant, withstanding drying of the feces. At first it was believed that the only method of inoculation was through excoriations caused by scratching, but it has been shown that it also may be conveyed by the bite of the louse. It is a filterable virus (Swift). It requires an incubation period in the louse of 7 to 8 days. The louse remains infective up to three weeks after its infection and possibly longer. The incubation period in man is 5 to 20 days. There are very few at any age who are immune to the disease and the immunity after an attack is very short lived, in some instances barely outlasting the attack. Symptomatology. This varies greatly in individual cases. It is characterized by the general discomforts attendant upon most acute infectious processes, so striking in some cases as to be likened to in- fluenza with its headaches, backaches and pains in the extremities, and flares in temperature or to Dengue with its severe pains in the extremi- ties and post orbital pains; an illusion heightened by the saddle-back temperature of some of the cases, relatively slow pulse and its rash. This sudden onset occurs in about half the cases. Shin pains seem quite characteristic, even if not constant, and pain in muscles and joints may be mistaken for rheumatism. The conjunctiva? are injected. Some authors speak of lateral nystagmus as characteristic; others as being no more common than in other acute diseases. Giddiness may be a feature of the onset. Sweating and polyuria may occur. The pulse is relatively slow in comparison with temperature, though some observers find its acceleration corresponds with the temperature; the spleen is enlarged and palpable; a characteristic, but evanescent rash occurs in the early febrile periods. It consists of small macules 752 TREATMENT OF ACUTE INFECTIOUS DISEASES like rose spots, disappearing on pressure and distributed especially on the trunk, coming in crops in each relapse. The blood usually shows a leucocytosis, 14,000-16,000, large mono- nuclears and lymphocytes are relatively increased, though in some cases decided leucopenia is observed. Leucocytosis is the rule with the fever, and mononuclear increase in the afebrile periods. The temperature may be continuous, of short duration, or lasting two or three weeks and resembling a typhoid or paratyphoid fever curve; on the other hand it may be interrupted, a relapsing type of temperature; there are three or four days of fever, 12 to 24 hours of normal temperature, another period of from 3-4 days and recovery, or with shorter febrile periods of 24 to 30 hours occurring at intervals of 5-6 days. Prognosis. The prognosis is good. The disease is not fatal; about 90 per cent, get well promptly on symptomatic treatment; 10 per cent, run a long course. Treatment. Even if delousing has been accomplished, isolation is necessary, as the infection is conveyed not only by the louse, but by the virus excreted with the urine and saliva of the patient. If a case were seen in civil practice, one would urge the necessity of rest in bed, even in the lighter cases, as probably having a beneficial effect on the course. The choice of room, bed, care of patient, and preliminary catharsis with enemas and light cathartics later are deter- mined by the same considerations and exercised in the same manner as in Typhoid or Pneumonia or Influenza. (See Chaps. XIV or IX and XII.) The urine and sputum, both of which are infectious, should be de- stroyed by heat or the use of such antiseptics as cresol or lysol. (See Typhoid Fever, Chap. XIV.) The diet should be sufficient to meet the caloric needs of the patient (see Chap. II) and chosen much as Typhoid Fever. (See Chap. XIV.) Water should be freely administered, or fruit drinks, lemonade, orange- ade or alkaline drinks. Aches and pains are to be met by the use of aspirin, the coal tars, acetphenetidin (phenacetin), acetanilid, antipyrin or in more severe cases by codeine or even morphine, for the detailed administration of which see Grippe (Chap. XI). Insomnia. For use of hypnotics, consult Chapters on Grippe (XI), or Pneumonia (IX) or their summaries. Nervousness. May be lessened by warm sponge baths and the administration of bromides. In long standing cases anemia ensues. This should be met with a sufficiency of good food, air, sunlight and the use of iron, as Vallet's TRENCH FEVER 753 mass or Eland's pills gr. x (0.66 Gm.) three times a day with arsenic, as arsenious acid gr. 1/40 (0.0015 Gm.) at the same intervals, combined with iron or as cacodylate of soda hypodermically, gr. ss.-i (0.03-0006 Gm.) a day. Considering that spirochetes have been suspected as the infecting organism it seemed reasonable to try arsphenamine (salvarsan), but its use was not followed by gratifying results. Serum from convalescent cases was administered without success. Richter reported that the intravenous injection of 10 c.c. of 1 per cent, collargol every two or three days during the acute stages was followed by a rapid cure. (Quoted from Swift.) Complications and sequelae. A large percentage of cases of D. A. H. (disordered action of the heart) or cardio-vascular asthenia or effort syndrome, in the British Army had trench fever, which played its role in all probability in the acquisition of that condition. Small doses of thyroid have been recommended as likely to lessen the incidence of this condition. Leg pains and lumbar pains were sometimes exceedingly persistent. The patient should not be discharged until the dangers of relapses have probably passed, as he will constitute a pool of virus for the in- fection of lice and so of other individuals in contact with him. He should be kept in bed at least a week after the last relapse. He should then be gotten up gradually and put through graduated exercises. A change of environment, fresh air, sunlight, good food are all helpful. The convalescence is often slow and some five per cent, manifest the neurasthenic symptoms mentioned as a sequel and which probably represent continued infection. These cases require much attention, tact and ingenuity in the handling. Prophylaxis. Trench fever is transmitted by the louse, Pediculus Humanus, and hence it is very important that any patient suffering from trench fever be carefully deloused. The hair of his head, axillae, pubis and chest should be shaved and burned. The patient should then be bathed with warm water and soap followed by an alcohol (50 per cent.) sponge. He should then be put to bed in another room in another bed known to be free from vermin. The patient should be daily in- spected for nits and lice. The room previously occupied by the patient and all articles of furniture, clothing, bedding and mattress should be disinfected even though there is no trace of lice, for the virus of trench fever is excreted in the urine and saliva of patients and in the feces of the louse and may still be viable. Those who carry out the disinfection should wear rubber gloves and avoid rubbing the contaminated material on the skin. 754 TREATMENT OF ACUTE INFECTIOUS DISEASES Disinfection may be effected by moist heat at a temperature not lower than 120 F. for one-half hour. All persons who have been in contact with patients should be ex- amined for lice and nits and if infected should be deloused and watched for 30 days, for a person may develop the disease after he is freed from the lice. Bedding and mattresses as well and clothing should be disinfected by heat. (See Typhus Fever, Chap. XXVIII.) If heat is not used, soaking in a 2 per cent, solution of liquor saponatus cresoli fortis or 2 per cent, solution of crude phenol and soft soap, equal parts at any temperature above '32 C. for 20 minutes or 1 per cent, solution at 60 C. to 63 C. for 20 minutes. The patient once infected is a source of virus and as the case is often chronic and the relapses very far apart, carriers of this virus are pretty sure to carry the disease into civil life. SUMMARY Treatment Isolate the patient until del ousing is completed; when this is accom- plished isolation is no longer necessary. Rest in bed. H I (See Typhoid Fever, Chap. XIV, Pneumonia, Care of patient ' Cha P' IX > or Influenza > Cha P- XIL > Catharsis. Diet. Should contain 3,000 or more calories if well taken. (For items of dietary, see Typhoid Fever, Chap. XIV.) Drinks. Water freely, lemonade,^orangeade, alkaline drinks, weak tea, cocoa, buttermilk. Aches and pains. Acetyl salicylic acid (Aspirin), gr. v-x (0.33-0.66 Gm.), every 2 or 3 hours; or: Acetphenetidin (Phenacetin), gr. iii-v (0.2-0.33 Gm.); or: Antipyrin, gr. ii-iv (0. 125-0.250. Gm.); or: Acetanilid, gr. iss.-gr. iii (0.10-0.2 Gm.) at the same intervals. (See also, Grip, Chap. XI.) TRENCH FEVER 755 In severe cases. Codeine phosphate or sulphate, gr. 1/8-1/2 (0.008-0.030 Gm.) by mouth or hypodermically; or: Morphine sulphate, gr. 1/8-gr. 1/4 (0.008-0.015 Gm.), hypodermic- ally; Insomnia. (For choice and use of hypnotics, see Grippe, Chap. XI, or Pneumonia, Chap. IX, or their summaries.) Nervousness. Warm sponge baths. Bromides in doses of gr. xv-xxx (1-2 Gm.) in water. Anemia. Good food and sufficient. Fresh air and sunlight. Iron as Blaud's pills or Vallet's mass (Massa ferri carbonatis) gr. x (0.66 Gm.). Arsenic well to combine it with the iron. Arsenious acid (Arseni trioxidum), gr. 1/40 (0.0015 Gm.) Sodium cacodylate, gr. ss.-i (0.030-0.060 Gm.) given hypodermic- cally. Collargol. Intravenous injection of 10 c.c. of a 1 per cent solution, every 2 or 3 days during the acute stages. (Richter.) Sequelae. Disordered action of the heart (D. A. H.), the effort syndrome or cardio-vascular neurasthenia. Probably represents low-grade infection. Good food, fresh air, graduated exercises, tactful handling. Small doses of thyroid. Leg pains and lumbar pains. Local measures. Aspirin in small doses. Convalescence. Keep in bed at least a week after last relapse. Get up gradually. Graduated exercises. Good food. Fresh air. Change of environment, if possible. Prophylaxis. Delousing. (See Typhus Fever, Chap. XXVIII.) Clothes submitted to steam under pressure. (See Typhus Fever, Chap. XXVIII.) 756 TREATMENT OF ACUTE INFECTIOUS DISEASES Shave pubic and axillary hair. Cut hair on head close. Bedding and mattresses submitted to heat; steam under pressure. Bed clothing if not disinfected by heat may be soaked in 2 per cent. solution of liquor saponatus cresoli fortis. or: 2 per cent, solution of crude phenol and soft soap, equal parts at any temperature above 32 C. for 20 minutes; or: 1 per cent, solution at 60 C.-63 C. for 20 minutes. CHAPTER XLV SEPTICAEMIA AND PYAEMIA ALTHOUGH this condition affords a fairly definite picture, it is by no means easy of definition. Septicaemia is a state of infection in which the infecting organism is not only encountered in the blood, but is multiplying there, and yet evidences of infection with recovery of the infecting organism from the blood does not necessarily constitute a septicaemia but may exemplify a far less serious infection called bacteriaemia and the same organism may be concerned in one or the other condition. For example, the pneumococ- cus may be, often or usually is, isolated from the blood of a lobar pneu- monia and its presence in the blood in no way modifies the picture, course or issue of the pneumonia or on the other hand it may be causal of a true septicaemia. What relationship of infecting organism and host determines the relatively innocuous bacteriaemia and the profoundly serious septi- caemia is not yet clear. If suppurative foci appear in a septicaemia the process is spoken of as pyaemia. Toxaemia is a term used to express the effects on the body of the toxins or products of bacterial activity irrespective of whether that activity is local in some tissue or general throughout the body in the blood. As the essence of septicaemia and pyaemia is the same (presence and multiplication of virulent organisms in the blood), and their difference determined only by the presence or absence of multiple suppurative foci they will be considered together. The organisms commonly responsible for septicaemia are strepto- cocci; and, indeed, it is a streptococcus septicaemia that the unquali- fied term " septicaemia " usually connotes to the ear of the general practitioner, but the invasion of the blood by many other forms of bacteria may constitute a septicaemia; e. g., the staphylococci; and a staphylococcus septicaemia is usually characterized by the multiplicity of abscesses accompanying it (pyaemia), the pneumococci, the gonococci, the typhoid bacilli, the colon bacilli, the influenza bacilli, pyocyaneus, proteus, Friedlander's bacillus, micrococcus tetragenus, anthrax, bacillus aerogenes capsulatus, meningococcus. 758 TREATMENT OF ACUTE INFECTIOUS DISEASES The general symptoms of septicaemia and. pyaemia (septico-pyaemia) are due to the toxaemia; and the focal and local lesions to the thrombo- phlebitis and emboli producing infarcts, and abscesses. The. valves of the heart and adjacent structures, like the veins, may be the seat of bacterial activity and furnish infective thrombi (bacterial or ulcerative or malignant endocarditis) ; and the effects they have upon the organs concerned constitute the pathology of the disease. The early symptoms are due to the toxaemia and the toxaemia is intense; and, in the absence of a local lesion, suggest one of several conditions such as typhoid fever, acute miliary tuberculosis, pneu- monia with tardy consolidation, aestivo-autumnal malarial fever. In children B. coli pyelitis and, more rarely, grippe and otitis media simulate a septicaemia. A more accurate diagnosis in the early stage awaits the result of blood examination; its cytology, serum reactions and most of all its culture returns. Later, heart murmurs, hemorrhagic spots (petechijse) , splenic, pul- monary and renal infarcts, cerebral embolism, suppurative foci, retinal hemorrhages, assure a septicaemia; while the other suspected conditions would take on gradually their classic characterization. The early symptoms are fever, often initiated by chills (and the chills may be repeated or long continued, and, indeed, are character- istic of pyaemia); loss of appetite, delirium or stupor or the typhoid state. TREATMENT Rest. Insistency on rest in its broadest significance should be considered imperative. This means a quiet room, comfortable bed, competent nursing, freedom from worries and anxieties, exclusion of visitors. Room. Whether in the house or in the hospital, it should be chosen with reference to light, ventilation, conveniences of bath-room, access to the open air by veranda or porch, and remoteness from the noises of the street and of the household. Light is an important therapeutic agent, the operation of which is too little known in its details. In- dividuals respond differently to light both in its quality and quantity. One has but to consult his own personal experiences in health to realize what an extraordinary effect upon our moods and emotions and so upon our bodily functions light and shade, sunshine and shadow have, aside from the direct effects of the rays of light upon the body cells themselves. In disease these effects of light should be taken into consideration and SEPTICAEMIA AND PYAEMIA 759 the grateful effects of morning or evening sun and the irritating action of the noon-day glare be provided for or avoided. The destructive effect of sunlight on germ life is too well known to dilate upon here. Fresh Air. Maximum ventilation is desirable and a corner room with a number of windows affords this. All that has been said of fresh air in pneumonia obtains here both as regards the rationale of its thera- peutic action and the technique of exposing the patient to the open air. (See Pneumonia, Chap. IX.) The room should be stripped of all unnecessary furnishings and be devoted entirely to the patient. The use of the same room to sleep or rest in by the nurse is to be deprecated because of the bad results to both in ways readily imagined. If it is not possible to have more than one nurse, she should be re- lieved at suitable periods by members of the family, to secure her rest in a quiet room remote from the scene of her duties. Bed. For details, see Pneumonia, Chap. IX. Diet. While the most virulent cases of septicaemia run a rapid course and are accompanied by anorexia that makes feeding very difficult, the vast majority run a fairly long course that compels knowl- edge of the theoretical needs of the patient and the arrangement of a dietary to meet them. The theoretical needs have been detailed in Chap. II, while arrangements of dietaries to fulfil them may be seen under Typhoid Fever, Chap. XIV, Pneumonia, Chap. IX, and else- where. (Consult Summaries.) To epitomize, we endeavor to achieve 3,000 calories daily in the diet and as much more as the patient handles well. The proteid con- tent should be about 80 grams, but need not be rigidly fixed ; milk, eggs, bread, cereals, broths (especially those fortified with farinaceous flours), purees, form the basis of this diet and the use of sugar in the milk, in jellies, on cereals, in fruit drinks, and the use of fats, such as cream in the milk, on cereals and butter on bread add to the caloric content of the diet. Variety is secured by using various milk preparations; butter-milk, koumys, matzoon, zoolak, junket, ice-cream; of eggs by preparing them in different forms; coddled, custard, egg-nog, egg-white, poached; of cereals by using different kinds, incorporating them in broths, or as some of the invalid or infant foods, so numerous on the market; the bread as bread and butter, toast, dry or wet, milk toast, bread and milk, crackers, biscuit. Frequency of feeding should be every two or three hours as the patients bear it best. 760 TREATMENT OF ACUTE INFECTIOUS DISEASES Fluids should be given in abundance; alUthat the patients want and to those delirious, stuporous or too sick to ask for it, it should be offered at least every hour. It may be given as water, plain, or if grateful, aerated; as lemonade, orangeade or other diluted fruit juices or Imperial drink. (See summary for formula.) When first seen the bowels should be freely opened either by castor oil or a salt, Epsom, Rochelle, sodium phosphate, in doses of one or the other of gss.-l (15-30 c.c. or Gm.) or by calomel gr. ii (0.12 Gm.), best in divided doses, followed by the above or by Hunyadi or equivalent water, or milk of magnesia gi to ii (30-60 c.c.) or liquor magnesii citratis 5viii-xii (240-360 c.c.). Later the bowels should be kept open by the use of the milder salines mentioned above or by enemata. Care of the Body. For all the details of care of skin, mouth, nose, eyes, genitals, consult Pneumonia, Chap. IX, or Typhoid Fever, Chap. XIV, or the Summaries. Local suppurative processes in pyaemia, of course, indicate surgical procedures. SYMPTOMATIC TREATMENT Fever. The nature of the infecting organism, the virulency of the toxins, the presence or absence of suppurative foci, all determine differ- ences in the fever curve. The temperature may run continuously high with slight excursions, or show wide excursions, accompanied by rigors and sweating, especially in pyaemia, or may be relatively low in the more chronic cases. Hyperpyrexia but rarely occurs; but a sustained high temperature of 104 F. to 105 F. is more common and has the same deleterious effect upon the vital centres. These cases indicate the local appli- cation of cold in the shape of cold packs or cold sponges repeated at three to four hour intervals if necessary, and prolonged until some effect is made upon the temperature. The most beneficial effects of these baths is upon the circulatory and nervous system. When the rise of temperature is initiated by a chill, hot drinks may be administered and heat applied to the feet and body surface until the rigor has passed. The sweats that follow the febrile exacerbations call for luke warm sponges, change of linen and application of sterile dusting powders. Sometimes the excursions are so tremendous that collapse may ensue and demand the application of heat, hot drinks, diffusible stimu- lants, such as the stronger water of ammonia held near the nose on a towel, hypodermics of adrenalin, camphor or caffeine or strophanthin. At the onset there may be some vomiting, but as a rule this is not SEPTICAEMIA AND PYAEMIA 761 prolonged or violent enough to demand interference. Cracked ice may be sucked and counter-irritation applied to the epigastrium in the shape of mustard paste. Should it become more persistent, as it may, one has to modify the diet, giving the food in smaller quantities more frequently, cutting down the cream in the milk or lessening the intake of sugar, trying various modifications of milk. If the stomach tube is well borne, lavage with warm water may be helpful and the food administered by the tube. In persistent cases rectal feeding may be required. Nervous Symptoms. Restlessness, insomnia, stupor, delirium, headaches are all common. Delirium may be low, muttering, a typhoid state or noisy and wild. The items of importance to be considered in this state are fresh air, cold sponges or packs, a sufficiency of food and particularly an abun- dance of water. When it is difficult to give the patient enough by the mouth (3 to 5 quarts) one should have recourse to colonic irrigations and especially the drip or drop method of Murphy. Noisy delirium is also to be combated by the application of the ice-bag to the head. The patient should never be left alone, lest he do himself harm and in the wild cases restraint becomes necessary. The most humane method is by so attaching the bed covers to the side of the bed that his hands and arms cannot escape or the patient sit up, but allowing his body some freedom of movement. At times it is imperative to tie the extremities to the bed; knots must be so made that they will not slip and tighten upon the wrists and ankles to their injury. Drugs. At times are necessary. If the condition is one rather of restlessness and excitability bromides in doses of 15-30 grains (1-2 Gm.) ; either the potassium salt or the mixed salts of potassium, sodium and ammonium in equal parts may be administered late in the after- noon and repeated in the evening, as the condition is likely to be worse at this time. In more severe delirium codeine is indicated, best as the soluble phosphate in doses of gr. 1/4 (0.015 Gm.) hypodermically. In still more severe cases morphine is indicated, given hypodermically as the sulphate gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) or Majendie's solution m. iv to m. viii (gr. 2/15-4/15; 0.008-0.015 Gm. morphine). If morphine is not well borne or excites as it does in the rare case, one may have recourse to hyoscine hydrobromide in doses of gr. 1/200 to gr. 1/100 (0.0003-0.0006 Gm.) hypodermically. Insomnia is met by much the same measures, ice to the head, hot 762 TREATMENT OF ACUTE INFECTIOUS DISEASES drinks, heat to the feet, if they are cold, and this is especially so in young subjects; by bromides, trional gr. xv '(I Gm.), chloralamid gr. xxx (2 Gm.), any one of which may be repeated in two or three hours, or by codeine and morphine. Headaches may be due to the iriitating effects of the toxins or to a localization of bacterial activity in the brain or its coverings. It may be relieved by the application of an ice-bag or ice-coil or by the use of drugs. The use of coal tar derivatives is to be deprecated as depressing to the circulation. A very severe headache is better controlled by morphine. Convulsions may occur, but are due in most cases to thrombo- phlebitis or embolism and not likely to be repeated or prolonged. Mor- phine sulphate hypodermically in doses of gr. 1/4 to gr. 1/3 (0.015-0.02 Gm.) is the best emergency drug. If convulsions are repeated the same procedures are indicated as in convulsions from other causes. (See Scarlet Fever, Chap. XVII.) Circulation. Sooner or later the circulatory apparatus is imperilled either by the effects of the toxins on the centres or on the myocardium or by a localization of the process on the endocardium, a malignant endocarditis. For a detailed use of circulatory stimulants, see Pneumonia, Chap. IX. It is my growing belief that the value of no circulatory stimulant in acute infectious disease is comparable to digitalis and strophanthin. The latter I use in emergency gr. 1/90 to gr. 1/60 (0.00075-0.001 Gm.) intramuscularly or intravenously and repeat in six to twelve hours if needed. Follow with digitalis m. xxx (2 c.c.) of the tincture [=gr. iii (0.2 Gm.) of the leaf] or its equivalent in dosage of some other official preparation three or four times a day until its pharmacological or toxic action is obvious. I do not believe in the use of alcohol. Further treatment is directed to the accidents of the disease. These are determined by localization of the process by thrombophlebitis, by embolism and in pyaemia by suppurative foci. The process may localize on the endocardium or may originate at this site and the treatment becomes that of malignant endocarditis, its attendant embolisms and circulatory impairment. It may localize upon the brain, giving rise to a meningitis, and is to be treated like a cerebro-spinal meningitis (see Chap. XXV) symp- tomatically. Thrombophlebitis may occur in the veins of the extremities and demand rest, slight elevation of extremities, applications of heat, as fomentations, and protection with cotton batten. SEPTICAEMIA AND PYAEMIA 763 Thrombophlebitis may occur in deeper organs, giving rise to second- ary results. It is this occlusion of the vein by inflammatory products that furnishes a nidus for the organism and with the heart valves fur- nishes the infective emboli, which are carried to the brain and cause hemiplegia, monoplegia, aphasia or other disturbances of cerebral function. The treatment is only tentative. Emboli may plug the central artery of the eye and cause blindness, plug the pulmonary arteries and cause infarcts or abscesses and empyema; may plug the coronary arteries, giving rise to sudden and alarming symptoms of dyspnoea and precordial distress or even death. Treatment of conditions follow- ing pulmonary infarcts is that of Pneumonia (see Chap. IX) with surgical intervention when suppuration intervenes. Splenic infarcts are common; often of diagnostic import. The pain accompanying them is relieved by local applications of heat or in the worst cases by morphine. The veins of the liver may become involved and a pylephlebitis, giving the worst prognosis, ensue. The abdominal viscera may become involved and abscesses result. Visceral abscesses, pylephlebitis, meningitis and endocarditis, all, are of the most ominous significance. The bones may be affected and osteomyelitis demand surgical inter- ference. The joints may be the site of a mild arthritis and should be treated as such (see Rheumatic Fever, Chap. Ill) or may suppurate and need evacuation. The muscles and skin, especially in staphylococcus in- fection, may be the site of multiple abscesses and require incision. The kidneys may become involved. Infarcts with hematuria occur, needing only expectant treatment, or an acute nephritis, to be treated as such (see Scarlet Fever, Chap. XVII), or the kidneys become the site of suppuration and, if localized, are amenable to surgery. Hemorrhages into the skin, petechiae, are highly diagnostic, espe- cially those in the conjunctive. These latter occur peculiarly when the heart is involved. Erythemata also occur and icterus, but none of these require treat- ment. In pyaemia the original site of infection and abscesses secondary to the infection indicate, of course, surgical measures. Certain differences depend on the nature of the infecting or- ganism. Of the common forms of infection streptococcus septicaemia is sup- posed to be the worst, though there is little difference in prognosis 764 TREATMENT OF ACUTE INFECTIOUS DISEASES between it and staphylococcus septicaemia, if, indeed, the latter is not the worse. Streptococci affecting the heart valves, or. the meninges or causing pylephlebitis or visceral abscess lead to an almost certainly fatal issue; although endocarditis of the more chronic type, "endocarditis lenta," "bacterial endocarditis," due to the streptococcus viridans of Schot- muller seems occasionally to get well and even one apparently true case of streptococcus meningitis has been reported cured. Particularly ominous, too, are the streptococcus septicaemias oc- curring in small pox, scarlet fever, diphtheria and secondary to sur- gical procedure. Of better prognosis is the streptococcus septicaemias of the puerperium. Staphylococcus Septicaemia is almost certainly fatal, its course being characterized by multiple abscesses. Pneumococcus septicaemia gives little chance of cure. Among other forms of septicaemia are those due to diphtheria ba- cilli (though streptococcus, staphylococcus and pneumococcus are commonly recovered from the blood with it), to typhoid bacilli, colon bacilli, bacillus pyocyaneus, meningococci, bacilli dysenteriae and even bacilli fusiformis. Specific Treatment. For only two of the organisms mentioned have we specific sera, bacillus diphtheriae and pneumococcus type I ; for some of the others, sera containing certain dimly visualized antibodies have been elaborated. Scarlet Fever. Streptococci may be recovered from many cases that run a relatively mild course,. a bacteriaemia, and it is difficult to establish a criterion for true septicaemia in the sense of this discussion and, hence, to judge of the efficacy of streptococcic sera. Nicoll, discussing this subject, accepts a certain clinical picture commencing forty-eight hours or longer after the onset, as constituting sepsis; "no fall of temperature or a renewed rise; abnormal swelling of the mucous membrane of the throat; with or without superficial sloughing; profuse nasal discharge; marked cervical adenitis; rapid, often irregular pulse; mental apathy; active or low delirium." He, working in the Scarlet Fever Hospital of the Department of Health of New York City, used a serum prepared under the direction of Dr. Park. Eleven strains of streptococci recovered from the blood, throat and other sources from scarlet fever patients were used in the animals to elaborate this serum; hence, a polyvalent serum. His dose of this particular serum was 200 c.c.; in young children, 50-100 c.c. injected into loose tissue, repeated 2 to 3 times at 6 to 8 hour intervals depending on the results obtained. SEPTICAEMIA AND PY^MIA 765 His results warrant his advice to use the serum in all very severe cases of scarlet fever. Similar efforts with polyvalent sera have been made for some years past, especially in European clinics. One of those best known in Europe is the Moser serum so persistently advocated by the late Professor Escherich of Vienna. My own impression is that polyvalent streptococcus sera are well worth using in this condition, with the realization that the strains used may or may not be biologically identical with the organisms re- sponsible for the individual case; hence, may be more or less efficacious, depending in a measure on chance. The dose of the commercial serum is that used by Nicoll. More recently serum from patients convalescent from scarlet fever has been used with some show of success. The dose is just the same as that for the commercial sera. Vaccine Therapy. Our knowledge of the possibilities and limitations of vaccine therapy is too limited to discuss didactically the application of this measure to septicaemia. Reasoning that the body is already overwhelmed with virulent toxins, and that the addition of more in the shape of vaccines (endotoxins) is illogical we pause before using them; on the other hand the belief that the response in terms of antibodies may be local at the site of injection urges us to take a chance. Indeed, its use in the severer cases is that of appeal to the last resort and is so far justifiable, but then only with a clear knowledge of the theory and uses of vaccine therapy. In the more chronic cases the use of vaccines is more encouraging and some cures of malignant endocarditis by the use of vaccines have been reported from reliable sources. Autogenous vaccines should be used when possible. If the organism cannot be recovered from the blood, local lesion or other reliable source, one may use a .polyvalent vaccine with a lesser expectation of success. Puerperal Sepsis. As I have said the outlook in this form of sepsis is better than in those already mentioned. Here again the polyvalent streptococcic sera may be used in the streptococcus cases and the vaccines, too, with a greater hope of suc- cess, though here, too, it is in the subacute cases that the best results follow. G. T. Western, studying 96 cases of puerperal sepsis, 39 of whom gave positive cultures (36 were streptococci), treated with vaccine 56 with a mortality of 32 per cent., and treated without vaccines 44 with a mortality of 55 per cent. Even better results have been reported by others. Others report less enthusiastically. I imagine that in this 766 TREATMENT OF ACUTE INFECTIOUS DISEASES particular form of sepsis the management of the case in other respects plays a major part in the results. What the management of a puerperal sepsis case should be I am not competent to judge in the midst of argu- ments pro and con, but, influenced by environment, quote Ward from the Sloan Maternity Hospital, New York: "A. Obtaining adequate uterine drainage, first, by simple vaginal and intrauterine saline douches. This proving insufficient to control the process, explore the uterus once, and once only to make sure it is empty of foreign products, using the finger for the exploration, and with a minimum of trauma to the uterine tissues. "B. Treat expectantly secondary foci as they arise, and C. Sup- port the general condition of the patient." (J. A. M. A., April 12, 1913.) Staphylococcus Septicaemia may be treated on the same principles with sera and vaccines with even less anticipation of results. Pneumococcus Septicaemia. Hope from sera depends on the de- termining strain. Grouping pneumococci according to the classification followed at the Rockefeller Institute, types I and II against which sera have been elaborated may be combated by the use of the sera as in Pneumonia, but practically it has been found that type I serum alone is efficacious. Types III (mucosus) and IV (a heterogenous group) yield no active sera. As a vaccine, group I (Neufeldt) may be used as in pneumonia and some believe that the antibodies provoked are in some measure operative against the other organisms, or a polyvalent vaccine may be used. Again it must be insisted that these measures are adopted by the desire to leave no stone unturned rather than by anticipation of favorable results. Gonococcus, B. coli, streptococcus mucosus and other forms of septicaemia may be attacked in the same manner, but with a full realiza- tion of the paucity of published results and with the sense of responsi- bility towards the patient in handling these powerful agents. Transfusion of Blood. At the present time I am using transfusion in septicaemia and in severe infections that may not be truly classed as such, on account of a remarkable experience of my own, the first case in which to my knowledge the method was used for this purpose. A case of sepsis in a child of twelve, seemingly moribund, recovering after five transfusions from the father's blood. The case is reported with others by Dr. Lindeman in the Journal of the American Medical Association, October 31, 1914. Reports of the experience of others since and my own observations SEPTICAEMIA AND PY^MIA 767 of improvement in other cases in which the transfusion has been done make me feel that the measure has a place in the therapy of septicaemia. It is more than probable that the blood of healthy individuals con- tain in a large per cent, of cases immune bodies to most of the common infections. The studies of the antitoxin content of normal blood by the Schick reaction for Diphtheria reveals such astonishing positive results, that in the absence of a practical test for other immune substances the use of healthy blood would seem entirely reasonable. In addition the introduction of fresh blood must be welcome to the patient in an anemic state so decided as that of septicaemia, while other theoretical considerations could be cited for argument's sake. My experience with transfusion leads me to believe that its value lies in its application to those diseases whose natural history is to recover under favorable conditions, e. g., it would be of value in puerperal sepsis, while it holds out no hope in cases of acute malignant endocarditis. Methods of transfusion much more facile than the old direct method have been elaborated of late for which special treatises must.be consulted. See Lindeman, Am. Jour. Diseases of Children, Vol. VI, No. 1, Lindeman, Jour. A. M. A., June 7, 1919, Vol. 72, pp. 1661-1665; Satterlee and Hooker, Archives of Internal Medicine, January, 1914, and Unger, Jour. A. M. A., 1915, LXIV, 582; Sanford, Med. Clinics of North America, Nov., 1919, p. 801; Losee, A. J. M. Sc., Nov., 1919, No. 5, Vol. CLVIII, p. 711. The donors must be healthy, show a negative Wassermann and prove to have a blood congenial to that of the patient (non-hemolytic). For the technique of these tests one should consult hand-books of laboratory method. (See Hiss and Zinsser's Bacteriology.) Theoretically, a parent's blood should be better than a stranger's as more likely to represent the biological characteristics, but this is by no means without exception. Again, theoretically, a brother's or sister's blood should be better than the parents', but at times it is absolutely uncongenial. The amounts depend on age, weight, the patient's reaction, and the donor's condition. In my first case 200 c.c. to 300 c.c. were given at weekly intervals for five weeks. In older cases 800 c.c. to 1,000 c.c. may be given. If a good response is obtained it is better to use the same donor than to change, as every now and then in spite of satisfactory laboratory tests an hemolysis in the veins of the recipient occurs with dangerous or disastrous results. Ottenberg and Libman, however, place implicit reliance in the results of the agglutination and hemolytic test and say, 768 TREATMENT OF ACUTE INFECTIOUS DISEASES "In no case in our series in which hemolysjs or agglutination did not occur in the test-tube were any untoward symptoms observed which could be attributed to these phenomena." Their article on Blood Transfusion in the Am. Jour. Medical Sciences, July, 1915, is most illuminating. If the infecting organism is known it is possible to inoculate a donor with vaccines made from it and enhance the protective power of blood before he donates. Human serum has been advocated especially by Welch. See New York State Medical Journal, November, 1913. As the serum contains most of the immune bodies an argument might be made for its selection in preference to whole blood and it certainly is less likely to result in unfortunate accidents. On the other hand I feel that the whole blood is more likely to give the maximum benefit than serum alone. Prophylaxis. This begins with proper surgical consideration of foci of infection, but the internist must remember that these foci may be latent in tooth, tonsil, sinus and other anatomical nooks and corners and include all these in his routine examination of patients. SUMMARY Treatment Rest. Quiet room, comfortable bed, competent nursing, freedom from worries and anxieties, exclusion of visitors. Room. Provide for light, air, bath-room facilities, approach to porch or verandah if possible. Bed. Hospital type, half or three-quarters width, woven wire springs, firm mattress. Diet. At onset, don't push. Later, provide for 3,000 calories, or as much as is well taken, and for 80 grams of proteid. Milk, buttermilk, koumys, matzoon, zoolak, junket, ice-cream. Eggs, coddled, poached, custard, egg-nog, egg white. Cereals, different varieties thoroughly cooked, used in broths, various invalid and infant foods. Bread, bread and butter, toast, milk toast, bread and milk, crackers, biscuit. SEPTICAEMIA AND PY^MIA 769 Cream, butter, cocoa, sugar in milk, in cereals, in jellies, in drinks. Give food every two or three hours. Fluids. Water, plain or aerated, lemonade, orangeade, diluted fruit juices. Imperial drink (1 tablespoonful of cream of tartar to 3 pints of boiling water, add sugar and lemon peel to flavor). Bowels. When first seen. Calomel in divided doses, followed by salts or salts alone or castor oil. Calomel, gr. 1/4 (0.015 Gm.), every quarter hour for six doses; follow in two or three hours by Epsom, Rochelle, or Glauber's salt or sodium phosphate; of either 5ss. to i (15-30 Gm.), or milder salines. Such as Hunyadi water. Milk of magnesia, 5i-ii (30-60 c.c.), Liquor magnesii citratis, Jviii-xii (240-360 c.c.), Castor oil, 5ss.-i (15-30 c.c.). or A salt or castor oil without calomel in same or double doses. Later. Milder salines mentioned above. Enemata. Care of the body. (See Pneumonia, Chap. IX, or Typhoid Fever, Chap. XIV.) Local suppurative processes. Surgical procedure. Symptomatic treatment Fever. Cool or lukewarm sponges. Hypersemia. Cold sponges. Cold packs. Cold baths. Chills. Heat to feet and body surface. Hot drinks. Collapse. Heat to body and feet. Hot drinks. Diffusible stimulants. Stronger water of ammonia on a towel held to nose. Adrenalin (1:1000) m. x to m. xv (0.65-1 Gm.) intramuscularly. Camphor gr. v (0.30 Gm.) in oil, intramuscularly. 770 TREATMENT OF ACUTE INFECTIOUS DISEASES Caffeine sodium benzoate or sodium saliqylate gr. v (0.30 Gm.) in water intramuscularly. Strophanthin, gr. 1/120 to gr. 1/90 (1/2-3/4 mg.) intravenously or intramuscularly. Vomiting. Cracked ice. Mustard paste 1 in 2, 3 or 4 to epigastrium. Cut down on diet, and fats and sugars in diet. Lavage and gavage. Rectal feeding. Nervous symptoms. Delirium. Fresh air. Cold sponges or packs. Abundance of water. Ice-bag to the head. Never leave patient alone. Restraint in mild delirium. Bromides, gr. xv to gr. xxx (1-2 Gm.). Codeine phosphate, gr. 1/4 (0.015 Gm.) hypodermically. Morphine sulphate, gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) hypodermic- ally. Hyoscine hydrobromide gr. 1/200 to gr. 1/100 (0.0003-0.0006 Gm.) hypodermically. Insomnia. Bromides, gr. xv to gr. xxx (1-2 Gm.). Trional, gr. xv (1 Gm.). Repeat in two or three hours if neces- sary. Chloral amid, gr. xxx (2 Gm.). Repeat in two or three hours if necessary. Codeine phosphate, gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) hypoder- mically. Morphine sulphate in persistent cases, gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) hypodermically. Headaches. Ice-bag or ice-coil. Morphine gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) in severe cases. Convulsions. Morphine sulphate, gr. 1/4 (0.015 Gm.) hypodermically. (See Scarlet Fever, Chap. XVII.) Circulation. Digitalis m. xxx of the tincture (2 c.c.) or gss. (15 c.c.) of the in- fusion or gr. iii (0.2 Gm.) of the leaf three or four times a day. Strophanthin in emergency, gr. 1/90 to gr. 1/60 (0.00075-0.001 Gm.) intravenously or intramuscularly and repeat in six to twelve hours if needed. (See Pneumonia, Chap. IX.) Accidents of the disease. Endocarditis. Meningitis. SEPTICAEMIA AND PYAEMIA 771 (See Cerebro-spinal Meningitis, Chap. XXV.) Thrombophlebitis. Rest. Elevation of extremity affected. Application of heat, fomentations. Protection with cotton batten. Embolism infarcts. Of the lung. (See Pneumonia, Chap. IX.) Of the spleen. For pain. Local application of heat. Morphine sulphate, gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) hypodermically. Arthritis. (See Rheumatic Fever, Chap. III.) If joints suppurate, evacuate. Muscles, abscesses, incise. Kidneys. Infarcts expectant treatment. Nephritis. (See Scarlet Fever, Chap. XVII.) Specific treatment Bacillus diphtheria* septicaemia. Diphtheritic antitoxin. Large doses intravenously. (See severest cases, Diphtheria, Chap. XVIII.) Scarlet fever. Polyvalent streptococcic sera. (See text.) Vaccine therapy. (See text.) Puerperal sepsis. (See text.) Staphylococcus septicaemia. lactines. } < See text ') Pneumococcus septicaemia. (See text.) Transfusion of blood. (See text.) Use of human serum. (See text.) Prophylaxis. CHAPTER XLVI ERYSIPELAS ERYSIPELAS is a disease, deriving its name from its chief clinical characteristic, a redness of the skin due to an inflammation of this structure, resulting from an invasion by the streptococcus pyogenes, sometimes called streptococcus erysipelatis of Fehleisen. Morphologically and culturally there is no difference between strep- tococcus pyogenes and streptococcus erysipelatis, but it is probable that the affinity of the organism for the skin is determined by some biological differences and these biological differences constituting strains, and, by mutations, varieties and species, affords one of the most in- teresting studies of the present moment. Not only is the skin involved but in rarer instances the mucous membranes. The manner of skin involvement is a very definite one and entirely different from a lymphangitis or cellulitis although the three conditions are but different expressions of the invasion of the skin by the streptococcus pyogenes. The intensity of the inflammation varies, too, from the usual brawny indurated area of erythema, to vesiculation, pustulation, suppuration and necrosis. Any trauma, however trivial, and sometimes too slight to be detected, affords the portal of entry. Again, that something so difficult of definition, which we call susceptibility and affinity determine certain sites of election in the skin. By far the most common site of the infection is the skin of the face (facial erysipelas) constituting 88 per cent, of the whole; the next most common site is the leg. In infants it usually begins about the umbilicus. As a rule it is confined to the part first affected, but may pass from site to site over the whole body and is spoken of as migrating erysipelas. Infections after trauma, after operation and in parturient women constitute another class. The symptoms are those attributable to streptococcus toxins, in any case of acute infection by these organisms; after an incubation of three to ten days there is a sudden invasion with chilly sensations or a distinct chill, a rapid rise of temperature, malaise, headache, nausea or vomiting, anorexia, etc. The temperature may run from 102 F. to 104 F. and be very irregular, it may remain high, 104 F. to 106 F. a few days and then become irregular and fall by lysis, or it may remain high throughout ERYSIPELAS 773 and fall by crisis like a pneumonia. The duration of the attack is one to two weeks. The local symptoms are those of a slowly advancing deep scarlet, brawny indurated area of inflammation with a clear-cut border as a rule. It may advance up or down a limb and has no respect for direction of lymphatic flow. The skin is hot, tense, burning. In facial erysipelas the usual site of entry is the mucous membrane of the nose and the skin over the nose is first affected. Out on either side, shaped like a butterfly, spreads the expanding area of inflamma- tion, until the whole face, eyes, ears and scalp are involved. As it recedes the swelling diminishes and the skin looks dry and burned. TREATMENT Isolation. Opinions differ about the necessity for isolation. The spread in a ward, in a family and among attendants is relatively rare, so rare as to make the strict rules of quarantine observed in such dis- eases as small pox, scarlet fever and diphtheria unnecessary if not unjustifiable; but willing to be charged with an ultra conservatism, I prefer to isolate the patient in a separate room in a hospital or in a house, forbidding visitors and having a special nurse or member of the family, who shall be instructed to burn dressings, properly sterilize her hands after contact with the patient and change her clothes before mingling with the family or others. The physician has but to remember that his hands and instruments are the means of conveyance of infection and he should therefore wear rubber gloves in dressing the lesions. Double precaution must be taken by a surgeon and by the obstetrician. Room. The room chosen should be light and well ventilated and as remote from the rest of the household as possible while fulfilling these requirements. The facilities of an adjacent bathroom are desirable and access to a verandah, porch or balcony a valuable adjuvant to the patient's com- fort and welfare. An open hearth affords the best means of disposing of infected dress- ings. Bed. The hospital type is preferred, a half or three-quarter iron bed- stead with woven wire springs and a firm mattress. For technique of bed-making, see Pneumonia, Chap. IV. Diet. During the early hours anorexia forbids forcing the food. The swollen condition of the face adds to the difficulty of eating and, of course, when, in the rare case, the pharynx is involved, the difficulty is greatly enhanced. When food can be entertained an effort must be 774 TREATMENT OF ACUTE INFECTIOUS DISEASES made to meet the theoretical requirements (see^Chap. II). This is the more imperative in the long continued cases,' more particularly the migrating forms. Water and drinks made from fruit juices should be administered freely. Care of the Body. A sponge bath with soap and warm water should be given daily. The mouth should receive special attention. (For details, see Chap. IV.) The eyes should be carefully cleansed with boric acid solution 2 per cent, to 4 per cent., and as in the facial form the eyelids may be greatly swollen, especial care must be given to this part of the toilet; cold cloths wet with boric acid solution may be applied to the swollen lids with comfort to the patient. A cathartic should be given when the patient is first seen. Epsom salt (magnesium sulphate), Rochelle salt (sodium potassium tartrate) or Glauber's salt (sodium sulphate) may be given in doses of 3ss.-i (15- 30 Gm.) in three-quarters of a glass of water. One may precede this by fractional doses of calomel gr. 1/10 to gr. 1/4 (0.006-0.015 Gm.) every ten to fifteen minutes until gr. i to gr. iss. (0.060-0.10 Gm.) are taken; the salt following in two to three hours. The smaller doses are especially indicated if there is nausea, as they are credited with being antiemetic. Later one may rely on milder salines, such as liquor magnesii citratis 5 viii (240 c.c.), milk of magnesia 5ii (60 c.c.), a Seidlitz powder or Hunyadi water to keep the bowels open; or enemata may be given in preference. Treatment of Symptoms. Prodromal symptoms of malaise, loss of appetite, headache and a little temperature require no consideration. At the onset the discomforts of a high temperature may be relieved by cool sponges and, in very high fever or long sustained, cold baths may be used, much as in Typhoid Fever. Headache may be relieved by the ice-bag, by small doses of phenacetin gr. iii (0.20 Gm.) every hour for three to four doses or acetanilid gr. iss. (0.10 Gm.) at the same intervals. Later on coal-tar derivatives should not be used. Nervousness and sleeplessness may be met by bromides in doses of gr. xv to gr. xxx (1-2 Gm.) or chloralamid gr. xx to gr. xxx (1.30-2 Gm.) given in the early evening and repeated if needed late in the evening. If there is delirium, morphine sulphate hypodermically in doses of gr. 1/8 to gr. 1/4 (0.008-0.015 Gm.) is indicated or in the sthenic period hyoscine hydrobromide gr. 1/200 to gr. 1/100 (0.0003-0.0006 Gm.) hypodermically. ERYSIPELAS 775 If there are evidences of circulatory failure support must be offered in the same way as in Pneumonia. (See Chap. IX.) LOCAL TREATMENT Facial Erysipelas. Many measures and applications have been advocated. To enumerate them would be only to confuse and in no way to edify or help. I will mention only those that seem to me to have value. My personal preference has heretofore been for ichthyol which I have used in 25 per cent, to 50 per cent, ointment or painted on pure, applied after carefully washing the face with soap and warm water, but the face is more likely to be dry and uncomfortable under the pure ichthyol. Over this one applies gauze, and a roughly made mask with tapes, to keep it in place, may be applied over all. The advance of the lesion has been thought to have been modified by compression of the healthy skin adjacent. The most common way of effecting this is by the application of collodion. This I have done with most of my cases in combination with the ichthyol treatment, sometimes feeling that I had effected something, again seeing no progress whatever. The experience of Inata and Woodyatt at Camp Cody during the war would seem to accentuate the value of this effort to limit the spread by the use of collo- dion (U. S. P.) applied to the skin within half an inch to an inch in ad- vance of the line of induration. The application must be thorough, leaving no break by which the lesion may spread, repainting if such occurs. They combine this treatment with the application to the area affected of a cloth wet with a cold saturated solution of magnesium sulphate. My own belief is that it is not easy to convince oneself of the useful- ness of any local measure in a self-limited disease, running so short a course and having so low a mortality as facial erysipelas. Erdman gave the average duration of 500 facial cases at Bellevue Hospital as between six and seven days and the mortality as 5.38 per cent. Objections to the ichthyol are its odor, its appearance and the be- smearing of everything about the patient. The substance is easily removed, however, from the skin or from fabrics by soap and water. Vaseline alone affords a certain degree of comfort. Erdman with his large experience is convinced that nothing local is better than simple wet dressings. He uses boric acid solutions, keep- ing the solutions cold with ice and applies frequently to the face gauze dressings dipped in them. Powders. Bland powders such as zinc oxide, starch, boric acid or a 776 TREATMENT OF ACUTE INFECTIOUS DISEASES combination f them, equal parts, dusted oa the skin liberally and covered with a light dressing of non-absorbent cotton relieves some of the disagreeable sensations. Erysipelas of the extremities runs a little longer course than the facial cases. Erdman's thirty-three leg cases averaged 10.88 days with a decidedly higher mortality (27.37), than the facial cases (5.38 per cent.) . Ichthyol is to be used in the same manner as in facial cases. A very excellent treatment of these cases is the wet dressing, especially that of aluminum acetate. 1 Boric acid solutions are also suitable for these cases, but I fail to see any advantage in the use of the stronger antiseptics, such as bichloride of mercury. Migratory Erysipelas. This is a very severe form of the disease, both because of the extent of the body involved and because it includes so many of the infant cases. The mortality in Erdman's fifty-six cases was 50 per cent. The duration averaged 14.44 days. Ichthyol and the wet dressings, may be used in these cases, so far as the extent of the lesion makes these measures practical. Erysipelas in Infants. Some 8 per cent, of the cases of erysipelas occur in infants under two years of age. The affection is far more serious than in adult life. New-borns are especially liable to the disease. The portal of entry is the umbilical cord. The type is migrating; death usually occurs at the end of six to ten days. Complications are likely to occur. Treatment begins with prophylaxis and the proper care of cord, buttocks and vulva. The treatment consists in the use of ichthyol, wet dressings, vaseline and powders as in adult cases detailed above. The mortality of in- fants under two years averages about 40 per cent. From two years to sixteen years children are singularly free from the infection (about 1 per cent.). Specific Treatment. Drug specifics in disease have become in these days of searching criticism a woefully depleted company. Among those to deserve banishment from the category are iron and quinine in erysipelas. I can see no good, whatsoever, from their use, but some disadvantages, such as gastric irritation. Vaccines. One is loath to abandon the hope held out by the use of vaccines in erysipelas and yet the most extensive series of cases 1 Formula Aluminis 3i ss. (6 . 00) Plumbi acetatis 5i ss. (45.00) Aq. q. s. ad Oij (1000.00) ERYSIPELAS 777 (ninety-five) of which I am cognizant conducted by clinicians and bacteriologists with whom I am personally acquainted and for whose work I have the highest regard leads to these conclusions. "From our experience with vaccines in erysipelas I must state that the duration of the disease was not at all lessened, the mortality re- mained at the same level, and there was no immunity guaranteed against recurrence, against spreading of the lesion, nor were complications, such as cellulitis and abscesses prevented; from the statements furnished by the patient, moreover, I could not gather that there was any ameliora- tion of the subjective symptoms." (Erdman, J. A. M. A., December 6, 1913.) Transfusion of Blood. In severe cases I should consider the problem as one of septicaemia and hold the same attitude towards the measure as in that condition. (See Septicaemia, Chap. XXXIV.) Complications. Many of these are surgical and to be treated on surgical principles; phlegmon, gangrene, abscesses, otitis media, edema of the larynx, periostitis, purulent arthritis, suppurative adenitis, sinusitis. Others are medical such as Pneumonia and Pleurisy (see Chaps. IX and VIII), Acute Nephritis (see Scarlet Fever, Chap. XVII), Bron- chitis, Tonsillitis, Arthritis (see Chaps. Ill, V and VII), Endocarditis, Septicaemia and Pyaemia (see Chap. XLV). Most important among these as a cause of death are Septicaemia and Pneumonia. Immunity seems difficult to establish and the same individual is prone to suffer from the disease again and again. Moreover, relapses are of common occurrence. Prophylaxis. Proper attention should be given to lesser traumata that furnish the portal of entry, and particularly in those individuals who have already suffered from the disease. Such slight traumatisms may be looked for in the nasal mucosa and in the skin about the nose, ear and elsewhere about the face. A vaccination wound may be the site of infection, or an old ulcer of the leg. In infants it is commonly the navel, excoriated buttocks or vulva. Again operative wounds may be infected and every care should be exercised by the obstetrician to avoid contact with erysipelas. It is a wise precaution to disinfect a patient's clothes before his dis- charge from the sick-room. 778 TREATMENT OF ACUTE INFECTIOUS DISEASES SUMMARY Isolation. Safer to isolate. Room. Light and well ventilated. Remote from noise of household. Near bathroom. Accessible, if possible, to veranda or porch. Open hearth desirable. Bed. Hospital type; one-half or three-quarters iron bedstead. Woven wire springs; firm mattress. (For technique of bed-making, see Pneumonia, Chap. IX.) Diet. Early hours; don't force. Prolonged cases. (See Chap. II or Chap. IX.) Water, lemonade, orangeade, alkaline and aerated waters freely. Care of the body. (For details, see Pneumonia, Chap. IX.) Eyes, 2 per cent, to 4 per cent, boric acid solutions. Cold compresses to swollen lids. Bowels. Rochelle, Epsom or Glauber's salt, 5ss. to 5i (15-30 Gm.), or Calomel, gr. 1/10 to gr. 1/4 (0.006-0.15 Gm.), every ten to fifteen minutes until gr. i to gr. iss. are taken, followed in two or three hours by salts in doses named above. Later. Milder salines. Liquor magnesii citratis, 5viii (240 c.c.). Milk of magnesia, ii (60 c.c.). Seidlitz powder. Hunyadi water. Enemata. Treatment of symptoms. Fever. If high, cool sponges. Headache. Ice-bag to head. Phenacetin, gr. iii (0.20 Gm.) every hour for three to four doses, in early stages. Acetanilid, gr. iss. (0.10 Gm.) at the same intervals, in early stages. Nervousness. ERYSIPELAS 779 Bromides, gr. xv to gr. xxx (1-2 Gm.), either potassium or mixed bromides. Insomnia. Chloralamid, gr. xx to gr. xxx (1.30-2 Gm.), or Trional, gr. x to gr. xv (0.60-1 Gm.), in early evening and repeat if needed. Delirium. Morphine sulphate, gr. 1/3 to gr. 1/4 (0.008-0.015 Gm.), hypoder- mically. Hyoscine hydrobromide, gr. 1/200 to gr. 1/150 (0.0003-0.00045 Gm.), hypodermically, only in sthenic stage. Circulation. (See Pneumonia, Chap. IX.) Local treatment: use of rubber gloves. Facial erysipelas. Paint margin of advancing lesion with collodion. (See text.) Apply to area affected 25 to 50 per cent, ichthyol or cold saturated solution of magnesium sulphate; vaseline. Wet dressings of boric acid 2 per cent, to 4 per cent. Solutions kept cold with ice. Powders. Zinc oxide, boric acid and starch equal parts. Erysipelas of the extremities. Ichthyol: may be combined with the application of collodion. (See text.) Twenty-five per cent, to 50 per cent, or pure ichthyol. Wet dressings. Aluminum acetate. Boric acid solutions. Migratory erysipelas. Ichthyol. Wet dressings. Erysipelas in infants. Prophylaxis. Care of cord or excoriated buttocks or vulva. Ichthyol. Wet dressings. Powders. Vaseline. Specific treatment. (See text.) Vaccines, very little value. Transfusion of blood. (See Septicaemia, Chap. XLV.) Complications. Phlegmon, gangrene, abscesses, otitis media, edema of the larynx, periostitis, purulent arthritis, suppurative adenitis, sinusitis. Treat on surgical principles. 780 TREATMENT OF ACUTE INFECTIOUS DISEASES Pneumonia and Pleurisy. (See Chaps. IX and VIII.) Acute nephritis. (See under Scarlet Fever, Ghap. XVII.) Bronchitis, tonsillitis, arthritis. (See Chaps. Ill, V, VII.) Endocarditis, septicaemia and pyaemia. (See Chap. XLV.) - Prophylaxis. Attention to slight traumata about nose, ears, face; to old ulcers; to cord, buttocks and vulva in infants. Disinfection. Patient's clothes should be disinfected. INDEX Abdomen, protection of, in bacillary dysentery, 358 Abdominal muscles, paralysis of, in poliomyelitis, 600 Abdominal support in pertussis, 526, 533 Abortive poliomyelitis, 591 Abscess, liver, in amebic dysentery, 377, 378, 379 lung, in epidemic influenza, 254 retropharyngeal differentiated from diphtheria, 464 Abt, on diarrhea in infants, 360 Acetanilid, 221 chemistry of, 221 in bronchitis, 103, 109 in epidemic influenza, 244 in erysipelas, 774 in grip, 218, 231 in Malta fever, 659 in mumps. 547 in pleurisy, 118, 126 in poliomyelitis, 596, 605 in rheumatism, 45 in rhinitis, 72, 76 in small pox, 614 in tonsillitis, 83, 89 in trench fever, 752, 754 toxic effects of, 223 Acetphenetidin, 45, 66, and see Phenacetin Acetylsalicylic acid, 42, and see Aspirin Acidosis, 46 from salicylates, 46 in epidemic influenza, 251, 267 in rheumatism, 46 Aconite in febrile conditions, 6 in tonsillitis, 83, 89 Adenitis in diphtheria, 473 in glandular fever, 556, 558 in measles, 499, 509 in scarlet fever, 412, 437 in tonsillitis, 86 Adenoids, 80 attention to in bronchitis of children, 108, 111 removal of in prophylaxis of pneumonia, 193 in rheumatism, 62 in whooping cough, 537 Adrenalin, in asthmatic attacks in bronchitis of children, 108, 111 in bacillary dysentery, 365, 373 in coryza, 73 in diphtheria, 467, 482 in epidemic influenza, 243, 245, 248, 249, 267 in pertussis, 534, 542 in pneumonia, 144, 145, 177, 178, 204, 248 in rhinitis, 73, 74, 77, 78 in scarlet fever, 401, 406, 435 in sinus involvement of grip, 228, 233 Age, calorie requirements and, 12 in relation to rheumatism, 30 Agglutination method, in pneumonia, 130 Agramonte, food formula in yellow fever, 737 Air cushions for patient in bacillary dysentery, 357 Albuminuria complicating measles, 501 from salicylates, 40 in diphtheria, 473 in malaria, 336 in scarlet fever, 414 Alcohol, in diphtheria, 471 in malaria, 343 in scarlet fever, 401 in typhoid fever, 299 Alcohol sprays, for itching, in small pox, 612 Algid malaria, 336, 349 Alimentary canal, care of, see under the several Alkaline salts, as diuretics in scarlatinal nephritis, 420 Alkaline treatment for rheumatism, 46 Alkaline waters, in yellow fever, 738 Allergic following revaccination for small pox, 619 Amberg and Rowntree, on creatinin, 23 Amebic dysentery, 374 appendicostomy in, 383, 386 bed in. 355, 357, 370, 375 care of body in, 356, 370, 375 of bowels in, 359, 371, 376, 384 carriers of, 382, 386 complications of, 382 diet in. 358, 368, 371, 374 emetine treatment of, 376, 384 empirical treatment of, 375 entamoaba coli in, 374 histolytica in, 374 hepatitis in, 377, 378, 379, 385 ipecac in, 376, 384 pathology of, 375 prophylaxis of, 383, 386 quinine treatment of, 381, 385 relapses in, 380, 385 rest in. 354, 370, 375 room in, 356, 370, 375 sequel of, 382 specific organism of, 374, 384 summary of treatment of, 383 surgery in, 383, 386 symptomatic treatment of, 386 symptomatology of, 375 Amido-bodies, 24, 34 Ammonia, for prevention of collapse in malaria, 325 for prevention of collapse in pneumonia, 177 for prevention of collapse in septicemia, 760 Ammonium salts, in pneumonia, 166 Anaphylactic reaction in pneumonia, 134, 145, Anderson on yellow fever, 738 Anemia following diphtheria, 474, 485 following typhoid fever, 319 in malaria. 337, 351 in rheumatism, 57, 68 in scarlet fever, 423 Anesthetic for lumbar puncture in cerebrospinal meningitis, 570 Angina, in diphtheria, 465 in scarlet fever, 398, 432 Vincent's, 91, and see Vincent's angina Anthrax, 678 aim of treatment, 679 bed in. 682, 685 care of body in, 683, 685 cauterization of pustule, 679 circulation in, 683, 685 conveyance of, 678 convulsions in, 684 delirium in, 684, 686 diarrhea in, 684, 686 diet in, 683 disposal of discharges, secretions, etc., in, 683 excision of pustule in, 679, 680 expectant treatment in, 680 headache in, 683, 685 intestinal, 679 isolation in, 682 lesion of, 678 local treatment of, 679, 684 organism of, 678 782 INDEX Anthrax, prophylaxis of, 684, 686 rest in, 682 restlessness in, 663, 685 room in, 682, 685 sleeplessness in, 683, 685 specific treatment of, 681, 682, 684 summary of treatment of, 684 supportive treatment of, 682 symptomatic treatment of, 683 vomiting in, 683, 685 Anti-anthrax serum, 681 Antifebrin. See Acetanilid. Anti-lepral, 672 Anti-plague serum, 636 Anti-pneumonic serum, 132, 133 Antirabic treatment, 703 Antipyretics, chemistry of, 221 in febrile conditions, 6, 7, 9 toxic effects of, 223 Antipyrin, in bronchitis, 109 in coryza, 72, 73 in fibrinous pleurisy, 118, 126 in influenza, 218, 231, 245 in laryngitis, 98, 100 in measles, 498 in pertussis, 529, 540 in rheumatism, 45 in rhinitis, 72, 73, 74, 76, 77, 78 in tonsillitis, 83, 89 in trench fever, 752, 754 Antiseptics, in treatment of wounds, 722 Antitoxemic treatment of fever, 1 Antitoxin, administration of, 458, 480 in cerebrospinal meningitis, 567, 573 diphtheria, 454 death following use of, 459 disagreeable results of, 458 dosage of, 454, 457, 479 early administration of, 457 evidences of improvement due to, 458 immunizing dose of, 460, 481 precautions in use of, 481 preparation of, 454 unit of, 454 for hemorrhage of typhoid fever, 296 for laryngeal diphtheria, 461, 481 for laryngitis complicating measles, 498, 508 in pneumonia, 130 paralysis prevented by, 471 tetanus, 715, 722, 725, 727, and see Tetanus antitoxin Antitoxins, 453 Antitussin, in pertussis, 532 Antrum, involvement of, in coryza, 75 in influenza, 228, 233 in rhinitis, 75, 79, and see Sinusitis Apathy in encephalitis lethargica, 271 Aphthse epizooticae, 693, and see Foot and mouth disease Apparatus for paralysis in poliomyelitis, 602 Appendicostomy in amebic dysentery, 383, 386 Appetite, 11 Appetit-saft, 34 Apple, baked, food value of, 17 Argyrol, in coryza, 73 in rhinitis, 73, 77 Arsenic, for anemia in malaria, 339, 340 for convalescence from Malta fever, 660 in chorea, 60 in malarial cachexia, 339 substitute for quinine, 340 Arthritis in erysipelas, 340 in mumps, 551 in pneumonia, 191 in rheumatism, 51 in scarlet fever, 413, 417 in septicemia, 763, 771 Ascites, in scarlatinal nephritis, 415, 421 Ashburn and Craig, on dengue, 641 Ashurst and John, on tetanus, 711, 714, 717 Asiatic cholera, 646, and see Cholera, Asiatic Aspiration, in pleurisy with effusion, 120, 127 in pleurisy and empyema in epidemic influenza, technique of, 120 Aspirin, constitution of, 60 m bronchitis, 104, 109 in chorea, 60 in coryza, 72 in encephalitis lethargica, 274 in epidemic influenza, 245 in fibrinous pleurisy, 117, 126 in glandular fever, 556 in Malta fever, 659 in pneumonia, 145 in rheumatism, 42 in rhinitis, 72, 76 in scarlatinal arthritis, 413 in tonsillitis, 83, 89 in trench fever, 752, 754 toxic dose of, 43 Assimilation in acute infectious diseases, 18 efficiency of processes of, 3 Asthma, after administration of serum, 145 Astringents in diarrhea of bacillary dysentery, 364 Atropine, in Asiatic cholera, 648 in asthma, after administration of serum in pneumonia, 145 in bacillary dysentery, 365, 373 in diphtheria, 473 in lumbar puncture, 572 in pertussis, 530 in photophobia of measles, 494, 501 in pneumonia, 144, 145, 175, 178 in poliomyelitis, 600 in pulmonary edema of epidemic influenza, 249, 267 in rheumatism, 57 in sinus involvement of influenza, 228 in tetanus, 720 Auricular fibrillation in epidemic influenza, 257, 269 Auto-extubation, 464 Auto-serotherapy in chorea, 61 in pleurisy with effusion, 124, 127 Bacillary dysentery, 353 bed in, 355, 357, 370 care of body in, 356, 370 of bowels in, 359, 371 carriers, 369 change of environment in, 368 chronic form of, 366, 373 collapse in, 373 diagnosis of, 354 diarrhea in, 364, 372 diet in, 358, 368, 371, 374 duration of, 366 empirical treatment of, 361, 371 heart in, 366 nausea in, 360 pain in, 362 pathology of, 354 precautions of nurse in, 356, 370 of physician in, 356, 370 prophylaxis of, 369, 374 rest in, 354 room in, 356, 370 saline treatment in, 359. 362, 367, 372 serum in, 360, 371 specific treatment of, 360, 371 subacute form of, 366, 373 summary of treatment of, 370 symptomatic treatment of, 362, 372 tenesmus in, 363, 372 therapy of, 354 topical applications in, 362, 372 ulcers in, 367, 373 vaccine therapy in, 361, 366, 371, 373 vomiting in, 360 water in, 359 Bacilluria in typhoid fever, 300 Backache in smallpox, 614 in yellow fever, 738, 742 Bacon, food value of, 17 INDEX 783 Bacteremia, 757 Baking for paralysis of extremities in poliomye- litis, 601 Barker and Sladen on infectious jaundice, 732 Baruch on hydrotherapy, 5, 84, 97, 157, 159 Bass on blackwater fever, 343 on malaria, 328, 329 Bastedo on alkaline salts in rheumatic fever, 43 Baths. See under the several diseases, as antipyretic measure, 19 Brand, 288 in pneumonia, 161 in typhoid fever, 5, 288, 291 mustard, 546 Ziemssen's, 291 Bath-water, disinfection of, 281, 310 Beans, string, food value of, 17 Bed, see under the several diseases Gatch, 147 importance of in rest, 2 technique of making, 279 Bed linen, disinfection of, 281 Bed pan, disinfection of, 281 in dysentery, 357 in epidemic influenza, 243 Bedsores, in cerebrospinal meningitis, 581 in typhoid fever, 280, 310 Belladonna, idiosyncrasy for, 530 in mumps, 548, 553 in pertussis, 529, 540 in sinus involvement in influenza, 228 in tenesmus in bacillary dysentery. 363 Belt, abdominal, in pertussis, 526, 533 Benzoin, in bronchitis, 105, 109 in glanders, 689 in laryngitis, 96 in membraneous angina in scarlet fever, 401 in pertussis, 527 Benzyl benzoate, in amebic dysentery, 381, 385 chloride, in leprosy, 672 in pertussis, 532 Bercovitz, on treatment of leprosy, 673 Besredka's method of desensitization in pneu- monia, 136 Bethea's method in amebic dysentery, 378 of giving quinine in malaria, 329 Bilious remittent fever, 336 Bismuth, for diarrhea, in bacillary dysentery, 364,372 in epidemic influenza, 246 in infectious jaundice, 730 in plague, 636 in typhoid fever, 294 for nausea, in cerebrospinal meningitis, 565 in scarlet fever, 422 in typhoid fever, 295 for noma, in measles, 499 for retching, in smallpox, 615 for vomiting, in cholera, 648 in Malta fever, 659 in scarlet fever, 397 in typhoid fever, 295 in amebic dysentery, 382, 386 in foot and mouth disease, 695 in infectious jaundice, 730 Bitter bush, in treatment of amebic dysentery, 382 Bites, treatment of old. 709 Black vomit of yellow fever, 739, 742 Blackwater fever, 343, 352 prophylaxis of, 345, 352 summary of treatment, 352 symptoms of, 344 treatment of, 344, 352 Bladder, care of. See under the several diseases Blake, on typing of sputum, 132 Blaud's pill, for anemia, in diphtheria, 474, 484 in scarlatinal nephritis, 423, 441 in trench fever, 755 for convalescence from measles, 502, 511 from mumps, 551 from pertussis, 537 in glandular fever, 557 in malaria, 339, 351 Blindness, due to quinine, 333 Blisters, application of, 50 in fibrinous pleurisy, 116, 126 in rheumatism, 50 Blood, in amebic dysentery, 375 in encephalitis lethargica, 272 normal human, in scarlet fever, 409 typing of, in pneumonia, 130 Blood pressure, effects of cold water on, 5 of fresh air on, 4 Blood transfusion in erysipelas, 777 in septicemia, 766 method of, 766 Bloodgood, on anthrax, 681 on rabies, 701 on tetanus, 713, 720 Body, care of. See under the several diseases Body louse, in typhus fever, 624, 626 Body mechanism for conversion of energy, 27 Body surface and calorie measurement, 13 Bordet on pertussis, 520 Bowels, care of. See under the several diseases Bradycardia, in epidemic influenza, 257, 269 Bran bath in scarlet fever, 395 Brand bath, contraindications to, 291 in febrile conditions, 5 in pneumonia, 161 in typhoid fever, 288 method of, 288 Bread, food value of, 17 Break-bone fever, 641, and see Dengue Brill's disease, 625 Bromides, for convulsions, in pertussis, 536 in tetanus, 719 for delirium, in typhus fever, 629, 632 for headache, in pneumonia, 170, 202 for insomnia, in cerebrospinal meningitis, 566 in encephalitis lethargica, 275 in epidemic influenza, 245 in Malta fever, 659 in pertussis, 531, 533 in pneumonia, 169 in rheumatic fever, 37 in Rocky mountain spotted fever, 666 in scarlet fever, 407 in septicemia, 761 in smallpox, 415, 423 in tonsillitis, 84. 89 in typhoid fever, 298, 316 for nervous symptoms, in erysipelas, 774 in measles, 495, 506 in septicemia, 761 for restlessness, in cerebrpspinal meningitis, 566 in encephalitis lethargica, 275 in scarlet fever, 407 in poliomyelitis, 596, 605 per rectum, in rabies, 706, 709 Bromoform, in pertussis, 532 Bronchiectasis, in epidemic influenza, 255 Bronchitis, acute, 101 aches and pains in, 103, 109 care of bowels in, 103, 109 children, management of, 107, 110 cough in, 102. 106, 110 counterirritation in, 104, 109 cupping in, 104, 109 diet in, 103, 108 early measures in, 103, 109 etiology of, 101 expectorants in, 106, 107, 110 fever in, 102 fomentations in, 105, 109 headaches in, 103, 109 inhalations in, 105, 107, 109, 110 isolation in, 103, 108 local treatment of, 104, 109 pathplogy of, 101 physical signs of, 102 precautions in, 103, 108 prophylaxis of, 108, 111 room in, 102, 108 summary of treatment of, 108 symptoms of, 102 vaccines in, 108, 111 784 INDEX Bronchitis, capillary, 101 in grip, 227, 233 in measles, 498, 008 in pneumonia, 164 Bronchopneumonia, 101, 128, 179, and see Streptococcus pneumonia differentiated from laryngeal diphtheria, 464 in diphtheria, 473 in measles, 495, 507 in pertussis, 534, 542 in scarlet fever, 423 physiology of diet in, 3 specific treatment of, 179 Brook, on quinine treatment of amebic dysentery, 381, 385 Brown, on amebic dysentery, 376 Brown, Wade, on blackwater fever, 343 on malaria, 324, 337 Brown mixture, in bronchitis, 106, 110 Browne, on scarlet fever, 400 Bubonic plague, 634, and see Plague Burning and itching, in measles, 491, 505 in small pox, 612, 621 Butter, food value of, 17 Buttermilk, food value of, 17 Cachexia, malarial, 338, 350 Caffeine, double salts of, 6, 9 for prostration from belladonna, 531 in anthrax, 683 in bronchitis, 104, 109 in cerebrospinal meningitis, 566 in cholera, 651 in diphtheria, 470 in epidemic influenza, 244 in febrile conditions, 6, 9 in glanders and farcy, 689 in grip, 219 in malaria, 335, 349 in Malta fever, 660 iii measles, 495 in pleurisy with effusion, 123 in pneumonia, 176, 178, 204, 205 in poliomyelitis. 600, 606 in scarlatinal nephritis, 420 in scarlet fever, 405, 431 in tonsillitis, 83 in typhoid fever, 299 in typhus fever, 629 Calabar bean, for convulsions of tetanus, 721 Calcium chloride in black vomit of yellow fever, 739 lactate for hemorrhage in typhoid fever, 296 permanganate, in cholera, 648 Calmette's antivenomous serum for leprosy, 673 Calomel, anti-emetic effect of, in bacillary dysentery, 360 in bacillary dysentery, 359, 360 in cerebrospinal meningitis, 565, 582 in dengue, 642 in diphtheria, 452 in erysipelas, 774 in fibrinous pleurisy, 114, 125 in glandular fever, 555 in infectious jaundice, 730 in malaria, 324, 346 in Malta fever, 658 in measles, 493, 505 in mumps, 547 in paratyphoid fever, 324 in pertussis, 534 in plague, 635 in pneumonia, 151 in poliomyelitis, 594, 604 in rat bite fever, 746 in rubella, 513 in scarlet fever, 397 in septicemia, 760 in small pox, 613, 622 in tonsillitis, 82, 88 in typhoid fever, 314 in typhus fever, 629 in yellow fever, 738 Caloric balance of human body, 11 Caloric needs, determined by work, 11 in different callings, 12 of resting patient, 13, 27 Caloric output, determination of, 11 Caloric requirements, and age, 12 and body surface, 13 and weight, 13 of febrile patients, 20 of man at rest, 12, 27 Caloric value of foodstuffs, 13 Caloric values, Rubner's, 13 Calorie, 11 definition of, 3, 11 large, 11, 27, 34 small, 11, 27, 34 Calories of food required by patient at rest, 13 furnished by protein, in adult, 15 in infant, 15 measure of energy at rest, 3 required in sickness, 3 units of, in diet, 17 Camphor, for keeping mosquitoes away, 342 in anthrax, 683 in cholera, 651 in diphtheria, 470 in febrile conditions, 6, 9 in glanders and farcy, 689 in grip, 224 in malaria, 335 in Malta fever, 660 in measles, 495 in pneumonia, 176, 204 in scarlet fever, 406, 434 in septicemia, 760 in typhoid fever, 299 in typhus fever, 629 solution of in olive oil, 6 Cancrum oris, in Vincent's angina, 93 Cantharides blister, in rheumatism, 50 Capillary bronchitis, 101 complicating measles, 498, 508 Carbohydrates, 16, 26 in typhoid fever diet, 284 Carbolic acid. See Phenol Cardiac complications in rheumatism, 53, 67 in children, 55, 68 Cardiac dilatation complicating pneumonia, 192 Cardiac disturbances from salicylates, 41 Cardiac stimulants, 171, 203 Carpets, disinfection of, in smallpox, 616 Carr, J. W., on belladonna in children, 530 Carriers. See under the several diseases Carroll, on stegomyia calopus, 740 on yellow fever, 738 Carter on typhoid fever, 298 on yellow fever, 739 Castor oil, in bacillary dysentery, 359, 360, 361, 371 in epidemic influenza, 243 in fibrinous pleurisy, 114, 125 in glandular fever, 555 in Malta fever, 658 in measles, 493, 505 in poliomyelitis, 597 in rubella, 513 in scarlet fever, 397 in septicemia, 760 in typhoid fever, 292 in typhus fever, 629 methods of administering, 360 Catabolism, protein, influenced by pyrexia, 20 Catharsis, in bacillary dysentery, 359 in diphtheria, 452 in epidemic influenza, 243 in erysipelas, 774 in Malta fever, 658, 661 in measles, 493, 505 in poliomyelitis, 597 in rat bite fever, 746 in rheumatism, 35 in Rocky mountain spotted fever, 666 in scarlet fever, 397 in smallpox, 613, 622 in septicemia and pyemia, 760, 769 INDEX 785 Catharsis, in typhoid fever, 292 in typhus fever, 629 Cathartics in febrile conditions, 4, 9 Catheter, use of, for tympanites in typhoid fever, 293 Cattle, foot and mouth disease of, 693 Cauterization, contraindicated in tetanus, 714 in fibrinous pleurisy, 116, 126, 187 in noma of measles, 500, 509 in rabies, 700, 708 Cecil, on foreign protein therapy in rheumatism, 59 on pneumqcoccus vaccines, 194 Cell destruction, expression of, 26 Cell, energy transformer, 10 vitality of, 10 Ceratum cantharidis, 50, 67, and see Fly blis ter Cerebral disturbances in typhoid fever, 298 Cerebral symptoms from sahcylates, 41 Cerebrospmal fluid, in cerebrospinal meningitis, 568, 571 Cerebrospinal meningitis, 560 bed in, 563, 580 care of bladder in. 567, 583 of bowels in, 565, 582 of eyes in, 565, 582, 588 of mouth in, 564, 581 of nose in, 564, 582 of patient in, 561, 563, 581 of skin in, 564 carriers of, 561, 579, 589 causative agent of, 560 cerebrospinal fluid in, 568, 571 changes in mentality in, 577 chronic cases of, 576, 587 complications in, 577, 587 convalescence in, 578, 589 convulsions in. 566. 583 delirium in, 566. 582 diet in. 563. 581 disinfection of secretions in, 565, 580 of utensils in, 580 disposal of secretions in, 565 distension of bladder in, 567, 583 distribution of family in, 560, 579 drinks in, 564 drug treatment in, 567 ear complications in, 577, 588 early use of serum treatment in, 573 exacerbations of, 576, 588 eye complications in, 577, 588 fulminating cases of, 575, 587 hydrocephalus in, 576. 587 incubation period of, 561 intravenous treatment of, 574, 583, 587 intraspinal treatment of. 568, 584 isolation of contacts, 561 joint complications in, 577. 588 lumbar puncture in, 569, 584 meningococcic endocarditis in, 578 meningococcic serum and mortality in, 573 mortality from, 577 otitis in, 577 paralysis in, 577 precautions in sick-room in, 563, 580 of nurse in, 562, 580 of physician in, 562, 580 prophylaxis in, 578, 588 puncture of ventricles in, 576, 587 pyelitis in, 578, 588 quarantine in, 560, 579, 589 relapses in, 576, 588 restlessness in, 566, 582 room in, 562, 580 septic pneumonia in, 578 serum treatment of, 567, 573, 578, 583 sleeplessness in, 566, 582 specific treatment of, 567, 583 summary of treatment of, 579 support of circulation in, 566, 583 symptomatic treatment of, 566, 582 treatment of nausea in, 565, 582 vaccines in, 576, 578 Cerium oxalate, in anthrax, 683 in cerebrospinal meningitis, 566 in infectious jaundice, 730 in Malta fever, 659 in scarlet fever, 397 in typhoid fever, 295, 315 Chaparro amargosa, in amebic dysentery, 382 Charbon, 678 Charta sinapis. See Mustard Chaulmoogra oil, in leprosy, 671, 672, 674, 676 Cheese, food value of, 18 Chenopodium, oil of, in amebic dysentery, 383 Chest compresses, in bronchitis of measles, 498 in bronchopneumonia of measles, 496 in pneumonia, 157 Chicken, food value of, 17 Chicken pox, 515, and see Varicella Childhood, laryngitis in, 98, 100 rheumatism in, 30, 55 Chloral, in anthrax, 683, 684, 685, 686 in cerebrospinal meningitis, 566 in encephalitis lethargica, 275 in Malta fever, 659 in pertussis, 535, 543 in pneumonia, 202 in rabies, 706 in scarlatinal nephritis, 421 in small pox, 615 in tetanus, 719, 726 Chloralamid, in dengue, 643 in epidemic influenza, 246 in erysipelas, 774, 779 in Malta fever, 659 in measles, 495, 507 in pneumonia, 169 in rheumatism, 37 in scarlet fever, 407 in septicemia, 762, 770 in small pox, 615 in tonsillitis. 84, 89 in typhoid fever, 298, 317 Chloretone, for tetanus, 720, 726 Chloride of lime, in glanders and farcy, 690 Chloroform, in anthrax, 684 in pertussis, 528, 535, 543 in rabies, 706 in scarlatinal nephritis, 422 in tetanus, 719, 726 Cholecystitis, in typhoid fever, 298 Cholera, Asiatic, 646 anuria in, 649, 654 bed in, 646 cathartics in early treatment of, 647, 654 cause of, 646 circulation in, 647 complications of, 651 convalescence from, 652, 654 diet in, 646, 653 early treatment of, 647 hyperpyrexia in, 649 isolation in, 646, 651, 653 mortality of, 646 precautions in sick-room in, 646, 653 of nurse in, 646, 653 of physician in, 646, 653 prophylactic inoculation in, 651 prophylaxis of, 651, 655 quarantine in, 646, 651, 653 rest in, 653 specific treatment of, 650 stage of collapse in, 647, 649. 654 of reaction in, 649 stimulants in, 650 summary of treatment in, 653 uremia in, 650 vaccines in, 651 vomiting in, 649, 654 water in, 647 Chorea. 59 autoserotherapy in, 61 in rheumatism, 59, 69 local measures in, 60 treatment of, 59, 69 vaccines in treatment of, 60 786 INDEX Chromic acid, in Vincent's angina. 92. 93 Cinchonism, 333 " Circulation. See under the several diseases Circulatory failure in febrile conditions, 6 Citronella for keeping mosquitoes away, 342 Climate, change of, in convalescence from per- tussis, 537 in convalescence from scarlatinal nephritis 423 Clough, on foot and mouth disease, 693 Coagulen, in nose bleed of diphtheria, 467 Coakley, on nasal hemorrhage, 534 on scarification in edema of the larynx, 99 Coal-tar group, antipyretics of, 7 contraindicated in typhus fever, 628 in encephalitis lethargica, 274 in epidemic influenza, 244, 265 in febrile conditions, 6 in fibrinous pleurisy, 118, 126 in grip, 218, 231 in pneumonia, 170 in poliomyelitis, 596, 605 in small pox, 614, 622 in tonsillitis, 83, 89 Cocaine, for C9ugh in bronchitis, 106, 110 for earache in scarlet fever, 411 for lumbar puncture, 570 for vomiting in typhoid fever, 295, 315 in coryza, 73 in diphtheria, 466 in epidemic influenza, 251 in infectious jaundice, 730 in Malta fever, 659 in pertussis, 534 in rabies, 707 in rhinitis, 73 , in yellow fever, 739 Codeine, in anthrax, 683 in bronchitis, 106, 110, 498 in bronchopneumonia, 497 in cerebrospinal meningitis, 566 in chorea, 60 in chronic glanders, 497 in dengue 642 in encephalitis lethargica, 274, 275 in epidemic influenza, 245, 246, 250 in fibrinous pleurisy, 118, 126 in grip, 225, 233 in infectious jaundice, 730, 733 in laryngitis, 96, 99 in pertussis, 531, 541 in pneumonia, 166, 168, 170 in poliomyelitis, 596 in rheumatism, 37 in rhinitis, 76 in septicemia and pyemia, 761 in tonsillitis, 84, 89 in trench fever, 752, 755 Cohnheim, on food, 12 Cold in the head, 71, and see Coryza Cold, in febrile conditions, 7, 9 in hyperpyrexia, 6 in scarlet fever, 406, 432 in septicemia, 760, 761 in rheumatism, 49 Cold air, for diphtheria, 471 for measles, 489, 503 Cold applications, for adenitis in glandular fever, 556 for bronchitis, 105, 109 for conjunctivitis complicating measles, 501 for hyperpyrexia, 6, 7 in scarlet fever, 401 for membranous angina in scarlet fever, 401 Cold bath in pneumonia, 159 Cold compresses, in laryngitis, 97 in laryngitis complicating measles, 498 in pericarditis in pneumonia, 185 in pneumonia, 157 in rheumatism, 49 Cold pack, for delirium in septicemia, 761 for fever in small pox, 614 in pneumonia, 161 in rheumatism, 53 Cold sponges, for delirium in septicemia, 761 Cold sponges, in pneumonia, 161 Cold water,, for bronchopneumonia complicating measles, 496 in pneumonia, 161 in scarlet fever, 407 in typhoid-fever, 299, and see Brand bath treatment, see Hydrotherapy Cole, on pneumonia, 129 Cole s method of desensitization in pneumonia 136 Coleman, on typhoid fever, 22, 23, 25, 26, 283, Collapse, due to antipyretics, 223 during bath in measles, 493 in bacillary dysentery, 373 in diphtheria, 468, 483 in malaria, 325 in measles, 494 in pernicious malaria, 335 m pneumonia, 177, 204 in septicemia, 760, 769 threatened, in typhoid fever, 299, 318 Collargol, in trench fever, 753, 755 Collodion, in erysipelas, 775, 776 Colomc irrigation, for ileocolitis complicating in fibrinous pleurisy, 114, 126 Conner, on intravenous administration of sali- cylates, 47 on thrombophlebitis complicating typhoid Convalescence. See under the several diseases Convulsions. See under the several diseases Coryza, 71, and see Rhinitis, acute occurring in epidemic influenza, 251 Cough, in bronchitis, 102, 106, 110 complicating measles, 498 in bronchopneumonia complicating measles, in coryza, 75 in epidemic influenza, 237, 250 in fibrinous pleurisy, 113, 118, 126 in glanders, 689, 691 in laryngitis, 96, 99 in pertussis, 525, 540 in pneumonia, 161, 200 in rhinitis, 78 source of exhaustion, 1 Cqunterirritation, in bronchitis, 104, 109 in fibrinous pleurisy, 116, 126 in pericarditis complicating pneumonia 187 in rheumatism, 50, 67 in scarlatinal nephritis, 420 Cowling's rule for dosage, 37 Craig, on dengue, 641 Cream, food value of, 17 Creatin and metabolism, in acute infectious dis- eases, 24 Creatinin and metabolism, in acute infectious diseases, 22 Creatinin coefficient, 23 Creosote, in bronchitis, 105, 109 complicating measles, 498 in bronchopneumonia, complicating measles, in cough, of glanders, 689 in pertussis, 528 Crockery, disinfection of, 281 Croup, spasmodic, differentiated from laryneeal diphtheria, 464 Croup kettle, in laryngitis, 96, 99 in pertussis, 527 in scarlet fever, 401 Gumming, on rabies, 701 Cupping, in bronchitis, 104, 109 in bronchopneumonia complicating measles, 497 in fibrinous pleurisy, 117 in pneumonia, 165 in pulmonary edema, in epidemic influenza, in pneumonia, 17.9 in scarlatinal nephritis, 419 technique of, 164 INDEX 787 Cuahny on belladonna, 529 Cyanosis, due to antipyretics, 223 in epidemic influenza, 238, 249 Dakin's solution, in anthrax, 682 in streptococcus empyema, 212 Dandy fever, 641, and see Dengue Deafness, from quinine, 333 from salicylates, 40 in cerebrospinal meningitis, 577 De-amidation, defective, 24 Delafield, method in pleurisy with effusion, 119, 126 on bronchopneumonia, 208 prescription for dysentery, 361 for pneumonia, 166 Delirium, from belladonna, control of, 531 from salicylates, 40 in anthrax, 684 in bronchopneumonia complicating measles, 497 in cerebrospinal meningitis, 566, 582 in epidemic influenza, 246, 259, 266 in erysipelas, 774, 779 in hyperpyrexia, 53 in infectious jaundice, 731 in measles, 494 in plague, 636 in pneumonia, 168 in rheumatism, 40, 53, 61, 70 in scarlet fever, 407 in septicemia, 761, 770 in small pox, 614, 623 in typhoid fever, 317 in typhus fever, 629 Delousmg, in trench fever, 753, 755 in typhus fever, 627. 633 Dengue, 641 bed in, 641, 643 care of bowels in, 642. 644 circulation in, 642, 644 complications in. 643, 645 convalescence from, 643, 645 diagnosis of, 643 diet in, 642, 644 fever in, 642, 644 headache in, 642 hemorrhages in, 643 infecting agent in, 641 insomnia in, 642, 644 local treatment of pains in. 642 mortality in, 641 mosquito carrier of, 641, 643 nervous symptoms in, 643, 644 pains in, 642, 644 prophylaxis of, 643, 645 room in, 641, 643 summary of treatment of, 643 transmission of, 641 water in, 642, 644 Dermacentor, in Rocky mountain spotted fever 664 Dermacentroxenus, in Rocky mountain spotted fever, 664 Desensitization, in pneumonia, 135, 136 Diaphoresis, in scarlatinal nephritis, 417, 421 in scarlet fever, 417, 438 Diarrhea, in anthrax, 684, 686 in bacillary dysentery, 364, 372 in epidemic influenza, 246 in infectious jaundice, 730, 733 in pertussis, 534, 542 in plague, 636, 640 in poliomyelitis, 597, 606 in typhoid fever, 294, 315 in typhus fever, 633 Diet. See under the several diseases measure of in calories, 17 physiology of, in febrile conditions; 3 summary of, 27 Dietary, proportion of foodstuffs in, 16 Dietetics, science and art of, 27 Digitalis, in acute febrile conditions, 6 in anaphylactic shock in pneumonia, 145 Digitalis, in anthrax, 683 in bacillary dysentery, 365, 373 in cerebrospinal meningitis, 566 in cholera, 650 in diphtheria, 470 in glanders and farcy, 690 in Malta fever, 659 in pleurisy with effusion, 124 in pneumonia, 145, 171 in pneumonia complicating epidemic influenza, 247 in rheumatic fever, 54 in scarlatinal nephritis, 420 in scarlet fever, 404, 434 in septicemia and pyemia, 762, 770 in typhoid fever, 299 in typhus fever, 629 Digitahzation, 171, 203, 667 Diphtheria, 443 active immunization in, 447 adenitis complicating, 473 anemia in, 485 angina in, 465 antitoxin, 454, 479 bath in, 450 bed in, 450 bronchopneumonia complicating, 473 cardio-vascular apparatus in, 467, 469, 482 care of bowels in, 452 of genitals in, 452 of mouth in, 451 of nose in, 451, 452, 466 of patient in, 450, 478 of teeth in, 451 of throat in. 451, 465 carriers of, 475. 485 complicating measles, 501 convalescence from, 474, 484 culture taking in, 444, 477 death in. 468, 483 diet in. 450. 478 differential diagnosis of. 464 distribution of family in, 444, 477 extubation in, 463 feeding in, 450, 478 fever in, 465 hemorrhage from nose in, 467, 482 hot fomentations in. 462, 465 immunity to, 448 inhalations of steam in, 461 intubation in, 462 laryngeal, 460, 481, and see Laryngeal diph- theria antitoxin treatment of, 455, 481 differential diagnosis of, 464 dosage of antitoxin in, 455 extubation in, 463 intubation in, 462 symptomatic treatment of, 465, 481 late circulatory failure in, 468 malaise in, 443 malignant, dosage of antitoxin in, 455 mortality in, 456 nasal, 451, 482 antitoxin treatment of, 455 dosage of antitoxin in, 455 nephritis and, 473, 484 open-air treatment of, 471 otitis complicating, 473 paralyses in, 471, 483 pharyngeal, dosage of antitoxin in, 455 post-intubation, treatment, 463 precautions of nurse in, 449, 478 of physician in, 449, 478 prophylaxis of, 476 quarantine for, 474, 485 rest in, 450, 478 room in, 448, 449, 450, 477, 478 Schick reaction for, 444, 445, 449, 450 serum therapy in, 453 sterilization and fumigation following, 475, 485 summary of treatment of, 477 symptoms of, 443 788 INDEX Diphtheria, syncope in, 468, 483 taking cultures in, 444 treatment of symptoms of, 465 Diplosal, in rheumatism, 44, 65, and see Salicy- lates in tonsillitis, 83, 89 Disinfection. See under the several diseases Distribution of family. See under the several diseases Diuresis in scarlet fever, 439 Diuretics, in pleurisy with effusion, 123, 127 in scarlatinal nephritis, 420 Diuretin, in scarlatinal nephritis, 420 in pleurisy with effusion, 123 Dobell's solution, in bacillary dysentery, 357 in cerebrospinal meningitis, 564, 579' in diphtheria, 452, 466, 467, 476 in epidemic influenza, 242 in foot and mouth disease, 694 in glandular fever, 555 in measles, 492 in mumps, 525 in pertussis, 525 in scarlet fever, 396, 400 in varicella, 517 Dog, symptoms of rabies in, 702 Dogs and prevention of rabies, 707 Dosage, rules for, in children, 37 Dover's powder, in bronchitis, 104, 109 in bronchitis complicating measles, 498 in bronchopneumonia complicating measles, 497 in cholera, 647 in pertussis, 531, 541 in rhinitis, 72 Drainage, in streptococcus empyema, 213 Draper, on poliomyelitis, 595 Drinks. See under the several diseases. Dry tap, in lumbar puncture, 572 Dudley, on anthrax, 680 Dumb rabies, 702 Dunn, on cardiac complications in rheumatic fever, 55 on serum treatment of cerebrospinal menin- gitis, 576 Duval and Gurd, on leprosy, 674 Dyer, on leprosy, 673 Dysentery, amebic, 374, and see Amebic dysen- tery bacillary, 353, and see Bacillary dysentery Dyspnea, due to impurities in salicylates, 40 in epidemic influenza, 238, 249 in fiorinous pleurisy, 118, 126 in pneumonia, 179 in poliomyelitis, 600, 606 Earache, in measles, 499, 508 in scarlet fever, 411 Ears, and see Otitis buzzing in, from salicylates, 40, 41 care of, in pneumonia, 149 in scarlet fever, 392, 411 changes in, due to quinine, 333 complications of, in cerebrospinal meningitis, 577 examination of in infections, in children, 443 Edema, angioneurotic, due to antipyretics, 223 in scarlatinal nephritis, 420 in scarlet fever, 421, 438, 439 of larynx, 98, 100 intubation in, 99, 100 scarification in, 98, 100 tracheotomy in, 99, 100 pulmonary, in pneumonia, 178 subglottic, differentiated from laryngeal diph- theria, 464 Effusions, in rheumatism, 67 Eggleston's rule for digitalization, 171, 203 Eggs, food value of, 17 Einhorn's tube, use of in typhoid carriers, 305 Elastic belt in pertussis, 526, 533 Electric pad, in fibrinous pleurisy, 115, 126 Electricity for paralysis of extremities in polio- myelitis, 601, 607 Elser and Huntoon on cerebrospinal meningitis, .561 Embolism', in pneumonia, 190, 206 in septicemia and pyemia, 763, 771 Emetine, in amebic dysentery, 376, 384 toxic dose of, 380 Emphysema, in epidemic influenza, 256 Empyema, 112, 125, 127 in epidemic influenza, 253 in pneumococnus pneumonia, 181, 187 in streptococcus pneumonia, 209, 211 in typhus fever, 630 Empyema, pneumococcus, 112, and see Empyema Empyema (streptococcus and influenza types), 207, 211 aspiration in, 211 Dakin's solution in, 212 drainage in, 213 summary of treatment of, 215 treatment of, 211 Encephalitis lethargica, 271 bed in, 274, 275 care of body in, 274, 276 of bowels in, 274, 276 convalescence in, 275, 276 course of, 273 diet in, 274, 276 drinks in, 274, 276 fever in, 275, 276 hyperesthesia in, 275, 276 in epidemic influenza, 258 insomnia in, 275, 276 irritability and restlessness in, 275, 276 lumbar puncture in, 275, 276 mortality in, 273 pains and headaches in, 274, 276 paresthesia in, 275, 276 pathology of, 271 prognosis of, 273 room in, 274, 275 sequelae of, 273 summary of treatment of, 275 symptomatology of, 271 Endocarditis, in erysipelas, 777 in measles, 501 in pneumonia, 190 in rheumatism, 53 in scarlatinal nephritis, 422 in scarlet fever, 423 in septicemia, 762, 763 in septicopyemia, 758 meningococcic, 578 Endogenous metabolism, 23 Endotoxins, 453 Enemata, in bronchopneumonia complicating measles, 498 in diphtheria, 470 in epidemic influenza, 243, 251 in erysipelas, 774 in Malta fever, 658 in plague, 635 in pneumonia, 152 in poliomyelitis, 594 in rheumatism, 36 in septicemia, 760 in tympanites, 251, 294 in typhoid fever, 292 milk and molasses, 294 nutrient, 470 peppermint, 294 soapsuds, 36 turpentine, 293 Entamceba coli, 374, 376 histolytica, 353, 374, 376 Enteroclysis, in bronchopneumonia complicating measles. 498 in circulatory failure in diphtheria, 470 in scarlatinal nephritis, 422 in scarlet fever, 440 Environment, change of, in bacillary dysentery, 368 Epidemic influenza, 235 abdominal symptoms in, 260 abscess of lung in, 254, 268 INDEX 789 Epidemic influenza, abscess of muscles in, 260, 270 aches and pains in, 244, 265 acidosis in, 251, 267 bed in, 240, 263 blood in, 238 bronchiectasis in, 255 care of bowels in, 243, 264 of eyes in, 243, 264 of mouth in, 242, 263 of nose in, 243, 264 of patient in, 242, 263 of teeth in, 242, 264 carriers of, 261 circulation in, 246, 247, 266 convalescence in, 260, 269 cough in, 237, 250, 267 cyanosis in, 238, 249 delayed resolution, 252, 267 delirium in, 246, 266 diarrhea in, 246, 266 diet in, 244, 265 dyspnea in, 249 emphysema in, 256 empyema in, 253, 268 encephalitis lethargica in, 258 epistaxis in, 238 erythema in, 238 etiology of, 235 fluids in, 244, 265 headaches in, 245, 264, 265 heart and vessels involved in, 256, 268 incubation period of, 237 insomnia in, 245 isolation in, 239, 262 kidneys involved in, 257, 258, 269 meningitis in, 258 mental disturbance in, 259, 268 nervous system involved in, 258 nervousness in, 265 neuritis in, 259 onset of, 237 otitis media in, 260 parotitis in, 260 pathology of, 235 phlebitis in, 257, 269 pleurisy in, 253, 268 pneumonia in, 236, 239, 246, 266 precautions for nurse in, 241, 263 for physician in, 241, 263 prophylaxis of, 261, 270 prostration in, 238 pulmonary edema in, 248, 267 pulse in, 238 respiration in, 238 room in, 240, 262 summary of treatment of, 262 symptomatology of, 237 temperature in, 238 treatment of, 239. 262 tuberculosis in, 255 tympanites in, 251, 267 upper air passages involved in, 256 urine, retention of in, 238 vaccines in, 262 vomiting in, 246, 266 warnings to family in, 242, 263 Epinephrin. See Adrenalin Epistaxis, in epidemic influenza, 238, 256 in pertussis, 534 Epsom salts, in bronchitis, 103, 109 in dengue, 642 in diphtheria, 452 in epidemic influenza, 243 in erysipelas, 774 in fibrinous pleurisy, 114, 125 in grip, 217, 231 in laryngitis, 95, 99 in Malta fever, 658 in mumps, 547 in plague, 635 in pneumonia, 151 in rheumatism, 35 in scarlatinal nephritis, 417 Epsom salts, in scarlet fever, 397 in septicemia and pyemia, 760 in tonsillitis, 82, 88 in typhoid fever, 292, 314 in yellow fever, 738 Erdman, on erysipelas, 775, 777 Eruptions. See Skin eruptions Erysipelas, 772 bedin, 773, 778 care of body in, 774, 778 of bowels in, 774, 778 of eyes in, 774 of mouth in, 774 circulation in, 774 complications of, 777, 779 creatinin in, 24 delirium in, 774, 779 diet in, 773, 778 disinfection in, 777, 780 facial, 772, 773 local treatment of, 775, 779 fever in, 774, 778 headache in, 774, 778 immunity in, 777 in infants, 776, 779 incubation period of, 772 insomnia in, 774, 779 isolation in, 773, 778 local treatment of, 775, 779 migratory, 776, 779 nervousness in, 774, 778 of extremities, 776, 779 organism of, 772 prophylaxis of, 777. 780 room in, 773, 778 specific treatment of, 776, 779 summary of treatment of, 778 symptomatic treatment of, 774, 778 symptoms of, 772 transfusion of blood in, 777 vaccine treatment of, 776 Erythema, from antipyretics, 223 from diphtheria antitoxin, 458 from quinine, 333 from salicylates, 40 in epidemic influenza, 238 in scarlet fever, 387 in septicemia, 763 in varicella, 516 ' Eserine. See Physostigmine Euquinine, in malaria, 334 Ewing, on typhoid fever metabolism, 25, 286 Exogenous metabolism, 23 Expansion of lung in pleurisy with effusion, technique of, 124 Expectorants, in bronchitis, 106, 107, 110 in pneumonia, 166, 201 Exploratory puncture, in pleurisy with effusion, 120, 127 Exsanguination, in typhoid fever, treatment of, 316 Extubation, 463 Eyes, See under the several Faget's sign, in yellow fever, 735 Family, distribution of. See under the several Farcy, 687, and see Glanders acute, 689, 692 chronic, 687, 691 serum therapy in, 688 specific treatment of, 688 treatment of local lesions in, 688, 689 vaccine treatment of, 688, 691 general treatment of, 687 isolation in, 690 mortality in, 687 precautions of nurse in, 690 of physician in, 690 prophylaxis of, 690, 692 summary of treatment in, 690 Fat, in acute infectious diseases, 16, 26 in typhoid fever dietary, 284 790 INDEX Febrile conditions, 1 aconite in, 6 antipyretics in, 7, 9 " caffeine in, 6, 9 camphor in, 6, 9 cathartics in, 5, 9 diet in, 3, 8 digitalis in, 6, 9 drugs in, 5, 6, 9 fresh air in, 4, 8 rest in, 2, 8 specific treatment of. See under the several diseases strophanthin in, 6 strychnine in, 6 summary of, 7 water in, 3, 4, 5, 9 Febrile patient, calories required by, 20 Febris carnis, 286 Ferenbaugh, on Malta fever, 656 Fever, 1, and see under the several diseases meaning of, 19 open air treatment of, 4 in relation to disease, 19 starvation in, 29 water needs in, 29 Fitzgerald, on tetanus antitoxin, 718 Fixed virus, of rabies, 702 Fleas, and plague, 634 Flexner, on cerebrospinal meningitis, 569, 573 serum, for bacillary dysentery, 361 serum, mortality with in cerebrospinal menin- itis, 577 Fluoform, in pertussis, 532 Fly blister, in local treatment of rheumatism, 50 Focal symptoms, in encephalitis lethargica, 272 Folin, analysis of urines, 22, 25 Foodstuffs, standard portions of, 16 Fomentations, application of, 163 in bacillary dysentery, 362 in bronchitis, 105, 109 in bronchopneumonia complicting measles, 498 for buboes, in plague, 636 in diphtheria, 462 in fibrinous pleurisy, 115, 126 in glandular fever, 556 in laryngitis, 97 in mumps, 547 in pericarditis of pneumonia,- 187 in pneumonia, 163 for retention of urine, in Malta fever, 658 in rheumatism, 49 in scarlatinal nephritis, 420 Food, harm of withholding in fevers, 20 Foodstuffs, proportion of in average dietary, 16 Rubner's figures for caloric value of, 13, 14 Food values, in units of 100 calories, 17 Foot and mouth disease, 693 bed in, 694, 696 care of bowels in, 695, 696 of eyes in, 695, 697 of mouth in, 694, 697 of nose in, 697 of teeth in, 694 circulation in, 694 diarrhea in, 697 diet in, 694, 696 fever in, 694, 696 gastro-intestinal symptoms in, 695, 697 isolation in, 694 precautions of nurse in, 694, 696 of physician in, 694, 696 prognosis of, 695 prophylaxis of, 695 rest in, 694, 696 room in, 694, 696 summary of treatment of, 696 vesicles and ulcers of skin in, 695, 697 Foreign protein therapy, in rheumatism, 58 Forks, disinfection of, 281 Fowler's solution, in malaria, 339, 351 Fresh air, in convalescence from pertussis, 537 in febrile conditions, 4, 8 in leprosy, 671, 676 Fresh air, in pneumonia, 155 in septicemia. 759 Friction, in connection with hydrotherapy, 5 Frontal sinus involvement in influenza, 228, 23c Fuller's alkaline treatment for rheumatism, 46 Fumigation. See Disinfection Gatch bed, 147 G:.3tric distress, in typhoid fever, 315 Gastro-intestinal function, disturbance of, in infection, 8, 18, 28 Gaultheria, 43, and see Wintergreen Genitals, care of. See under the several diseases Genito-urinary infection, in epidemic influenza, 258 Gentry and Ferenbaugh, on Malta fever, 656 German measles, 512, and see Rubella Glanders, 687, and see Farcy acute, 689, 692 chronic, 689, 691 care of nose in, 689, 691 cough in, 689, 691 general treatment of, 687 isolation in, 690 mortality in, 687 precautions of nurse in, 690 of physician in, 690 prophylaxis of, 690, 692 summary of treatment of, 690 Glandular fever, 555 adenitis in, 556, 558 bed in, 555 care of bowels in, 555, 558 of mouth in, 555, 558 of nose in, 555 of throat in, 556, 558 complications of, 556, 558 convalescence from, 557, 559 diet in, 555, 557 fever in, 556, 558 glands involved in, 555 incubation period of, 555 inflammation of pharynx in, 556 isolation in, 555, 557 nephritis in, 556, and see Scarlet fever, neph- ritis in otitis in, 556 prophylaxis in, 557, 559 room in, 555, 557 summary of treatment of, 557 tonsils in, 556 toxemia in, 556, 558 Glauber's salts, in bronchitis, 103, 109 in erysipelas, 774 in fibrinous pleurisy, 114, 125 in laryngitis, 95, 99 in Malta fever, 658 in mumps, 547 in plague, 635 in rheumatism, 35 in scarlet fever, 397 in yellow fever, 738 Glottis, edema of, complicating small pox, 615, 623 phlegmon of, differentiated from laryngeal diphtheria, 464 Goat fever, 656, and see Malta fever Goats, carriers of Malta fever organism, 656 Goats' milk, in Malta fever, 657 Goodman, on autoserotherapy in chorea, 61 Gottlieb, on caffeine, in scarlet fever, 405 Graham, on dengue, 641 Gravity method, in lumbar puncture, 572 Grip, 216 antipyretics in, 218, 223, 231 antral involvement in, 228, 233 bed in, 217 bronchitis complicating, 227 care of bowels m, 217, 231 carriers of, 230 change of air in, 229 complications of, 225, 233 convalescence in, 225, 233 cough in, 225, 233 INDEX 791 Grip, diet in, 217, 225, 231, 233 drugs in, 218, 231 fever in, 220, 229, 231, 233 frontal sinus involvement in, 228, 233 mastoiditis complicating, 226, 233 mental depression in, 229, 234 neuritis in, 234 otitis media complicating, 226, 233 pleurisy in, 227 pneumonia in, 226, 233 prophylaxis of, 230, 234 rest in, 217 rhinitis in, 227 room in, 231 sinus thrombosis complicating, 226, 233 sthenic period of toxemia, 218 summary of treatment of, 231 symptomatic treatment of, 218, 231 tonics in, 225, 233 tonsillitis in, 227 tracheitis in, 224, 232 Growing pains and rheumatism, in childhood, 61 Guiacol, in abscess of lung in epidemic influenza, 255 in mumps, 548, 553 Guiteras, on yellow fever, 736. 739 Gurd and Duval, on leprosy, 674 Gynocardia. See Chaulmoogra oil. Haas, on adenitis in glandular fever, 556 Haffkine's vaccine for plague, 635, 638 Hale, Worth, on toxicity of acetanilid, 219 on trikresol and meningococcic serum, 569 Halibut steak, food value of, 17 Hanzlik, on rheumatism, 39, 44 Headache. See under the several diseases. Hearing, effect of antipyretics on, 223 effect of quinine on, 333 Heart involvement, in bacillary dysentery, 366 in epidemic influenza, 256, 268 in malaria, 337, 350 in measles, 501 in rheumatism, in children, 30 in scarlet fever, 423 Heat, for chill in malaria, 324 for collapse in pneumonia, 177 for earache in scarlet fever, 411 for laryngitis in measles, 498 for otitis in measles, 499 for pain in bacillary dysentery, 552 for parotitis in mumps, 552 in fibrinous bronchitis, 115, 126 in malaria, 336 in pericarditis, 186 in pneumonia, 162 in poliomyelitis, 596, 597 in rheumatism, 49 Heine-Medin disease, 271 and see Poliomyelitis Hematuria, from salicylates, 40 Hemoglobinuria, in blackwater fever, 343 Hemoplastin, in nose bleed of diphtheria, 467 Hemorrhage. See under the several diseases Hepatic abscess, in amebic dysentery, 377, 379 Heroine, for cough, in bronchitis, 106, 110 in epidemic influenza, 250 in grip, 225, 233 in laryngitis, 96, 99 in pertussis, 532 Herrick, on serum treatment of cerebrospinal meningitis, 574 Heyn, on rectal administration of salicylates, 47 Hides, and anthrax, 678, 684 Hill, Miner C., on intubation in diphtheria, 462 Hill on prognosis of tetanus, 721 on transmissibility of poliomyelitis, 592 Hilprit, on synthetic sodium salicylate, 42 Holt, croup kettle, 96, 527 on diphtheria, 474 on dosage, of diphtheria antitoxin, 456 of quinine, 330 on mortality, in measles, 487 on oxygen inhalations in pertussis, 536 on pertussis, 528 Hominy, food value of, 17 Hooker, on blood transfusions, 767 Horse serum, for hemorrhage in typhoid fever, 296 in poliomyelitis, 605 in tetanus, 713 Horses, glanders and farcy and, 687 Hot air bath, in scarlatinal nephritis, 417 Hot bath, in laryngitis, 95, 99 in rhinitis, 72 Hot compresses, in laryngitis of measles, 499 in scarlatinal nephritis, 417, 418 Hot fomentations, for angina in laryngeal diph- theria, 465 in diphtheria, 462 in poliomyelitis, 596 Hot milk, in laryngitis complicating measles, 499 Hot pack, in chorea, 60 in scarlatinal nephritis, 417, 418 Hot water bag, in fibrinous pleurisy, 115, 126 Hot water bottle, in rhinitis, 72 Hubbard, ointments used by, in small pox, 612 formula for itching, in measles, 492 Huntoon and Elser, on cerebrospinal meningitis, 561 Hydrocephalus, in cerebrospinal meningitis, 576 Hydrochloric acid, in acute infectious diseases, 18 Hydrogen dioxide, in local treatment of tetanus, 714 in treatment of wounds, 722 Hydrophobia, 699, and see Rabies Hydrotherapy. See Baths, and also under the several diseases in febrile conditions, 3, 4, 7, 9 Hydrothorax, in scarlatinal nephritis, 421 Hyoscine, for chorea, 61 for convulsions of tetanus, 720 for delirium, in anthrax, 684 in epidemic influenza, 246 in erysipelas, 774 in cerebrospinal meningitis, 566 in pneumonia, 169 in rabies, 707 in Rocky mountain spotted fever, 667 in septicemia in pyemia, 761 Hyperpyrexia. See under the several diseases Hypertonic glucose solution in cerebrospinal meningitis, 567 Hypertonic solution, in cholera, 647, 652 Hypnotics, in pneumonia, 169, 202 in rheumatism, 37 in small pox, 615 Hypodermoclysis, in diarrhea of bacillary dysen- tery, 365, 373 in diphtheria, 471 with quinine, 331 Ice, for gastric distress in yellow fever, 738 for nausea, in scarlet fever, 422, 431 in vomiting of typhoid fever, 295, 315 Ice-bag, application of, 163 for angina, in laryngeal diphtheria, 465 for buboes, in plague, 636 for cerebral disturbances, in typhoid fever, 298 for delirium, in septicemia, 761 in pneumonia, 168 for gastric distress, in yellow fever, 738 for headache, in anthrax, 684 in bronchitis, 104, 109 in scarlatinal nephritis, 422 in septicemia, 762 in small pox, 614 for hemorrhage in typhoid fever, 296 for pains, in dengue, 642 in fibrinous pleurisy, 115, 126 in laryngitis complicating measles, 498 in pericarditis complicating pneumonia, 185 in pneumonia, 163 in rheumatism, 49 in Rocky mountain spotted fever, 667 in typhoid fever, 294 Ice-cap, for headache in pneumonia, 168 in cerebrospinal meningitis, 566 in measles, 494 in scarlet fever, 407, 413 792 INDEX Ice-coil. See also Ice-bag in cerebrospinal meningitis, 566 in rheumatism, 49 in tympanites of typhoid fever, 294 Ice-collar, in laryngitis, 97 Ice-poultice, in mumps, 548, 553 Ichthyol, in erysipelas, 775, 776 in glandular fever, 556 in mumps, 548, 553 in scarlet fever, 413 Immunity, active, 454 passive, 454 Imperial drink, in rhinitis, 72 Infantile paralysis, 590, and see Poliomyelitis Infectious diseases, acute, diet in, 10 to 29 Infectious jaundice, 728 active immunization in, 731 bed in, 729 care of bowels in, 730, 732 colic in, 733 convalescence from, 733 diarrhea in, 730, 733 diet in, 729, 732 fever in, 729, 731 headache in, 733 hemorrhages in, 731 . icteric stage of, 729 incubation period of, 728 jaundice in, 729, 731 lesions of, 728 nausea in, 730, 733 nephritis in, 731 nervous symptoms in, 731 organism of, 728 pain in legs in, 731, 733 prophylaxis of, 731, 734 room in, 729 specific treatment of, 730 summary of treatment of, 732 symptoms of, 728 vomiting in. 730, 733 water in, 732 Influenza empyema, 211, and see Empyema, in- fluenza type epidemic, 235, and see Epidemic influenza sporadic, 216, and see Grip Inhalations, in abscess of lung in epidemic in- fluenza, 255 in bronchitis, 105, 109, 110 in bronchitis in measles, 498 in coryza, 74 in grip, 225 in la laryngitis, 96, 98, 99 in laryngitis in measles, 499 in membranous angina in scarlet fever, 400, 401 in pertussis, 527 in pneumonia, 165, 201 in rhinitis, 74, 77 in tracheitis of grip, 225, 232 oxygen, for dyspnea in pneumonia, 179 in pertussis, 536 steam, in bronchopneumonia, 180 in bronchopneumonia complicating measles, 497 in diphtheria, 461 in glanders, 689 in laryngitis in small pox, 615 in laryngitis in typhus fever, 630 in pneumonia, 165 Inhalers, 96, 99 Insomnia, in anthrax, 683 in dengue, 642, 644 in encephalitis lethargica, 272, 275 in epidemic influenza, 245 in pertussis, 533, 541 in poliomyelitis, 596, 605 in rheumatism, 36, 68 in septicemia, 761, 770 in small pox, 614, 623 in tonsillitis, 84, 89 Intestinal anthrax, 679 Intestinal infection, and rheumatism, 62 Intracerebral administration of antitoxin, 717, 725 Intramuscular administration of antitoxin, 717, 725 ., Intraneural administration of antitoxin, 717, 725 Intraspinal administration of antitoxin, 716, 725 of magnesium sulphate, in tetanus, 719 treatment of cergbrospinal meningitis, 668, 584 Intravenous injection, of adrenalin in pneumonia, 177 of diphtheria antitoxin, 457, 480 of foreign protein in rheumatism, 58 of quinine, 332 of salicylates, 47, 66 of saline solution in cholera, 647, 652 of tetanus antitoxin, 716, 725 Intubation, in diphtheria, 462 indications for, 463 in edema of larynx, 99 in pertussis, 528 post-intubation treatment, 463 procedure, 462 Iodine, for itching and burning of small pox, 613 for lesions of farcy, 689 for local treatment of tetanus, 722, 725 for odor of small pox, 613 for membranous angina in scarlet fever, 401 in fibrinous pleurisy, 116, 126 in rabies, 701 in treatment of wounds, 722, 725 in Vincent's angina, 92, 93 lodoform, for odor of small pox, 613 in glanders, 689 in treatment of wounds, 722 Ipecac, in amebic dysentery, 376 in anthrax, 681 in laryngitis, 96, 98, 99, 100 Iron, for anemia, in malaria, 339, 351 in scarlatinal nephritis, 423 for convalescence. See under the several Irrigation, colonic, for ileocolitis complicating measles, 500, 509 in otitis of scarlet fever, 410 nasal, in diphtheria, 452, 466 in glanders, 689 of throat, in scarlet fever, 400 oral, in foot and mouth disease, 694 rectal, in bacillary dysentery, 362, 363 Isolation. See under the several diseases Itching and burning, in measles, 491, 505 in small pox, 612, 621 in varicella, 516 Jackson, on plague, 637 Jacobi, on belladonna, in pertussis, 530, 540 Jalap, in Malta fever, 658 Jalap powder, compound, in scarlatinal nephritis, James, on dosage of quinine, 330 on relapses in malaria, 338 Jaundice, complicating pneumonia, 191 Jaundice, infectious, 728, and see Infectious jaundice Jenner, on small pox, 608 John and Ashurst, on tetanus, 711, 714 Johns, on blackwater fever, 343 on malaria, 324, 327 Joints, care of in Malta fever, 658 in cerebrospinal meningitis, 577 in rheumatism, 31, 48, 50, 66 in scarlatinal arthritis, 413, 437 in septicemia, 763, 771 Kemp, on rheumatism, 54 Ker, on orchitis in mumps, 549 on pertussis, 528, 534 Kerr and Stimson, on rabies, 708 Kidneys, complication of, in diphtheria, 473 in malaria, 336, 350 congestion of, in yellow fever, 739 functions of, 393 hemorrhage from, due to quinine, 334 involvement of, in epidemic influenza, 257 in measles, 501 in scarlet fever, 414 INDEX 793 Kidneys, in septicemia, 763 Kilmer's belt, in pertussis, 526, 533 Klemperer, on gastrointestinal function, 18 Klercner, on typhoid fever, 24 Knee-joint, paracentesis of, 51 Knives, disinfection of, 281 Koch, on blackwater fever, 344 method of giving quinine in malaria, 329 Koumyss, food value of, 17 Krehl, on toxemia, 21 Krumwiede-Valentine, method of typing sputum, 131 Lamb, food value of, 17 Lambert, on pneumonia, 22, 25 Langmead, on rheumatism in children, 31 Laryngeal diphtheria, 460, and see Diphtheria, laryngeal Laryngeal spasm, in pertussis, 528 Laryngitis, acute, 94 abortive treatment of, 95, 99 care of bowels in, 95, 99 in children, 98, 100 cold compresses in, 97, 100 complications in, 98, 100 cough in, 96, 99 diagnosis of, 94 edema of larynx in, 98, 100 etiology of, 94 fomentations in, 97, 100 ice collar in, 97. 100 in epidemic influenza, 256 in measles, 498, 508. 511 in small pox, 615, 623 in typhus fever, 630 inhalations in, 96, 98, 99 local treatment of, 97, 99, 100 rest in, 95, 99 smoking prohibited in, 95, 99 sprays in, 97, 100 summary of treatment of, 99 symptomatology of, 94 Laryngoscope, use of, 94 Latham, on chaulmoogra oil in leprosy, 672 on lumbar puncture, 573 Lawson, Mary R., on malaria, 328, 337 Leeching. See Cupping Lees, on rheumatic fever, 39, 54 Leprolin, for leprosy, 674 Leprosy, 670 baths in, 671 Calmette's antivenomous serum in, 673 diet in, 671, 676 disposal of excreta and secretions in, 670 distribution of, 670 empirical treatment of, 671, 676 fresh air in, 671, 676 isolation in, 670, 675 local treatment of, 672, 676 organism of, 670 precautions for attendants in, 670, 675 prognosis of, 674 prophylaxis of, 674, 677 specific treatment of, 673, 676 summary of treatment of, 675 surgical treatment of, 674 tonic treatment of, 674, 676 X-ray treatment of, 674 Leyden, von, on gastro -intestinal function, 18 Light, importance of in treatment of septicemia, 758 Lillienthal's method of aspiration, 254, 268 Lindeman, on blood transfusion in sepsis, 767 Lipovaccines, in typhoid fever, 309 Liver abscess, in amebic dysentery, 378 Lockjaw, 712 Loeffler's solution, in diphtheria, 466 for membranous angina in scarlet fever, 401 Loewe, on blood typing in pneumonia, 131 Longcope, on serum treatment in pneumonia, 130 Lord, on fluid in chest in pneumonia, 180 on lung expansion in pleurisy with effusion, 124 Losee, on blood transfusion, 767 Louse, and trench fever, 751, 753 and typhus fever, 624, 626 Lovelace, on treatment of blackwater fever, 344 Lovett, on operative treatment in poliomyelitis, 602 on prevention of contracture in poliomyelitis, 599 Ludke, on pyrexia, 19 Ludy, on anthrax, 681 Lumbar puncture, for cerebral disturbances in typhoid fever, 298 for convulsions in pertussis, 536 for headache in scarlatinal nephritis, 422 in cerebrospinal meningitis, 569, 584 amount of fluid withdrawn, 571 anesthetic for, 570, 585 appearance of fluid in, 571 bad results of, 573 collecting fluid in, 571 dry tap in, 572 flow in, 571 needle for, 570 position of patient in, 570 preparations for, 570 reaction in, 572 site of, 569 the tap in, 571 in encephalitis lethargica, 275 in meningitis following grip, 229 in meningo-encephalitis of mumps, 551 Luminal, for restlessness in chorea, 60 Lung, abscess of, in epidemic influenza, 254 complications of in malaria, 337, 350 expansion in pleurisy with effusion, technique of, 124, 127 Lusk, on infectious fevers, 20 on functions of protein, 15 Lyssophobia, 706 MacCallum, on pyrexia, 19 on streptococcus pneumonia, 208, 209 Maclagan, on salicin, 37 McCoflom, method of fumigation recommended by, 475 on dosage of diphtheria antitoxin, 455 on irrigation, in nasal diphtheria, 466 on laryngeal diphtheria, 461 on scarlet fever, 388, 402 McCrae, on prophylaxis of typhoid fever, 303 McGlannan, on rabies, 701 McGuire, on noma, 424, 429 Macaroni, food value of, 17 Mackerel, food value of, 17 Magnesium sulphate. See Epsom salts Magnus-Levy, on metabolism, 12 Malaria, 322 algid form of. 336, 349 anemia in, 337, 350, 351 bed in, 323 cachexia in, 338, 350 care of bowels in, 324, 346 carriers, 343 chill in, 324, 346 choleraic form of, 336, 350 classes of, 322 collapse in, 325, 335 complications of, 336, 350 convalescence from, 340 diet in, 323, 346 fever in, 325, 346, 349 headache in, 325, 347 hyperpyrexia in, 325, 349 isolation in, 342 latent, 338, 350 masked, 338, 350 multiple infectious, 336 nervous manifestations in, 339, 351 pernicious, 330 cerebrospinal type of, 335, 349 collapse in, 335 comatose form of, 335, 349 hyperpyrexia in, 335 irritative form of, 335, 349 paralytic form of, 335, 349 794 INDEX Malaria, pernicious, quinine treatment of, 330, sequelae of, 337, 350,. symptomatic treatment of, 335, 349 prevention of collapse in, 325, 346, 347 prophylaxis from, 340, 351, 342 protection of individual in, 341, 352 relapses in, 337, 350 rest in, 323, 345 room in, 323, 345 sequete of, 337, 350 specific treatment of, 326, 346 summary of treatment of, 345 sweating in, 326, 347 symptomatic treatment of, during paroxysm, 324,346 vomiting in, 325, 346 Malignant pustule, 678, 679, 684, and see An- thrax Mallein, use of in farcy, 688 Malta fever, 656 bed in, 657, 661 care of body in, 657, 661 of bowels in, 658, 661 of joints in, 658 carriers of, 660 constipation in, 658 convalescence from, 660, 663 diet in, 657, 661 disinfection in, 660 disposal of excreta in, 660 distribution of, 660 drinks in, 658 fever in, 659, 662 goats carriers of, 656 hyperpyrexia in, 659 incubation period of, 656 orchitis in, 660 pain in, 658, 662 precautions of nurse in, 657, 661 of physician in, 657, 661 prognosis in, 660 prophylaxis of, 660, 663 relapses in, 657 rest in, 657, 661 retention of urine in, 658, 662 room in, 657, 661 sleeplessness in, 659, 662 specific treatment of, 658 summary of treatment of, 661 symptomatic treatment of, 658, 662 symptoms of, 656 toxemia in, 659, 662 vomiting in, 659, 662 Mammary gland involvement in mumps, 550 Mania, from salicylates, 40 Manson, theory on malaria, 329 Mask, for physician and nurses in influenza, 241 Mattresses, disinfection of, 282 Maxwell and Pope, on ice poultice in mumps, 549 on mustard bath, 95 on hot air bath, 418 Measles, 487 adenitis complicating, 499 bath in, 490, 504 bed in, 490, 504 bronchitis complicating, 498, 508 bronchopneumonia complicating, 495, 507 care of bowels in, 493, 498, 505 of cardiovascular system in, 494, 498 of eyes in, 492, 501, 503, 505, 510 of genitals in, 493, 505 of mouth in, 492 of nose in, 492, 505 of patient in, 490, 504 of skin in, 491, 505 complications of, 495, 507 convalescence from, 502, 511 cough in, 497 diet in, 490, 496, 504 diphtheria complicating, 501, 510 disinfection in, 503, 511 distribution of family in, 488, 503 fresh air in, 489, 503 gastro-intestinal complications of, 499, 509 German, 512, and see Rubella heart complications of, 501, 510 ileocolitis complicating, 500, 509 infectivity of, 487 kidney involvement in, 501, 510 laryngitis complicating, 498, 508, 511 mortality in, 487 noma complicating, 499, 509 open air treatment of, 496 otitis complicating, 499, 508 photophobia complicating, 501, 510 precautions in sick room in, 490, 504 of nurse in, 489, 503 of physician in, 490, 504 quarantine in, 488, 502, 511 room in, 488, 503 sleeplessness in, 495, 507 summary of treatment of, 503 treatment of fever in, 493, 497, 506 of nervous symptoms in, 494, 506 of respiratory failure in, 494 tuberculosis complicating, 502, 511 ulcerative stomatitis complicating, 499, 509 water in, 491, 504 Medinal, in pneumonia, 169 Meltzer, on magnesium sulphate as a test for typhoid carriers, 305 on magnesium sulphate in tetanus, 720 Meningismus, in epidemic influenza, 269 in typhoid fever, 302 Meningitis, cerebrospinal, 560, and see Cerebro- spinal meningitis Meningococcic serum, in cerebrospinal menin- gitis, 567 dosage of, 568 early use of, 573 intradural administration of, 569 intravenous administration of, 574 mode of preparation of, 568 results of, 573 Meningo-encephalitis in mumps, 550 Mental rest, importance of in febrile conditions, 2 Menthol, in bronchitis, 105, 109 in epidemic influenza, 243 in pertussis, 528 in Malta fever, 658 in small pox, 612 Methyl sahcylate. See Salicylates Methylene blue, as a substitute for quinine, 339, 351 Meyer and Gottlieb, on caffeine in vasomotor weakness, 405 Milk, analysis of, 16, 28 in acute infectious diseases, 16, and see under the several diseases (diet) caloric value of, 16, 35 food value of, 17 Milk supply, typhoid fever and,'JJ04 Miller, on acidosis, 46 Morphine, for choleraic form of malaria, 336 for convulsions in anthrax, 684 in pertussis, 536 in rabies, 706 in scarlatinal nephritis, 422 in septicemia, 761 for cough, in bronchitis, 106, 110 in glanders, 689 in laryngitis, 96, 99 in pneumonia, 166 for delirium, in anthrax, 684 in epidemic influenza,*246 in erysipelas, 774 in infectious jaundice, 733 in measles, 495 in pneumonia, 168 in scarlet fever, 407 in septicemia, 761 in small pox, 614 in typhus fever, 629 for gastric distress, in yellow fever, 739 for headache, in dengue, 642 in malaria, 325 in pneumonia, 170 INDEX 795 Morphine, for hemorrhage, in typhoid fever, 296 for ileocolitis complicating measles, 501 for insomnia, in anthrax, 684 in epidemic influenza, 246 in plague, 636 in pneumonia, 169 in Rocky mountain spotted fever, 666 in small pox, 615 in tonsillitis, 84, 89 in typhoid fever, 298 for late circulatory failure, in diphtheria, 469 for pain, in dengue, 642 in epidemic influenza, 245 in mumps, 551 for restlessness, in chorea, 61 for vomiting, in cholera, 648 in infectious jaundice, 730 in malaria, 325 in Malta fever, 659 in cerebrospinal meningitis, 566 in encephalitis lethargica, 275 in fibrinous pleurisy, 118, 126 in poliomyelitis, 596 in rheumatism, 46, 53, 61 in trench fever, 752, 755 to facilitate nasal feeding, in tetanus, 719 Morphine suppository, for tenesmus in bacillary dysentery, 364, 372 Mpser serum, in scarlet fever, 409 in septicemia, 765 Mosquito, and dengue, 641 and malaria, 322 and yellow fever, 735 destruction of, in prevention of malaria, 341 in prevention of yellow fever, 740 Mouth, care of. See under the several rtinnaitu Mumps, 545 arthritis in, 551 baths in, 546, 552 care of bowels in, 547, 552 of mouth in, 546, 552 of nose in, 546, 552 of patient in, 546, 551 of secretions in, 546 complications of, 549, 553 convalescence from, 551, 554 disinfection after, 551, 554 diet in, 546, 552 distribution of family in, 545, 551 drugs in, 548 fever in. 547, 552 gland involvement in, 549, 552 in adults, 546 incubation period of, 545 infection through third person, 546 local treatment in, 547 meningo-encephalitis in, 550, 554 nephritis in, 551 nervousness in, 551, 554 orchitis complicating, 549, 553 pain in, 551, 554 pancreatitis in, 550, 553 precautions of nurse in, 546, 552 of physician in, 546, 552 release from quarantine in, 551, 554 room in, 546, 551 sleeplessness in, 551, 554 summary of treatment of, 551 symptoms of, 545 thrums gland in, 550 treatment of parotitis in," 547, 552 vulvitis complicating, 550,^553 Murphy drip, 154 apparatus, 153, 154 in bronchopneumonia complicating measles, 498 in cholera, 648 in diphtheria, 451 in pneumonia, 154 in septicemia, 761 in yellow fever, 739 Mustard bath, for convulsions of pertussis, 535 in laryngitis, 95, 99 in measles, 493 Mustard bath, technique, 535 footbath, hot, for headache in yellow fever, 738 in laryngitis, 95, 99 in rhinitis, 72 pack, for convulsions in pertussis, 535 pastes, plasters, and poultices, for backache in yellow fever, 738 for bronchitis, 104, 109 for bronchitis complicating measles, 498 for bronchopneumonia complicating measles, 493, 497 for cough in pleurisy, 162 for epidemic influenza, 246, 251 for fibrinous pleurisy, 116, 126 for gastric distress in yellow fever, 738 for nausea in cerebrospinal meningitis, 565 for nausea in infectious jaundice, 730 for nausea in scarlet fever, 422 for vomiting, in malaria, 325 in Malta fever, 659 in septicemia, 761 in typhoid fever, 295, 315 in fibnnous pleurisy, 116, 126 in pneumonia, 162, 187 Mustard plaster, application of, 163 Muzzling law, for prevention of rabies, 707 Myositis, in scarlet fever, 414 Nagele method of breaking spasm in pertussis, 528 Nasal diphtheria, 451, and see Diphtheria, nasal Nasal feeding, in tetanus, 713, 724 Nasal hemorrhages in pertussis, 534 Nasal passages, care of in prophylaxis of pneu- monia, 192 Nasopharynx, care of in pneumonia, 149 portal of entry of bacillus leprae, 670 Nastin, in leprosy, 673 Nausea. See under the several diseases Negri bodies, in rabies, 699 Nephritis, in diphtheria, 473, 484 in epidemic influenza, 258 in glai _ glandular fever, 556 in infectious jaundice, 731 in measles, 501 in mumps, 551 in scarlet fever, 388, 414 in tonsillitis, 86 Nervousness, in epidemic influenza, 265 Neuritis, following influenza, 259 Nightgown, special, in rheumatism, 32 in scarlet fever, 392 Nitrate of silver, in amebic dysentery, 383 in bacillary dysentery, 367 for ulcerative somatitis complicating measles, 500 for wound in rabies, 701 Nitric acid, for noma complicating scarlet fever, 424 for noma complicating measles, 500 for wound in rabies, 700, 708 Nitrogen, elimination of, 21 partition, 21 rest, 24 role of, in acute infectious diseases, 21 total, 22 Nitroglycerin, in convulsions in scarlatinal nephritis, 422 in pneumonia, 177 Noguchi, on yellow fever, 735 Noma, complicating measles, 499, 509 in scarlet fever, 424 Norris, on fluid in chest in pneumonia, 180 on pericarditis in pneumonia, 184 Normal salt solution. See Saline solution Northrup's directions for release of scarlet fever patient, 442 Nose, care of. See under the several diseases (nose, or body, or patient) Nose-bleed, in dengue, 643 in diphtheria, 467, 482 in pertussis, 534 Nurse. See under the several diseases Nux vomica. See Strychnine 796 INDEX Oatmeal, food value of, 17 Odor of small pox, 613, 622 Oil, food value of, 18" Oil of chenopodium, for amebic dysentery, 383 Oil of gaultheria, 43 Oil of wintergreen, 43 Oleum betuhe, 43 Oleum gynocardise, in leprosy, 671 Open air treatment, of bronchopneumonia com- plicating measles, 496 of bronchopneumonia complicating pertussis, 534 of diphtheria, 471 of fever, 4 of measles, 496 of pneumonia, 155, 168, 199 of typhoid fever, 279 of typhus fever, 630, 632 Ophthalmoscope, use of, 94 Opium in anthrax, 684 in bacillary dysentery, 363, 365, 372, 373 in cholera, 647. 654 in foot and mouth diseases, 695 in ileocolitis complicating measles, 501 in infectious jaundice, 730 in pertussis, 531, 536, 543, 641, in typhoid fever, 294 Orchitis, in Malta fever, 660 in mumps, 549, 553 Otitis. See under the several diseases Otoscope, use of, 94 Ottenberg and Libman, on blood transfusion, 767 Ouabain, in pneumonia, 174 Ovaries, involvement of in mumps, 550 Oxygen inhalations, in bronchopneumonia of measles, 497 in convulsions of pertussis, 536 in dyspnea of pneumonia, 179 in poliomyelitis, 600 in pulmonary edema of epidemic influenza, 249 Packs, cold, in bronchopneumonia complicating measles, 497 in measles, 493 in pneumonia, 161 in typhoid fever, 291 hot, for backache in yellow fever, 738 in chorea, 60 mustard, for convulsions in pertussis, 535 Pain, See under the several diseases Pancarditis, in rheumatism, 54 Pancreas, involvement of in mumps, 550 Paquelin cautery, in noma complicating measles, 499 Paracentesis, for hydrothorax, in scarlatinal nephritis, 421 for pericarditis of pneumonia, 184 in mastoiditis complicating grip, 226 in otitis complicating scarlet fever, 410 of knee joint, 51 Paraldehyde, for sleeplessness in pneumonia, 170 Paralysis. See under the several diseases infantile, 590, and see Poliomyelitis Paratyphoid fever, 320 preventive inoculation, 320 treatment of, 321 Paregoric, in cholera, 647 in pertussis, 531, 541 Park, on diptheria antitoxin, 454. 456, 460 on rabies, 702, 703, 705 on tetanus antitoxin, 715, 716, 717 on vaccine therapy in farcy, 688 Parotitis, 545, and see Mumps complicating pneumonia, 191 complicating typhus fever, 630, 633 in epidemic influenza, 260 in glandular fever, 556 treatment of in mumps, 547, 552 Parrots, psittacosis and, 698 Pasteur treatment of rabies, 703 Patient, care of, see under the several diseases Payne, on specific organism of rheumatism, 30 Peas, food value of, 18 Pediculus vestimenti, typhus fever transmitted by, 624 Pembrey, on respiratory exchange, 4 Peptonized milk, enema in tetanus, 713 Perforation in typhoid fever, 297 Pericarditis, in measles, 501 in pneumonia-, 184 in rheumatism, 53 in scarlet fever, 423 Perinephritic abscess, in epidemic influenza, 258 Peritonsillar abscess, 86 Pernicious malaria, 335, and see Malaria, per- nicious Pertussis, 520 abdominal support in, 526, 533 avoidance of emotional states in, 527 bacillus of, 520, 532 baths in, 524, 539 bed in, 524, 539 bromides in, 531. 536, 541 bromoform in, 532 bronchopneumonia in, 534 care of bowels in, 525, 539 patient in, 525, 539 secretions in, 523 carriers of infection of, 522 catarrhal stage of, 520 change of climate in convalescence from, 543 chloroform for paroxysms of, 535 clothing in, 523, 538 complement fixation test in, 521 complications of, 533, 542 contagiousness of, 520 convalescence from, 536, 543 convulsions in, 535, 542 cough in, 525, 540 diarrhea in, 534, 542 diet in, 524, 539 disinfection of room in, 522 distribution of family in, 521, 537 drugs in, 528, 540 elastic belt in, 526 fever in, 525, 539 fixation test in, 521 fresh air in, 537, 538 hemorrhages in, 534, 542 hygiene in, 525, 539, 544 hyperexcitability of larynx in, 528 incubation period of, 520 inhalations in, 527 insomnia in, 533, 541 intubation in, 528 isolation in, 521, 537 laryngeal spasm in, 528 local procedures in, 526 mechanical support in, 526 mode of infection in, 522 mortality in, 520 nose bleed in, 534, 542 open air treatment of, 522, 538 precautions in sick room in, 523, 538 of nurse in, 523, 538 of physician in, 523, 538 prophylactic use of vaccine in, 523, 538, 544 prophylaxis of, 537 quarantine in, 536 release from quarantine in, 536, 543 removal of adenoids in, 537 removal of tonsils in, 537 room in, 522, 538 sera in, 532 specific treatment of, 532 summary of treatment of, 537 symptomatology of, 521 tonics in convalescence from 537, 543 treatment of severe cases, 526, 540 ulcer of frenum in, 534, 542 vaccines in, 532 vomiting in, 520, 521, 533 Pestis minor, 634 Pharyngeal diphtheria, antitoxin in, 455 Pharyngeal paralysis in diphtheria, 451, 472 Pharyngitis, in epidemic influenza, 256 in poliomyelitis, 597 INDEX 797 Phenacetin, chemistry of, 222 in bronchitis, 104, 109 in coryza, 72 in epidemic influenza, 245 in erysipelas, 774 in fibrinous pleurisy, 118, 126 in glandular fever, 556 in grip, 218, 231 in Malta fever, 659 in measles, 495, 498 in mumps, 547 in pneumonia, 161 in poliomyelitis, 596 in rheumatism, 45 in rhinitis, 72, 76 in scarlatinal nephritis, 422 in scarlet fever, 407 in small pox, 614 in tonsillitis, 83, 89 in trench fever, 752, 754 toxic effects of, 223 Phenol, for itching in scarlet fever, 395 for itching in small pox, 613 for itching in varicella, 516 for noma complicating measles, 500 for otitis complicating measles, 499 for wound in rabies, 701, 708 in anthrax, 679, 680, 681 in earache of scarlet fever, 411 in farcy, 689 in measles, 492, 505 in tetanus, 718, 722 Phenylsalicylate. See Salol Phlebitis, in epidemic influenza, 257 in typhoid fever, 302 Photophobia complicating measles, 501, 510 Phthalein test of renal function, 415 Physician, precautions of. See under the several Physiological salt solution. See Saline solution in diphtheria, 466 in rabies, 701 Physostigma, for convulsions of tetanus, 721 Physostigmine, for tympanites in typhoid fever, 294 Pilocarpine, in scarlatinal nephritis, 419 Pituitrin, in pneumonia, 152 in pneumonia of epidemic influenza, 248 in tympanites of epidemic influenza, 251 in tympanites of typhoid fever, 294 Plague, 634 abortive, 634 ambulatory, 634 bed in, 635, 638 buboes in, 636, 63H bubonic, 634 care of bladder in, 635, 639 of body in, 635 of bowels in, 635, 639 of patient in, 635, 638 carriers, 634 circulation in, 635 convalescence from, 637, 640 delirium in, 636, 639 diarrhea in, 636, 640 diet in, 635, 639 disinfection in, 637 disposal of excreta in, 635 fever in, 635, 639 fulminating, 634 headache in, 636 immunization in, 638 intestinal, 634 isolation in, 634 nervous symptoms of, 636, 639 organism of, 634 pneumonic, 634 precautions for nurse in, 635, 638 for physician in, 635, 638 prophylactic inoculation against, 638 prophylaxis of, 637, 638 room in, 634, 638 role of rats and fleas in, 637 septicemic, 634 Plague, sequelae of, 637 sleeplessness in, 636, 639 serum treatment of, 636 specific treatment of, 636 summary of treatment of, 638 Pleurisy, 112 dry, 112, 125 types of, 112 Pleurisy, fibrinous, 112 blisters in, 116, 126 care of bowels in, 114, 125 cautery in, 116, 126 coal-tar preparations in, 118, 126 cough in, 113, 118, 126 counterirritants in, 116, 126 cupping in, 117 diet in, 113, 125 drinks in, 114, 125 drugs in, 117, 126 dyspnea in, 118, 126 electric pad in, 115, 126 fomentations in, 115, 126 heat in, 115, 126 hot water bag, 115, 126 ice bag in, 115, 126 iodine in, 116, 126 local measures in, 114, 126 mustard in, 116, 126 pain in, 113 poultice in, 116, 126 room in, 113, 125 strapping the chest in, 114, 126 summary of treatment of, 125 Pleurisy, purulent. See Empyema Pleurisy with effusion, 118 after-treatment of, 125, 127 aspiration in, 120, 127 autoserotherapy in, 124 convalescence in, 124, 127 Delafield's method in, 119, 126 diuretics in, 123. 127 expanding lung in, 124 exploratory puncture in, 120, 127 general care of, 119, 126 summary of treatment of, 126 thoracentesis in, 119 treatment of, 119 Pleuritis, 112, and see Pleurisy Pneumococcus, carriers, 193 serum, 130, and see Serum treatment in pneu- monia types of, 129 vaccines, prophylactic use of, 193 Pneumonia, lobar, 128, and see Peumonia (Pneu- mococcus) Pneumonia (Pneumococcus), 128 abdominal pain in, 191 agglutination test in, 130 anaphylaxis in, 134, 145 arthritis in, 191 bath in, 147 bed in, 146, 155, 195 bronchitis in, 164 bronchopneumonia, in, 179 care of body in, 147, 197 of bowels in, 151, 198 of circulation in, 170, 203 of ears in, 149 of eyes in, 149 of fissures in, 149 of genitals in, 149 of mouth in, 148 of nose in, 149 of teeth in, 148, of tongue in, 148 carriers of, 193 collapse in, 177, 204 complications of, 180, 205 convalescence from, 192, 20o cough in, 161, 200 desensitization in, 135, 136 diet in, 149, 197 drinks in, 151, 198 drugs in, 161, 166, 168, 200 798 INDEX Pneumonia, dyspnea in, 179, 205 embolism complicating, 190 empyema complicating, 181, 187 enemata in, 152 endocarditis in, 190 etiology of, 128 fever in, 161, 200 following influenza, 226, 233, 236, 239, 246, 266 fluid in chest in, 180 herpetic eruption in, 149 hydro therapy in, 157 in cerebrospinal meningitis, 588 in grip, 226, 233 in rheumatism, 68 inhalations in, 165, 201 jaundice in, 191 local treatment of, 167 meningitis complicating, 191 Murphy drip in, 154 open air treatment of, 155, 168, 199 pain in, 166 parotitis complicating, 191 pericarditis complicating, 184, 205 peritonitis complicating, 191 pleurisy in, 161 prophylaxis of, 192 relapses in, 191 rest in, 146, 194 room in, 147, 195 sensitization in, 134, 135 serum treatment of, 130, and see Serum treat- ment of Pneumonia specific treatment of, 129, 195 summary of treatment of, 194 symptomatic treatment of, 155, 160, 200 toxemia in, 167, 201 treatment of collapse in, 177, 204 of cough in, 161 of delirium in, 168, 201 of dyspnea in, 179, 205 of fever in, 161, 200 of headache in, 170, 202 of pulmonary edema in, 178, 205 of sleeplessness and restlessness in, 169, 202 of toxemia in, 201 tympanites in, 152, 199 types of, 128, 129 use of rectal tubes in, 152 vaccines, 193 Pneumonia (Streptococcus), 208 empyema in, 209 pathology of, 208, 210 summary of treatment of, 215 symptomatology of, 210 treatment of, 210 Poliomyelitis, 590 abortive cases of, 591 active movements in, 601 bed in, 593, 603 bulbospinal type of, 599, 606 care of bladder in, 594, 604 of bowels in, 594, 604 of patient in, 592, 593, 603 carriers of, 590 cerebrospinal fluid in, 591 contractures in, 599, 602 convulsions in, 596, 605 diarrhea in, 597, 606 diet in, 593, 604 disinfection in, 592 gastrointestinal symptoms in, 596, 606 hyperesthesia in, 605 insomnia in, 596, 605 involvement of muscles of trunk and dia- phragm in, 600 isolation in, 592, 603 meningo-encephalitic type of, 598 operative treatment of, 602 paralysis of extremities in, 600, 606 paralytic period of, 600, 606 passive movements in, 601 pathology of, 597 pharyngitis in, 606 precautions of nurses in, 592 Poliomyelitis, precautions of physicians in, 592 preparalytic period in, 594, 604 prognosis of, 1 602 prophylaxis of, 607 protection of community in, 590 room in, 592, 603 serum treatment of, 594, 595, 604, 605 specific treatment of, 594 summary of treatment of, 603 symptomatic treatment of, 593, 604 tonsillitis in, 606 transmission of, 590, 592 types of, 597 unne in, 594, 604 Pope and Maxwell, on hot air bath, 418 on ice poultice in mumps, 549 on mustard bath, 95 Potassium chlorate, in foot and mouth disease, 695 for gargling in small pox, 611 for ulcerative stomatitis complicating measles, 499 Potassium iodide, in rheumatism, 46 Potassium permanganate, for membranous angina in scarlet fever, 401 for noma complicating measles, 500 for sterilization, 475 in cholera, 648 in diphtheria, 466 in foot and mouth disease, 695 in glanders, 689 in small pox, 611 Potassium salts, for nervous symptoms of sep- ticemia, 761 in nephritis of scarlet fever, 420 Potato, food value of, 17 Poultices, in adenitis of scarlet fever, 413 dry, for orchitis in mumps, 549 hot, in anthrax, 681 in cholera, 647 in dengue, 642 in fibrinous pleurisy, 116, 126 in pericarditis of pneumonia, 186 in pneumonia, 163 in scarlatinal nephritis, 420 ice, in mumps, 548 in bacillary dysentery, 362 in bronchitis, condemned, 105 Poynton and Payne, on specific organism of rheumatism, 51 Precipitation method, in pneumonia, 130 Pregnancy, use of quinine during, 334 Premature systole, in epidemic influenza, 257, 268 ' Pressure, in local treatment of rheumatism, 51 Proescher, on rabies, 704 Prophylaxis. See under the several diseases Protargol, in amebic dysentery, 382, 386 Protein, amount necessary to replace wear and tear, 15 amount needed in fever, 3 amount needed in health, 3 amount needed in infectious diseases, 28 amount needed in typhoid fever, 282 assimilation of, in acute infectious diseases, 18 destruction of by fever, 20 functions of, 14, 28 percentage of, in milk, 17 needs, 14, 28 source of heat, 15 toxic destruction of, 20 Protein therapy, foreign, in rheumatism, 58 Psittacosis, 698 prognosis of, 698 prophylaxis of, 698 summary of treatment of, 698 Psychasthenia, in epidemic influenza, 259 Psychoses, in epidemic influenza, 266 Puerperal sepsis, 765 Pulmonary complications, in rheumatism, 56, 58 Pulmonary edema, in epidemic influenza, 248 in pneumonia, 178 Pulmonary embolism, complicating pneumonia, 192 INDEX 799 Pulmonary exercises, following pneumonia, 192 Pulse, in typhoid fever, effect of baths on, 290 Purgation, in scarlatinal nephritis, 417 Purpuras, in rheumatism, 57 Pustule, in varicella, 516 malignant of anthrax, 678 Pyelitis, in cerebrospinal meningitis, 578 Pyelonephritis, in epidemic influenza, 258, 269 Pyemia, 757, and see Septicemia abscesses in, 763 in erysipelas, 777 surgical treatment of abscesses, 760 Pylephlebitis, in septicemia, 763 Pyrexia, 19, and see Fever, and under the several diseases destructive action on protein, 20 factor in feeding in infectious diseases, 18 factor in fever, 19 increased caloric demand in, 28 significance of, 3 and toxemia, parallelism of, 1 Quarantine. See under the several diseases Quigley, on typing of urine, in pneumonia, 132 Quinine, action of, 326 for children, 329. 348 contraindications to, 334 desensitization, 334 dosage, 328 fastness, 329 hypodermic use of, 331, 348 hypodermoclysis with, 331 idiosyncrasy to, 334 intramuscular use of, 331 intravenous administration of, 332, 348 immunity, 329 preparations of, 328 prophylactic use of, 327, 342 substitutes for, 340, 351 time for administration of, 327 toxic effects of, 333 Quinine, in amebic dysentery. 381 in black water fever, 344, 352 in bronchitis, 104 in diphtheria, 474, 485 in epidemic influenza, 244 in grip, 224, 232 in malaria, 326 to 335 and 347 to 349 in pertussis, 532 Rabies, 699 confirmation of diagnosis of, 701 convulsive paroxysms of, 706, 709 detention of dogs for prevention of, 707 diet in. 709 immunity in, 699 in America, 708 incubation period of, 699, 700 licensing of dogs for prevention of, 707 maniacal periods in, 707, 710 muzzling law for prevention of, 707 Pasteur treatment of, 703 preventive treatment of, 702 procedures in, 700 prophylaxis of, 707, 710 quarantine in, 707, 710 results of preventive treatment in, 705 room in, 706, 709 summary of treatment of, 708 stages of, 706 symptoms of, 706 in dog, 702 transmission of, 699 treatment of, at a distance, 704 of developed disease, 706, 709 of old bites, 709 of wound in, 700, 708 virus of, 699 Rash, due to diphtheria antitoxin, 458 Rat-bite fever, 744 anemia in, 748, 750 bed in, 746 blood picture in, 745 care of body in, 746 Rat-bite fever, care of bowels in, 746, 748 of mouth in, 746 of skin in, 747, 749 cause of, 744 circulation in, 747, 749 complications of, 748 convalescence in, 748, 750 delirium in, 747, 749 diet in, 746, 748 dizziness in, 747, 749 fever in, 744, 747, 749 fluids in, 746, 748 incubation period of, 744 nephritis in, 748 nervousness in, 747, 749 pains and aches in, 746, 749 prophylaxis in, 748, 750 room in, 746 sleeplessness in, 747, 749 specific treatment of, 747, 749 summary of treatment of, 748 symptomatology of, 744 Rats and plague, 634, 637 Ravenel, on farcy, 689 Rectal administration of coffee, in pneumonia, 176 of digitalis, 172 of salicylates, 47, 66 Rectal feeding, in diphtheria, 451 in foot and mouth disease, 694 in late circulatory failure in diphtheria, 469 in persistent vomiting in septicemia, 761 in tetanus, 713 Rectal irrigations, for pain in bacillary dysentery, 363 Rectal tubes, for tympanites in epidemic in- fluenza, 251 for tympanites in bronchopneumonia com- plicating measles, 498 for tympanites in pneumonia, 152 for tympanites in typhoid fever, 293 disinfection of, 281 Renal complications, from salicylates, 40 Renal function, in nephritis of scarlet fever, 415 Repair of wear and tear, function of protein in, 14,28 Resection of rib, for empyema, 188 Resistance exercises, in poliomyelitis, 601 Respiration, effects of cold water on, 5 effects of baths on, in typhoid fever, 290 Respiratory disturbances, from salicylates, 40 Respiratory failure, in diphtheria, 472 in measles, 494 in poliomyelitis, 600 Respiratory symptoms, in small pox, 615 Respiratory system, care of, in glanders and farcy, 689 Rest. See under the several diseases calories of energy in, 3 caloric requirements of man in, 12 in febrile conditions, 2, 8 physiological significance of, 2 Rest nitrogen, 24 Restlessness. See under the several diseases Retinal hemorrhages from salicylates, 40 in septicemia, 763 Retropharyngeal abscess, differentiated from diphtheria, 464 Revaccination, against smallpox, 619 against typhoid fever, 308 Rheumatic children, 63 joints of infancy, 30 Rheumatic fever, acute, 30 acetanilid in, 45 acidosis in, 46 adenoids in, 62 age in, 30 alkaline salts in, 43 alkaline treatment of, 46 antipyrin in, 45 arrhythmia in, 41 arthritis in, 48, 51 aspirin in, 42 autoserotherapy in, 61 bed in, 32, 63 800 INDEX Rheumatic fever, bowels in, 35, 64 bradycardia in, 41 cardiac complications in, 53, 55, 67, 68 catharsis in, 35 chorea and, 59 complications of, 52, 67 convalescence from, 61, 70 counter-irritation in, 50, 67 delirium in, 40, 53 diagnosis of, in infancy, 30 diet in, 33, 63 drugs to relieve pain, 66 dyspnea in, 40 effusions in, 67 etiology of, 30 fluids in, 35 foreign protein therapy in, 58 hyperpyrexia in, 52 in children, 30 in infancy, 30 insomnia in, 68 intestinal infection and, 62 intravenous injection of foreign protein in, 58 joints in, 31, 48, 50, 51 local applications in, 50, 67 morphine in, 46 paracentesis in, 51 phenacetin in, 45 pressure in, 51 prophylaxis in, 61, 70 pulmonary complications in, 56, 58 rest in, 31, 48, 63 room in, 33, 63 salicylates in, 37, 64 shock therapy in, 58 sleep in, 36, 68 soapsuds enema in, 36 specific treatment of, 37, 64 summary of treatment of, 63 symptomatic treatment of, 48, 66 symptomatology of, 31 teeth in, 62 theories of, 30 therapy of, 31 tonsils in, 62 vaccine therapy in, 57, 68 water in, 35 Rheumatism, 30, and see Rheumatic fever, acute scarlatinal, 413 Rhinitis, acute, 71 abortive treatment of, 72 aches and pains in, 72, 76 antral involvement in, 75, 79 complications of, 75, 78 C9ugh in, 75, 77 direct application in, 73 early treatment of, 72 etiology of, 71 in grip, 227, 233 in scarlet fever, 402 inhalations in, 74, 77 later treatment of, 74, 78 local treatment of, 73, 77 ointments in, 73 otitis complicating, 75, 79 personal hygiene in, 75, 79 prophylaxis of, 75, 79 removal of obstructions in, 75, 79 sinusitis complicating, 75, 79 sore throat in, 75 sprays in, 73, 74, 77, 78 summary of treatment of, 76 symptomatology of, 71 Rice, on anthrax, 681 Rice, food value of, 17 Richter, on trench fever, 753 Ringer's solution, 652 Ringing in the ears, due to quinine, 333 Roast beef, food value of, 17 Rochelle salts, in bronchitis, 103, 109 in cerebrospinal meningitis, 565, 582 in dengue, 642 in diphtheria, 452 in epidemic influenza, 243 Rochelle salts, in erysipelas, 774 in fibrinous pleurisy, 114, 125 in grip, 217,^31 in ileocolitis" complicating measles, 501 in laryngitis, 95, 99 in Malta fever, 658 in mumps, 547 in plague, 635 in pneumonia, 151 in rheumatism, 35 in scarlatinal nephritis, 417 in scarlet fever, 397 in septicemia, and pyemia, 760 in tonsillitis, 82, 88 in typhoid fever, 292, 314 Rocky mountain spotted fever, 664 aches and pains in, 664, 668 baths in, 665 bed in, 665 care of body in, 665 of bowels in, 666, 667 of eyes in, 666 of genitals in, 666 of mouth in, 666 of nose in, 666 of skin in, 666 cause of, 664 circulation in, 667, 668 complications of, 667 delirium in, 666, 668 desquamation in, 665 diet in, 666, 667 fever in, 664, 666, 668 fluids in, 667 headache in, 668 immune serum in, 667, 669 incubation period of, 664 insomnia in, 666, 668 prophylaxis in, 667, 669 pulse in, 665 'rash in, 665 room in, 665 summary of treatment of, 667 symptomatology of, 664 ticks and, 664 Rogers, on cholera, 647, 652 on dosage of quinine, 330 on emetine treatment in amebic dysentery, 377 Room. See under the several diseases Rosenau, on conveyance of smallpox, 608 on rabies, 701 on serum treatment in pneumonia, 130 Rosenow, on rheumatism, 63 theory of etiology of rheumatism, 30 Rost, on leprosy, 674 Rowntree and Amberg, on creatininin in infants, 23 Rubber sheets, disinfection of, 281 Rubella, 512 care of bowels in 513 complications of, 514 diet in, 513 isolation in. 512 summary of treatment of, 513 Rubner's caloric values, 13 Rudolph, on hemorrhage in typhoid fever, 295 Riihrah, on small pox, 612 Russell, technique of antityphoid vaccination, 307 Salicin, 45, and see Salicylates in glandular fever, 556 in grip, 224 in rheumatism, 37, 45 in scarlatinal arthritis, 413 in tonsillitis, 83, 89 Salicylates, 37 in anthrax, 683 in bronchitis, 104, 109 in cholera, 647 in chorea, 60 in dengue, 642 in epidemic influenza, 244, 245, 265 in fibrinous pleurisy, 117, 126 INDEX 801 Salicylates, in grip, 232 in infectious jaundice, 731 in Malta fever, 658 in poliomyelitis, 596 in rheumatism, 37, 39, 43, 46, 60, 64 in scarlatinal nephritis, 413, 420 in tonsillitis, 82, 89 Salicylates, acidosis from, 46 dyspnea from, 40 intravenous administration of, 47, 66 rectal administration of, 47, 66 synthetic, 42 toxic symptoms of, 39 Salicylic acid, 37, and see Salicylates Saline infusions, for hemorrhage in typhoid fever, 297, 316 in uremia in scarlatinal nephritis, 421 Saline irrigation, for collapse in pneumonia, 178 for diarrhea in typhoid fever, 294 in poliomyelitis, 597 Saline rectal injections, for renal congestion in yellow fever, 739 Saline solution, enteroclysis of, in diphtheria, 470 intravenous injection of, in cholera, 648 irrigati9n of nose with in glanders, 689 oral irrigation with in foot and mouth disease, 694 in tetanus, 714 Saline treatment of bacillary dysentery, 359, 362, 372 Salivary secretion, in acute infectious diseases, 18 Salmon, food value of, 17 Salt >I. in rheumatism, 45 Salt-bag, hot, for earache, 411 Salt solution, as mouth wash in measles, 492 in physiological, for membranous scarlet fever, 400 for nose in scarlet fever, 402 Salts. See Epsom salts, and Rochelle salts caloric value of, 13 excreted by intestines, 22 Sanford, on blood transfusion, 767 Salvarean, in malaria, 340 in rat bite fever, 747, 749 in trench fever, 753 in Vincent's angina, 92, 93 Sanitation, in prevention of typhoid fever, 304 Satterlee, on blood transfusion, 767 Scarlatinal nephritis, 414 Scarlatinal rheumatism, 413 Scarlet fever, 387 adenitis in, 412, 437 anemia in, 423, 441 angina in, 398. 432 arthritis in, 413, 437 bed in, 392, and see Pneumonia, bed in bronchopneumonia complicating, 423 cardiovascular apparatus in, 403 care of bowels in, 397, 431 of discharges in, 392 of eyes in, 431 of genitals in, 397, 431 of mouth in, 396, 430 of nose in, 396, 402, 431 of skin in, 395. 430 of teeth in, 396 of throat in, 396, 397, 431 catharsis in, 397 causative agent in, 387 circulatory failure in, 434 contacts, 389 convalescence from nephritis in, 423, 441 convulsions in, 422, 440 delirium in, 407 desquamation in, 388. 430 diaphoresis in, 421, 438 diet in, 392, 416, 429, 438 discharge of patient after, 424, 441 disinfection of utensils in, 392, 428 distribution of family in, 388, 427 diuresis in, 420, 439 drinks in, 395. 416, 430 earache in, 411 edema in, 421, 438, 439 Scarlet fever, eosinophilia in, 388 erythematous eruption in, 387 exfoliation in, 395 fever in, 397, 432 fumigation after, 425, 442 headache in, 422, 440 heart in, 423, 403 hypertension in, 439, 440 immune human serum in, 408 incubation period of, 387, 427 isolation in. 390 leucocytosis in, 388 muscular twitching in, 421, 439 myocarditis in, 423 myositis in, 414 nausea and vomiting in, 422, 431, 440 nephritis in, 388, 414, 437 nervous symptoms in, 407, 435 noma complicating, 424, 441 normal human blood in, 409 oliguria in, 438 onset and diagnosis of, 387, 427 otitis in, 409, 436 patient in. 392, 428 pericarditis in, 423 polyvalent serum from, 409 precautions in sick room in, 391, 428 of nurse in, 390, 428 of physician in. 391, 428 prophylaxis in, 426 protection of family in. 388 quarantine in, 424, 425, 426, and see Distri- bution of family, and Isolation recurrence of, 424 relapses in, 424, 441 release of patient after, 424 restlessness in, 407, 435 rhinitis in. 402, 433 room in, 389, 427 septicemia in, 764 serum therapy in, 407, 436 sleeplessness in, 407, 435 sore throat in. 387 specific treatment of, 407, 436 sterilization after, 425, 442 summary of treatment of, 427 suppression of urine in, 438 symptomatic treatment of, 397 temperature in, 387 tongue in, 388 uremia in, 421, 439 use of cold in 432 vaccine therapy in, 402, 407, 411, 436 vomiting in, 397 water in, 395 Schamberg, on iodine in small pox, 613 Schick reaction, in diphtheria, 444, 445, 449, 450.' 477 combined reaction, 447 control, 447 negative reaction, 446 pseudo-reaction, 446 technique of, 445 Setter's tablets in coryza, 73 in rhinitis. 73 Sellard's dosage of emetine in amebic dysentery, 377 method of determining acidosis, 251 treatment of Asiatic cholera, 648, 649. 651 Sensitization, in pneumonia, 134 determination of, 135 Septic conditions, physiology of diet in, 3 Septic sore throat, in tonsillitis, 85, 90 Septicemia and Pyemia, 757 accidents after, 770 arthritis in, 763, 771 bed in, 759, 768 blood transfusion in, 766 care of body in, 760 of bowels in, 760, 769 cerebrospinal meningitis in, 762 chills in, 760, 769 circulation in, 762, 770 collapse in, 760, 769 802 INDEX Septicemia and Pyemia, convulsions in, 762, 770 delirium in, 761, 770 diagnosis of in early stage, 758 diet in, 759, 768 drugs for nervous symptoms of, 761 early symptoms of, 758 emboli in, 763, 771 erythema in, 763 fever in, 760, 769 fluids in, 760, 769 form of in puerperal sepsis, 765 in scarlet fever, 764 fresh air in, 759 headache in, 762, 770 hemorrhages in, 763 hyperpyrexia, in, 760 icterus in, 763 in erysipelas, 777 - in nephritis, 86 in scarlet fever, 764 infarcts in, 763, 771 insomnia in, 761, 770 involvement of kidneys in, 763, 771 light in, 758 malignant endocarditis in, 762 nervous symptoms in, 761, 770 organisms of, 757 osteomyelitis in, 763 pneumococcus, 766 polyvalent serum in, 765 prophylaxis of, 768 rest in, 758, 768 restraint of patient in, 761 room in, 758, 768 specific treatment of, 764, 771 staphylococcus, 757, 764, 766 streptococcus, 757, 763 summary of treatment of, 768 symptomatic treatment of, 760, 769 sweats in, 760 thrombophlebitis in, 762, 771 vaccine therapy in, 765 visceral abscesses in, 764 vomiting in, 760, 770 Septicopyemia, symptoms of, 758 Serum, administration of, 133, 195 anaphylaxis after, 134, 145 apparatus, 137 dosage, 146, 196 injection of, 142 preparation of patient and operator, 141 precautions, 136 reaction after, 143, 196 shock after, 145 sterilizing apparatus, 140 symptoms after, 144 Serum sickness, pneumococcal, 196 Serum therapy. See under the various diseases Shad, food value of, 17 Shaffer, on typhoid diet, 22, 23, 25, 283 Shattuck, typhoid diet, 285 Shaving brushes and anthrax, 678 Sheet bath, technique of, 159 Shock, anaphylactic, in pneumonia, 145 Shock therapy, in rheumatic fever, 58 Sick room, care of. See under the several diseases Silver nitrate, in amebic dysentery, 382 in bacillary dysentery, 368 for oral ulcers in smallpox, 611 for ulcerative stomatitis complicating measles, 500 for ulcer of frenum in pertussis, 534 for ulcers of mouth in foot and mouth disease, 695 in tonsillitis, 84, 89, 90 in Vincent's angina, 92, 93 Silver preparations for carriers of cerebrospinal meningitis, 579 Sino-auricular block, in rheumatism, 41 Sinus arythmia, in epidemic influenza, 257, 268 Sinus thrombosis in grip, 226, 233 Sinuses, involvement of, in rheumatic fever, 62 in scarlet fever, 402 Sinusitis, complicating coryza, 75 epidemic influenza, 256 rhinitis, 75, 79 Skatol, in undetermined nitrogen, 25 Skin, care of. See under the several diseases Skin eruptions, complicating rheumatism, 57 due to antipyretics, 223 due to quinine, 333 due to salicylates, 40 Sladen, on infectious jaundice, 732 Sleeplessness. See under the several diseases Sleeping sickness, 271, and see Encephalitis lethargica Sliding in bed, to prevent, 147 Slush, in typhoid fever, 291 Small pox, 608 baths in, 611, 621 bed in, 610 care of bowels in, 613, 622 of eyes in, 611, 621 of mouth in, 610, 620 of nose in, 611, 621 of skin in, 611, 621 delirium in, 614, 623 diet in, 610, 620 disinfection in, 616 fever in, 614, 622 headache in, 614, 622 initial stage of, 613 insomnia in, 614, 623 isolation in, 608, 620 precautions for nurse in, 609, 620 for physicians in, 609, 620 quarantine in, 615, 624 respiratory symptoms in, 615, 623 room in, 608 summary of treatment of, 620 symptomatic treatment of, 613, 622 treatment of other members of family or ex- posed persons, 609, 612 vaccination against, 616 water in, 610 Smith, Theobald, on vaccine therapy in farcy, 688 Smoking prohibited, in bronchitis, 102 in laryngitis, 95, 99 Soapsuds enema, in rheumatic fever, 36 technique of, 36 Sodium benzoate and caffeine in febrile condi- tions, 6 in Malta fever, 660 in scarlet fever, 405 Sodium bicarbonate, for nausea, in cerebrospina meningitis, 566 in scarlet fever, 422 for laryngitis complicating measles, 499 for retching, in small pox, 615 for vomiting, in anthrax, 683 in poliomyelitis, 596 in epidemic influenza, 245 in infectious jaundice, 730 in measles, 491 in scarlatinal arthritis, 413 in scarlatinal nephritis, 420 in typhoid fever, 295 spray, for membranous angina in scarlet fever, 400 Sodium bromide, in laryngitis, 98, 100 in pertussis, 529 Sodium chloride solution in cholera, 648 for irrigating throat in diphtheria, 466 Sodium phosphate, in bronchitis, 103 in scarlatinal nephritis, 417 in septicemia, 760 in tonsillitis, 82 Sodium potassium tartrate. See Rochelle salts Sodium salicylate, in Malta fever, 660 in scarlatinal arthritis, 413 in scarlatinal nephritis, 420 in scarlet fever, 405 solutions of, doses, 41 synthetic, 42 toxic dose of, 39 Sodium sulphate. See Glauber's salts Soft palate, paralysis of in diphtheria, 472 INDEX 803 Sollman on caffeine in vasomotor weakness, 405 Sophian on cerebrospinal meningitis, 568, 571, 576, 579 Sordes, in cerebrospinal meningitis, 565 in diphtheria, 452 in measles, 492 in scarlet fever, 396 in typhoid fever, 280 Sore throat, 80, and see Tonsillitis diphtheritic, 81 in coryza, 75 in rheumatism, 57, 68 in rhinitis, 75 in scarlet fever, 387 Southey tubes, 421 Sparteine, in pneumonia, 175 Spasmodic croup, differentiated from laryngeal diphtheria, 464 treatment of, 98 Specific treatment. See under the several diseases Spinach, food value of, 17 Spinal fluid, in cerebrospinal meningitis, 568 in encephalitis lethargies, 272 in poliomyelitis, 591 Sponge bath, in cerebrospinal meningitis, 566 in grip, 217 Sponges, cold, in pneumonia, 161 in yellow fever, 739 cool, in chorea, 60 in dengue, 642 in measles, 494 in pertussis, 537 in typhoid fever, 291 Sponging, cold, for bronchopneumonia com- plicating measles, 496 for fever in measles, 494 Spoons, disinfection of, 281 Sporadic influenza, 216, and see Grip Spriggs, on excretion of creatinin, 23 Sputum, disinfection' of in typhoid fever, 281 typing of, in pneumonia, 131 Standard portions, Fisher's tables of, 17 Starva^n, 18 , 20, 29 in bacillary dysentery. 363 Steam inhalations. See Inhalations, steam Steak, fo9d value of, 17 Sterilization after scarlet fever, 425, 442 Stitt, method of giving quinine in malaria, 329 on treatment of hepatic abscess in amebic dysentery, 379 on yellow fever, 735 Still, on urethane for convulsions in pertussis, 536 Stimson, on rabies, 708 Stomach, hemorrhages from in dengue, 643 motility of in acute infectious diseases, 18 Stomach tube, in diphtheria, 451 Stomach washing, for vomiting in typhoid fever, 694 in infectious jaundice, 730 Stomatitis, in pneumonia, 148 in varicella, 517, 519 Stools, in acute infectious diseases, 21 disinfection of, 281 Strapping the chest, in fibrinous pleurisy, 114, 126 in pneumonia, 161 Streptococcus hemolyticus, complicating mea- sles, 489, 495, 502 Streptococcus empyema, 211, and see Empyema, streptococcus type Streptococcus pneumonia, 208, and see Pneu- monia, streptococcus Strong, on leprosy, 670 Strophanthin, in acute glanders and farcy, 692 in anaphylactic shock in pneumonia, 145 in anthrax, 683 in bacillary dysentery, 365, 373 in cerebrospinal meningitis, 566 in cholera, 650 in febrile conditions, 6, 9 in pneumonia, 145, 173, 178, 203 in pneumonia of epidemic influenza, 247 in pulmonary edema of epidemic influenza, 248, 267 Strophant'iin, in septicemia, 762, 770 in scarlet fever, 404, 434 in typhoid fever, 299 Strychnine, in anthrax, 683 for dyspnea in pneumonia, 179 for nervous symptoms of malaria, 339 in cerebrospinal meningitis, 566 in cholera, 650 in control of prostration from belladonna, 531 in convalescence from diphtheria, 474 from dengue, 643 from epidemic influenza, 261 from infectious jaundice, 733 from Malta fever, 660 from measles, 502 from typhoid fever, 303 in diphtheria, 470 in febrile conditions, 6 in glandular fever, 557 in grip, 225, 233 in pneumonia, 152 in poliomyelitis, 600 in scarlet fever, 406, 435 in typhoid fever, 299 in tympanites of epidemic influenza, 252 Stupes, for backache in yellow fever, 738 for pain in bacillary dysentery, 362 for pain in dengue, 642 for tympanites in epidemic influenza, 251 for tympanites in typhoid fever, 293 in cholera, 647 in pneumonia, 152 turpentine, preparation of, 363 Stupor, in measles, 494 in septicemia, 758, 761 in typhoid fever, 317 in typhus fever, 629 Subglottic edema differentiated from laryngeal diphtheria, 464 Sugar, food value of, 17 percentage of in milk, 17 Sulphates, ethereal, in endogenous metabolism, 23 Sulphur in metabolism, 24, 26 Sulphur dioxide, as disinfectant, 616, 737 Suspensory for orchitis complicating mumps, 549 Symptomatic treatment. See under the several diseases Symmers, on pneumonia in epidemic influenza, 236 Tachycardia, in epidemic influenza, 257, 269 in scarlet fever, 403 Tartar emetic, in laryngitis, 98, 99 Teeth, care of. See under the several diseases Tender toes complicating typhoid fever, 302 Tenesmus, in bacillary dysentery, 363, 372 Terpin hydrate, in bronchitis of children, 108 Testicle, involvement of in mumps, 549 Tetanus, 711 antiseptics in, 722 bed in, 713. 724 care of bladder in, 714, 725 of body in, 724 of bowels in, 714, 724 of circulation in, 721, 727 of mouth in, 724 causes of death in, 721 complicating vaccination, 618 diet in, 713, 724 drug treatment of, 718, 719, 720 fluids in, 724 incubation period of, 711, 723 local, 718 local treatment of, 714, 718, 722, 725 mortality in, 721 prodromata of, 712 prognosis of, 721 prophylaxis of, 712, 727 rest in, 712 retention of urine in, 714, 725 room in, 713, 723 specific treatment of, 714, 725 summary of treatment of, 723 symptoms of, 712, 723 804 INDEX Tetanus, treatment of convulsions in, 719, 726 treatment of developed form of, 712 Tetanus antitoxin, 706, 722, 725, 727 combined intraspinal, intravenous, and intra- muscular administration of, 726 dosage, 715, 716, 717, 722, 723 intracerebral, administration of, 717, 725 intramuscular administration of, 716, 717, 725, 726 intraneural administration of, 717, 725 intraspinal administratipn of, 716, 725 intravenous administration of, 716, 725 prophylactic use of, 721, 727 subcutaneous administration of, 715, 725 unit of, 715 use of, 715, 722 Tetanus ascendens, 711 descendens, 711 Theobromine, as diuretic in scarlatinal nephritis, 420 Theocine, in pleurisy with effusion, 123 Thermokinetic energy, 11 Thoracentesis, in empyema in pneumonia, 181 in pleurisy with effusion, 119, 127 technique of, 181 Throat, care of. See under the several diseases compress, in tonsillitis, 84 examination of in infections in childhood, 443 Thrombophlebitis, complicating typhoid fever, 302 in septicemia, 762 in septicopyemia, 758 Thromboplastin, in hemorrhage of typhoid fever, 296 in nosebleed of diphtheria, 467 Thrombosis of pneumonia, 190, 206 Thymus gland in mumps, 550 Ticks, and Rocky mountain spotted fever, 664 Tick fever, 664 and see Rocky mountain spotted fever Tissue destruction, in acute infections, 450 Tissue metabolism, creatinin as indicator of, 23 Tongue, care of, in pneumonia, 148 in scarlet fever, 396 in small pox, 610 in typhoid fever, 280 coated, in acute infectious diseases, 18 Tonics, in convalescence from diphtheria, 474 from grip, 225, 233 from epidemic influenza, 261 from infectious jaundice, 733 from pertussis, 536 Tonsillitis, 80 adenitis in, 86 care of body in, 83, 89 care of bowels in, 82, 88 care of heart in, 85 chronic, 87, 91 circulation in, 85 complications in, 86 convalescence from, 87, 90 cultures in, 81 diet in, 82, 88 differentiated from diphtheria, 80 drinks in, 82, 88 drugs in, 82, 89 etiology of. 80 fever in, 83, 89 gargle in. 84, 90 in epidemic influenza, 256 in grip, 227, 233 in poliomyelitis, 597 insomnia in, 84, 89 local treatment in, 84, 89 nephritis in, 86 peritonsillar abscess in, 86 precautionary measures in, 81 and rheumatism in childhood, 30 septic sore throat in, 85 septicemia in, 86 sequelae of, 86 serum therapy in, 86 summary of treatment of, 83 symptomatology of, 81 Tonsillitis, throat compress in, 84 toxemia in, 85, 90 treatment of, 81 urine, examination of, 85 Tonsils, 80 attention to in bronchitis of children, 108, 111 in glandular fever, 556 in rheumatism, 62 removal of, indications for, 88 in pertussis, 537 in pneumonia, 193 Toxemia, in acute infectious diseases, 20 caloric intake and, 28 factor in feeding in infectious diseases, 18 factor in fever, 19 hydrotherapy aimed at, 5 in glandular fever, 556 in Malta fever, 659 in pneumonia, 167 in tonsillitis, 85 meaning of, 757 parallelism of with pyrexia, 1 tissue destruction due to, 450 Toxins, 453 effect on nerve centers in febrile conditions, 5 factor in nitrogen loss in infectious diseases, 20 Tracheitis, 101, and see Bronchitis, acute in grip, 224, 232 Tracheotomy, in diphtheria, 464 in edema of larynx, 99 Transfusion of blood, in delayed resolution in influenza, 252 in erysipelas, 777 in hemorrhage of typhoid fever, 297 in pneumonia, in epidemic influenza, 252 in septicemia, 766 methods of, 767 Trench fever, 751 aches and pains in, 752, 754 anemia in, 752, 755 bed in, 752 cardio-vascular disturbances in, 753, 754 care of patient in, 752 carriers of, 754 catharsis in, 752 complications of, 753 convalescence in, 753, 755 delousing in, 753 diet in, 752, 754 disinfection after, 753 disposition of excretions in, 752 - drinks in, 752, 754 fever in. 752 incubation period of, 751 insomnia in, 752, 755 isolation in, 752, 754 louse and, 751, 753 mode of conveyance of, 751, 753 nervousness in, 752, 755 prognosis of, 752 prophylaxis of, 753, 755 rest in, 752 sequelae of, 753, 755 summary of treatment of, 754 symptomatology of, 751 Trional, in dengue, 643 in epidemic influenza, 246 in measles, 495 in mumps, 551 in pertussis, 533 in pneumonia, 169 in poliomyelitis, 596 in rheumatism, 37, 68 in scarlet fever, 407 in septicemia, 762 in small pox, 614 in tonsillitis, 84. 89 in typhoid fever, 298 Trismus, 712 Tuberculosis, complicating epidemic influenza, 255 complicating measles, 502 Turkey, food value of, 17 INDEX 805 Turpentine, in bronchitis, 105, 109 in black vomit of yellow fever, 739 in laryngitis complicating measles, 499 in pneumonia, 152 in tracheitis of grip, 224 in tympanites of typhoid fever, 293 Turpentine stupes, for pain in bacillary dysentery, 363 in pneumonia, 152 preparation of, 363 Tympanites, in bronchopneumonia complicating measles, 498 in epidemic influenza, 251, 267 in pneumonia, 152, 199 in typhoid fever, 292, 294, 314 Tvphoid fever, 277 'bed in, 279 bedsores in. 280, 310 Brand bath in, 288 care of alimentary tract in, 292, 314 of body in, 280. 309 of bowels in. 292, 314 of circulation in, 298, 317 of teeth in, 280 of tongue in, 280 of urinary tract in, 300, 318 carriers of. 304, 319 complications of, 302, 318 convalescence from, 303, 318 diet in, 282. 311 disinfection in, 281, 310 drinks in, 314 etiology of, 277 gastric distress in, 295, 315 hemorrhage in, 295, 316 hydrotherapy in, 287, 298, 314 isolation in, 304 lipovaccines in, 309 meningismus in, 302 mortality in, 277 influence of hydrotherapy on, 287 open air treatment of, 279 packs in, 291 pathology of, 277 perforation in, 297 phlebitis in, 302 physiology of diet in, 3 precautions for nurse in, 311 for physician in, 311 preventive inoculation for, 306, 319 prophylaxis from, 303, 319 pulse in, 290 rest in, 278 revaccination in, 308 room in, 279, 309 slush in, 291 summary of treatment in, 309 rptomatology of, 277 apy of, 278 treatment of cerebral disturbances in, 298, 316 of convalescence in, 303, 319 of diarrhea in, 294, 315 of hemorrhage in, 296, 316 of tympanites in, 292, 314 of vomiting in, 295, 315 use of alcohol in, 299 vaccine therapy in, 301, 318 vomiting in, 295, 315 walking, 278 water in, 287 Ziemssen's bath in, 291 Typhoid state, 300 Typhus fever, 625 bed in, 626 care of body in, 626, 627, 631 of bowels in, 629, 632 of circulation in, 629 of hair in, 626 of mouth and nose in, 628, 632 of patient in, 627 of teeth in, 628 cardiac weakness in, 626 complications of, 630 convalescence from, 630, 633 Typhus fever, diet in, 628, 632 disinfection in, 626, 627, 631, 633 incubation period of, 625 isolation in, 626, 631 louse and, 625, 626 nervous manifestations in, 629 onset of, 625 open air treatment of, 630, 632 otitis complicating, 630 parotitis complicating, 630, 633 prophylaxis in, 631, 633 room in, 626, 631 summary of treatment of, 631 treatment of constipation and meteorism in, 629 of delirium in, 629, 632 of diarrhea in, 630, 633 of edema of larynx in, 630, 633 of fever in, 628 of headache in, 629 of laryngitis in, 630 of nausea and vomiting in, 629 of stupor in, 632 Ulcerative stomatitis, complicating measles, 499, 509 in varicella, 517 Ulceration. in foot and mouth disease, 695 Ulcers, in bacillary dysentery, 367, 373 in chronic farcy, 688 in foot and mouth disease, 695 in measles, 501 in pertussis, 554 in small pox, 611. 612 Undulating fever, 656. and see Malta fever Unger. on olood transfusion, 767 Uremia, in cholera, 650 in diphtheria, 473 in scarlet fever, 415 Urea-forming function, 25 Urethane, for convulsions in pertussis, 536, 543 Uric acid, in endogenous metabolism, 23 excreted by kidneys in febrile conditions, 22, 24 Urinals, disinfection of, 281 Urinary tract, care of in typhoid fever, 300, 318 Urine, bacteria in, in typhoid fever, 300 creatin in, 24 disinfection of, 281 examination of, in tonsillitis, 85 Folin's analysis of, 22 nitrogen in, 22 retention of, in epidemic influenza, 238 in Malta fever, 658 in plague, 635 in poliomyelitis, 594 in tetanus, 714 in typhoid fever, 300 suppression of, in yellow fever, 739 typing of, in pneumonia, 132 Urticaria, complicating rheumatism, 57 due to antipyretics, 223 due to diphtheria antitoxin, 459 due to quinine, 333 due to salicylates, 40 due to sensitization in pneumonia, 134, 135 due to serum in pneumonia, 144 Urotropin, in bacilluria in typhoid fever, 300 in cerebrospinal meningitis, 567 in poliomyelitis, 597 Vaccination, in small pox, 616 complications of, 618 contraindications to, 619 general symptoms of, 618 technique of, 617 Vaccination, preventive against typhoid fever, 306,308 Vaccine therapy. See under the several diseases Vaccinia generalized, following vaccination, 619 Vallet's mass, for anemia following diphtheria, in scarlatinal nephritis, 423 of trench fever, 755 in convalescence from measles, 502 806 INDEX Vallet's mass, from glandular fever, 557 from pertussis, 537 Van Noorden, on diet for adults, 416 on gastrointestinal function, 18, 26 Varicella, 515, care of bowels, 517, 519 of patient in, 515, 518 of skin in, 516, 518 complications of, 517, 519 convalescence from, 517-519 corneal ulcer in, 519 diet in, 516, 518 disinfection in, 517, 519 distribution of family in, 515, 517 nervous symptoms in, 517, 519 precautions lor physician in, 518 quarantine in, 517, 519 room in, 515 stomatitis in, 517, 519 summary of treatment of, 517 treatment of fever in, 517, 519 Variola, 608, and see Smallpox Vedder, method of giving quinine in malaria, 329 on emetine in amebic dysentery, 377, 379 Venesection, for pulmonary edema in pneu- monia, 178 in uremia in scarlatinal nephritis, 420 Venous thrombosis complicating rheumatism, 67 Ventilation, ill, evils of, 4 Ventricles, dilatation of, in rheumatism, 54 puncture of, in cerebrospinal meningitis, 576 Veronal, for sleeplessness in pneumonia, 169 for sleeplessness in rheumatism, 37 Vincent's angina, 91 care of teeth in, 92, 93 diagnosis of, 91 etiology of, 91 malnutrition in, 92, 93 removal of membrane in, 92 severe cases of, 92, 93 summary of treatment of, 92 symptoms of, 91 Virus fixe, in rabies, 703 Vitamines, 27, 28 fat soluble A, 27 water soluble B, 27 Voit's figures concerning protein needs, 14 Vomiting. See under the several diseases and cardiac involvement, 46 from antipyretics, 223 from salicylates, 46 Vomitus, disinfection of, 281 Vulva, noma of complicating measles, 500 Vulvitis, complicating mumps, 550, 553 Walking typhoid, 278 Ward, on puerperal sepsis, 766 Wasting, in typhoid fever, 283 Water. See Baths and under the several diseases cold, effects of in febrile conditions, 3, 4, 5, 9 insufficiency of, in infectious diseases, 18 intake of, in infections, 3, 4 locally applied in febrile conditions, 2 needed in fever, 29 Waldeyer's ring, 80 Wallach, on blood typing in pneumonia, 131 Warburg's tincture, in malaria, 334 Weaver, on scarlet fever, 424 on dosage of diphtheria antitoxin, 455 Weaver, on vaccines in scarlet fever, 407 Wegeforth, on lumbar puncture, 573 Weight, caloric? requirements and, 12 Weight rule, for dosage, 37 Weil's disease, 728, and see Infectious jaundice Welch, on use of human serum, 768 . Wellman, on dosage of quinine in malaria, 329 Western, on puerperal sepsis, 765 Weston, on vaccines in scarlatinal otitis media, 411 Wet compress, technique, 97 Wherry, on prophylaxis in cholera, 651 Whey, food value of, 17 White's instructions on yellow fever, 736 Whoop, in whooping cough, 521 Whooping cough, 520, and see Pertussis Wickman, on types of poliomyelitis, 597 Wintergreen, oil of, 43, and see Salicylates Wolf and Lambert, 25 on pneumonia, 22 Woolen underclothing, in convalescence from scarlatinal nephritis, 423 Wooley, on leprosy, 673 Wool sorter's disease, 679, and see Anthrax Wound, treatment of in rabies, 700, 708 in tetanus, 722 Wright, Sir A. E., preventive inoculation in typhoid fever, 306 X-ray treatment of leprosy, 674 Yellow fever, 735 backache in, 738, 742 bed in, 737 black vomit in, 739, 742 blood pressure in, 735 care of body in, 738 of bowels in, 738, 741 cause of, 735 circulation in, 739, 742 congestion of kidneys in, 739, 742 convalescence in, 740, 743 diet in, 737, 741 drinks in, 738, 741 fever in, 739, 742 fumigation in, 737 gastric distress in, 738, 742 headache in, 738, 741 isolation in, 735, 741 precautions for non-immunes in, 740 for nurses in, 737, 741 for physicians in, 737, 741 - prophylaxis in, 740, 743 relief of black vomit in, 739 rest in, 737 room in, 736 specific treatment of, 738 summary of treatment of, 741 suppression of urine in, 739 symptoms of, 735 transmission of, 735 treatment of symptoms in, 738, 741 Yeo, on quinine in grip, 224 Young's rule for dosage, 37 Zeiler's method of using ipecac in amebic dysen- tery, 376 Ziemssen's bath, in typhoid fever, 291 Zingher, on human serum in scarlet fever, 408 THIS BOOK IS DUE ON THE LAST DATE STAMPED BELOW AN INITIAL FINE OF 25 CENTS WILL BE ASSESSED FOR FAILURE TO RETURN THIS BOOK ON THE DATE DUE. 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